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Day 1: MELD 15 hasn't become magic number

| Sunday, March 9, 2008

The nation's liver allocation system had to be fixed.

Far too many livers were being taken to transplant centers that were using them on patients on the lower end of the wait list. Sicker patients in the same region of the country never had a chance of getting them.

From 2002 through 2004, one in 10 liver transplants in the United States was done in a patient with a MELD score lower than 15. The University of Pittsburgh Medical Center led the nation in doing those surgeries with 38 percent of all livers going to patients who weren't critically ill.

The MELD -- Model End-stage Liver Disease -- ranking is based on three blood tests that predict a patient's need for a new liver within three months.

With a limited supply of organs, and with knowledge that most patients with MELD scores lower than 15 are better off waiting for a transplant until they are sicker, the federal government sought to create a broader sharing scheme.

Instead of organs being shared solely in descending order by the MELD scale, the so-called Share 15 policy, first used in 2005, says that those with a score of 15 or higher get first crack at the liver. First chance at the liver is within the transplant center's local area. If no one takes it there, the liver is offered within a wider regional area that can include several neighboring states.

People with lower scores are considered only when doctors for all higher-scoring patients in the region have passed on the organ.

"It was a way to show that with a score less than 15, you didn't get any benefits from transplantation," said Dr. John Fung, chairman of surgery at The Cleveland Clinic and former chief at UPMC.

The Share 15 plan worked - to a certain degree. From 2005 through 2007, the number of transplants nationwide on patients with MELD scores below 15 dropped to 846 from 1,627 in the previous three years. The Trib's analysis of low-MELD patients includes those who received extra points for illnesses that do not show up in the MELD tests, such as cancer.

Several centers, most notably UPMC and three others, continue to do those surgeries.

"It's irresponsible to list patients and not give them a chance," said Dr. Amadeo Marcos, UPMC's chief of transplantation until his resignation last week.

Federal officials are pleased with Share 15, saying it has resulted in a "considerable decrease" overall of low-MELD liver transplants.

Dr. James Burdick, director of the division of transplantation at the U.S. Health Resources and Services Administration, said the agency has no plans to stop or discourage programs from routinely doing transplants on patients with scores lower than 15.

"An important principle is to allow some physician-patient judgment for specific cases," Burdick wrote in an e-mail.

Marcos said the patients with lower MELD scores who get transplants are often people who are sicker than their scores would indicate.

"We are absolutely in the mainstream of what centers are doing," Marcos said.

"Now, still, you have to leave some room for that patient-doctor decision of when it's best to help them."

He said patients go to UPMC not because they do low-MELD transplants but because they have good outcomes. At UPMC, 84 percent of all patients were alive one year after transplant.

"We cannot expect all transplant surgeons to have the same philosophy, but they are doing, to the best of their knowledge, what helps patients," Marcos said.

"And that's the bottom line."

Luis Fábregas can be reached at lfabregas@tribweb.com or 412-320-7998. Andrew Conte can be reached at andrewconte@tribweb.com or 412-320-7835.

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About the data
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