The new liver allocation system: Moving toward evidence-based transplantation policy

TLDR

The Institute of Medicine proposed that a continuous disease‑severity score that down‑weights waiting time could improve liver allocation, and the MELD/PELD scores were chosen as the basis because they accurately predict mortality across diverse liver diseases. This study aimed to develop and initially implement a continuous disease‑severity scale that uses objective variables to predict mortality risk in end‑stage liver disease patients, thereby reducing reliance on waiting time. The new policy ranks patients continuously by MELD/PELD scores, uses waiting time only to break ties, and allows urgent candidates or those poorly served by the scores to be prioritized through a regional peer‑review system. The plan relies on objective, verifiable disease‑severity measures with minimal waiting‑time emphasis, offering an evidence‑based foundation for future refinements.

Abstract

In 1999, the Institute of Medicine suggested that instituting a continuous disease severity score that de-emphasizes waiting time could improve the allocation of cadaveric livers for transplantation. This report describes the development and initial implementation of this new plan. The goal was to develop a continuous disease severity scale that uses objective, readily available variables to predict mortality risk in patients with end-stage liver disease and reduce the emphasis on waiting time. Mechanisms were also developed for inclusion of good transplant candidates who do not have high risk of death but for whom transplantation may be urgent. The Model for End-Stage Liver Disease (MELD) and Pediatric End-Stage Liver Disease (PELD) scores were selected as the basis for the new allocation policy because of their high degree of accuracy for predicting death in patients having a variety of liver disease etiologies and across a broad spectrum of liver disease severity. Except for the most urgent patients, all patients will be ranked continuously under the new policy by their MELD/PELD score. Waiting time is used only to prioritize patients with identical MELD/PELD scores. Patients who are not well served by the MELD/PELD scores can be prioritized through a regionalized peer review system. This new liver allocation plan is based on more objective, verifiable measures of disease severity with minimal emphasis on waiting time. Application of such risk models provides an evidenced-based approach on which to base further refinements and improve the model.