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Are There Better Guidelines for Allocation in Liver Transplantation?: A Novel Score Targeting Justice and Utility in the Model for End-Stage Liver Disease Era

Dutkowski, Philipp MD*; Oberkofler, Christian E. MD*; Slankamenac, Ksenija MC*; Puhan, Milo A. MD; Schadde, Erik MD*; Müllhaupt, Beat MD; Geier, Andreas MD; Clavien, Pierre A. MD, PhD*

doi: 10.1097/SLA.0b013e3182365081
Original Article From the ESA Proceedings

Objectives: To design a new score on risk assessment for orthotopic liver transplantation (OLT) based on both donor and recipient parameters.

Background: The balance of waiting list mortality and posttransplant outcome remains a difficult task in the era of the model for end-stage liver disease (MELD).

Methods: Using the United Network for Organ Sharing database, a risk analysis was performed in adult recipients of OLT in the United States of America between 2002 and 2010 (n = 37,255). Living donor-, partial-, or combined-, and donation after cardiac death liver transplants were excluded. Next, a risk score was calculated (balance of risk score, BAR score) on the basis of logistic regression factors, and validated using our own OLT database (n = 233). Finally, the new score was compared with other prediction systems including donor risk index, survival outcome following liver transplantation, donor-age combined with MELD, and MELD score alone.

Results: Six strongest predictors of posttransplant survival were identified: recipient MELD score, cold ischemia time, recipient age, donor age, previous OLT, and life support dependence prior to transplant. The new balance of risk score stratified recipients best in terms of patient survival in the United Network for Organ Sharing data, as in our European population.

Conclusions: The BAR system provides a new, simple and reliable tool to detect unfavorable combinations of donor and recipient factors, and is readily available before decision making of accepting or not an organ for a specific recipient. This score may offer great potential for better justice and utility, as it revealed to be superior to recent developed other prediction scores.

A new and simple score system including donor and recipient parameters, developed in the large United Network for Organ Sharing database to predict survival in liver transplant recipients, is shown to be superior to other available prediction systems.

*Swiss HPB and Transplant Center, Department of Surgery and Transplantation;

Department of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland;

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Reprints: Pierre A. Clavien, MD, PhD, Swiss Hepato-Pancreatico-Biliary and Transplant Center, Department of Surgery, University Hospital Zurich, Rämi-strasse 100, CH-8091 Zurich, Switzerland. E-mail:

Disclosure: The authors declare that they have nothing to disclose. The data reported here have been supplied partially by the United Network for Organ Sharing as the contractor for the Organ Procurement and Transplantation network. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the Organ Procurement and Transplantation network or the US Government.

P.D. and C.E.O contributed equally.

© 2011 Lippincott Williams & Wilkins, Inc.