MELD-based liver allocation deteriorates liver transplant outcome and waiting list mortality in Germany

Introduction MELD-based liver allocation, including exceptions, was implemented 2006 in the Germany followed by many countries in order to reduce waiting list mortality and ensure fair allocation. Herein, the effects of MELD-based liver allocation on waiting list mortality and post-transplant survival in Germany, a country with an extremely low donation rate, were compared to United Network for Organ Sharing (UNOS) data.

Methods Waitlisted candidates as well as liver transplants from 2003-2017 in Germany and 1999-2017 in the USA were analyzed. Pediatric recipients, living donations and multi-organ transplants were excluded from the analysis. The data were obtained from Eurotransplant (ET) and UNOS.

Results In the respective time periods, 201293 patients were waitlisted for liver transplantation (n=22446 for Germany, n=178847 for the USA) and 108614 patients were effectively transplanted (n=12537 for Germany, and n= 96007 for the USA, respectively). Organ donation rates in Germany have been on a low level (2018: 9.7 per million inhabitants), while they are steadily rising in the USA (2018: 32.8 per million inhabitant). After the introduction of a MELD-based allocation algorithm, laboratory MELD scores increased in both countries at time of transplantation (Germany: 17 to 19; USA: 17 to 22, both p< 0.001). Unfortunately, the aim of reducing waiting list mortality could not be achieved in Germany (Odds Ratio (OR) of MELD era compared to pre-MELD era=1.015, 95% Confidence Interval (CI)=0.943-1.093, p=0.690) in contrast to the USA (OR=0.674, CI=0.651-0.698, p< 0.001). While survival in the USA after transplantation improved over the years (three-year patient-survival: 75.3% to 83.5%; p< 0.001), results deteriorated in Germany after the introduction of MELD (three-year survival: 68.7% to 62.3%, p< 0.001).

Conclusion While lower waiting list mortality and even better survival rates were observed within UNOS after implementation of MELD based liver allocation, the contrast occurred in Germany parallel to a dramatic lack of organ donors. MELD-based liver allocation may not appropriately fulfill expectations for countries with a low donation rate and should be reconsidered.

Publication History

Article published online:
07 September 2021