![]() For example, if an organ became available, it was prioritized to the patient with the highest MELD score within that DSA. However, distribution of donor livers prioritized patients within the local donation service area (DSA), followed by the UNOS region, and finally the nation. The use of the MELD score led to more transplants for sicker patients and reduced waitlist mortality without reducing post-transplant survival. In February 2002, donor liver allocation based on MELD score was implemented in the United States. The Final Rule led to the Organ Procurement and Transplant Network to implement the MELD score to prioritize patients awaiting deceased donor liver transplantation using only three objective lab values in its calculation-serum bilirubin, serum creatinine, and INR. However, etiology of liver disease was shown to have minimal impact on outcomes and was later removed from the scoring system. The MELD score incorporated serum bilirubin, serum creatinine, international normalized ratio (INR) for prothrombin time, and etiology of liver disease. A year later this scoring system was shown to also be a reliable predictor of three-month mortality in patients with cirrhosis and became known as the MELD score. The Mayo transjugular intrahepatic portosystemic shunt (TIPS) model was originally developed in 2000 as a scoring system to predict three-month mortality in patients with cirrhosis who underwent a TIPS procedure. ![]() In 2000, the United States Department of Health and Human Services released the Final Rule, which mandated that organ allocation should be based upon medical urgency that is determined by objective and reproducible data and that access to transplant should not be affected by geography.Īdoption of MELD score and donation service areas In 1973, Pugh et al modified the scoring system by adding prothrombin time and removing nutritional status which became known as the CTP score. The CTP score was originally proposed in 1964 by surgeons Child et al as a way to assess operative risk in patients undergoing surgical portosystemic shunt for variceal bleeding-patients were given a subclass score of A-C depending on bilirubin, albumin, ascites, hepatic encephalopathy, and nutritional status. The CTP score incorporated objective data into waiting list priority, but still included subjective grading of encephalopathy and ascites which allowed for wide variability and the potential for inappropriately scoring the severity of a patient’s condition. In 1998, United Network for Organ Sharing (UNOS) adopted the Child-Turcotte-Pugh (CTP) scoring system to stratify patients as Status 2A, 2B, or 3 for patients at high risk of death without transplantation, with Status 1 reserved for patients with acute liver failure. This system was based on subjective criteria that could be manipulated by hospitalizing patients or admitting to the ICU when there was no medical indication, thereby fraudulently giving a patient an advantage over others. For example, a patient in the intensive care units (ICU) was given priority over a non-ICU hospitalized patient who was given priority over an outpatient. ![]() Prior to 1997, liver transplant priority was determined by hospitalization status and time on the waiting list. This review highlights policy changes since the adoption of the MELD score, addresses limitations of the MELD score, reviews proposed alternatives to MELD, and examines the specific implications of these changes and alternatives for ACLF. Alternatives to the MELD score have been proposed and studied, however MELD score remains as the current system used for allocation. This underscores the limitations of the MELD score and raises the question of whether MELD is the most accurate, objective allocation system. Acute-on-chronic liver failure (ACLF) is a subset of liver failure where prevalence is rising and has been shown to have an increased mortality rate and need for transplantation that is under-demonstrated by the MELD score. However, geographic differences in median MELD at time of transplant remain as well as limits to the MELD score for allocation, as etiology of liver disease and need for transplant changes. These changes include the creation and adoption of the MELD-Na score for allocation, Regional Share 15, Regional Share for Status 1, Regional Share 35/National Share 15, and, most recently, the Acuity Circles Distribution Model. Since the adoption of the model for end-stage liver disease (MELD) score for organ allocation in 2002, numerous changes to the system of liver allocation and distribution have been made with the goal of decreasing waitlist mortality and minimizing geographic variability in median MELD score at time of transplant without worsening post-transplant outcomes.
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