Disparities in liver transplantation in the post-model for end-stage liver disease era: Are we there yet? Commentary

Section of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
Hepatology (Impact Factor: 11.06). 09/2009; 50(3):981-4. DOI: 10.1002/hep.22939
Source: PubMed
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    ABSTRACT: There are three possible policies for prioritization for liver transplantation: medical urgency, utility and transplant benefit. The first is based on the severity of cirrhosis, using Child-Turcotte-Pugh score and, more recently, the Model for End-stage Liver Disease (MELD) score, or variants of MELD, for allocation. Although prospectively developed and validated, the MELD score has several limitations, including interlaboratory variations for measurement of serum creatinine and international normalized ratio of prothrombin time, and a systematic adverse female gender bias. Adjustments to the original MELD equation and new scoring systems have been proposed to overcome these limitations; incorporation of serum sodium improves its predictive accuracy. The MELD score poorly predicts outcomes after liver transplantation due to the absence of donor factors incorporated into the scoring system. Several utility models are based on donor and recipient characteristics. Combined poor recipient and donor characteristics lead to very poor outcomes, which in a utility system would be considered unacceptable. Finally, transplant benefit models rank patients according to the net survival benefit that they would derive from transplantation. However, complex statistical models are required, and unmeasured characteristics may unduly affect the models. Well-designed prospective studies and simulation models are necessary to establish the optimal allocation system in liver transplantation.
    Nature Reviews Gastroenterology &#38 Hepatology 11/2010; 7(12):659-68. DOI:10.1038/nrgastro.2010.169 · 12.61 Impact Factor
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    ABSTRACT: This study examined factors associated with the gender disparity in wait-list mortality in the MELD era. Adult patients listed for liver transplantation from 2002 to 2008 were included. Females [12 585(36%)] and males [22 126(64%)] differed clinically by age (54 vs. 52 years), height (1.6 vs. 1.8 m), listing estimated glomerular filtration rate [(eGFR); 70 vs. 83 mL/min] and cirrhosis etiology. Holding MELD constant, females were at 19% (95% CI, 1.13-1.25, p < 0.001) higher risk of wait-list mortality than males under the current allocation system. The relative hazard increased with worsening renal function, whether measured by serum creatinine or eGFR. Adjustment for MELD, age, African-American race, cirrhosis etiology, region and ABO group attenuated this relative hazard (HR 1.16; 95% CI, 1.10-1.22; p < 0.001) but additional adjustment for height completely explained this gender disparity in wait-list mortality (HR 1.05; 95% CI, 0.98-1.12; p = 0.2). Transplantation rates, however, remained lower among females, even after adjustment for height (HR 0.88; 95% CI, 0.82-0.92; p < 0.001). In conclusion, under the current liver allocation system, women have a 19% increased risk of wait-list mortality compared to men with the same MELD scores. Height contributes to this gender disparity, possibly reflecting differences in transplantation rates for shorter individuals.
    American Journal of Transplantation 11/2010; 10(12):2658-64. DOI:10.1111/j.1600-6143.2010.03326.x · 5.68 Impact Factor
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    ABSTRACT: Cirrhosis is a common yet generally irreversible medical condition which would cause damaged liver function and regeneration after resection. When the disease progressed to end stage, liver transplantation, cadaveric or live donor, would be the only way to eliminate the disease. But both have their confinements, such as organ shortage, detriments to the donors, and immunosuppression. Now that the techniques of auxiliary transplantation are in practice, and the phenomenon of graft repopulated by cells of host origin has been observed, and that elevated blood inflow would stimulate the regenerative response, the combination of the three might give rise to a non-immunogeneic customized liver. We hypotheses that it can be achieved through a auxiliary transplantation of a extremely small but normal graft combined with progressive portal control on the portal inflow of the native liver to induce atrophy of the cirrhotic liver and the regeneration of the graft, as well as postoperative administration of bone marrow mobilizing agents and reduced administration of immunosuppressants to initiate repopulation. This will not only solve the issue of organ shortage as one organ can be shared by more, and in case of live donor, less detriments would occur due to reduced size needed; but diminish, even eliminate the adverse effect caused by immunosuppression as well.
    Medical Hypotheses 05/2012; 79(2):241-5. DOI:10.1016/j.mehy.2012.04.048 · 1.07 Impact Factor

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