Zusammenfassung
Im Dezember 2006 wurden in Deutschland und anderen Eurotransplant (ET)-Ländern die Vermittlungsregeln für postmortale Spenderlebern weiterentwickelt. Das zuvor von ET angewandte Allokationssystem basierte auf der Child-Turcotte-Pugh (CTP)-Klassifikation, wobei darüber hinaus der Wartezeit eine besondere Bedeutung zukam. Aktuell wurde es durch ein primär dringlichkeitsorientiertes, auf dem „model for end-stage liver disease“ (MELD) basierenden Allokationssystem ersetzt. Die MELD-Klassifikation ist – wie erste Erfahrungen in den USA gezeigt haben – in der Lage, die Prognose der Mehrzahl der Indikationen zur Lebertransplantation gut abzubilden. Durch die MELD-basierte Allokation konnten in den USA die Wartezeit der transplantierten Patienten und die Mortalität auf der Warteliste reduziert werden. Die MELD-Klassifikation wird jedoch nicht allen Lebererkrankungen gerecht. Aus diesem Grund sind in dem durch ET eingeführten Allokationssystem Ausnahmeregelungen vorgesehen. Zudem wird angestrebt, im Sinne eines lernenden Systems, durch fortlaufende Analyse der Allokation, eine kontinuierliche Feinabstimmung der Verteilungsregeln zu erzielen, um eine gerechte und effiziente Verteilung der Spenderorgane zu gewährleisten.
Abstract
In December 2006 the allocation of livers from deceased donors in Germany and several other Eurotransplant countries was reset. The previous allocation system relied on CTP score to assess the need of transplantation, but it also assigned to waiting time a prominent role in prioritization. That system was replaced by the primarily urgency-oriented model of end-stage liver disease (MELD) allocation system. First experience with this classification in the U.S.A. shows that MELD scores are able to identify the urgency of liver transplantation correctly in most types of liver disease. Due to the MELD-based allocation, the growing waiting time and waiting-list mortality could be counteracted. At the same time it became evident however that MELD scores do not reflect mortality on the waiting list or thus the urgency for all types of liver diseases. Therefore the new allocation system introduced in the Eurotransplant countries contains standardized and flexible exceptions for these diseases. In addition the new allocation rules were created as a learning system. Repeated “fine tuning” of the allocation process based on continuous monitoring of daily allocation practice and clinical studies aim at just and effective distribution of the precious and limited supply of donor organs.
Abbreviations
- ACO:
-
Approved combined organ
- CTP:
-
Child-Turcotte-Pugh-Klassifikation
- ELAC:
-
Eurotransplant Liver Advisory Committee
- ET:
-
Eurotransplant
- ELAS:
-
Eurotransplant Liver Allocations System
- HU:
-
High urgency
- INR:
-
International standardized ratio
- LTX:
-
Lebertransplantation
- MELD:
-
Model for end-stage liver disease
- SE:
-
Standard exceptions
- UNOS:
-
United Network for Organ Sharing
Literatur
Austin MT, Poulose BK, Ray WA et al. (2007) Model for end-stage liver disease: did the new liver allocation policy affect waiting list mortality? Arch Surg 142: 1079–1085
Biggins SW, Bambha K (2006) MELD-based liver allocation: who is underserved? Semin Liver Dis 26: 211–220
Cholongitas E, Shusang V, Marelli L et al. (2007) Review article: renal function assessment in cirrhosis – difficulties and alternative measurements. Aliment Pharmacol Ther 26: 969–978
Cholongitas E, Marelli L, Shusang V et al. (2006) A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplantation. Liver Transplantation 12:1049–1061
Freeman RB, Wiesner RH, Edwards E et al. United Network for Organ Sharing Organ Procurement and Transplantation Network Liver and Transplantation Committee (2004) Results of the first year of the liver allocation plan. Liver Transpl 10: 7–15
Freeman RB, Harper A, Edwards EB (2005) Excellent liver transplant survival rates under the MELD/PELD system. Transplant Proc 37: 585–588
Heumann D, Mihas A (2003) Utility of the MELD score for assessing 3-month survival in patients with liver cirrhosis: One more positive answer. Gastroenterology 125: 992–993
Huo TI, Wu JC, Lin HC et al. (2005) Evaluation of the increase in model for end-stage liver disease (Delta MELD) score over time as a prognostic predictor in patients with advanced cirrhosis: risk factor analysis and comparison with initial MELD and Child-Turcotte-Pugh score. J Hepatol 42: 826–832
Renz JF, Kin C, Kinkhabwala M et al. (2005) Utilization of extended donor criteria liver allografts maximizes donor use and patient access to liver transplantation. Ann Surg 242: 556–565
Kamath PS, Wiesner RH, Malinchoc M et al. (2001) A model to predict survival in patients with end-stage liver disease. Hepatology 33: 464–470
Lopez PM, Martin P (2006) Update on liver transplantation: indications, organ allocation, and long-term care. Mt Sinai J Med 73: 1056–1066
Malinchoc M, Kamath PS, Gordon FD et al. (2000) A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 31: 864–871
Austin MT, Poulose MK, Ray WA et al. (2007) Model for end-stage liver disease. Arch Surg 142: 1079–1085
Lopez PM, Martin P (2006) Update on liver transplantation. Mt Sinai J Med 73: 1056–1066
Pugh R, Murray-Lyon I, Dawson J (1973) Transsection of the oesophagus for bleding oesophageal varices. Br J Surg 60: 646–649
Brown RS Jr, Russo MW, Lai M et al. (2003) A survey of liver transplantation from living adult donors in the United States. New England J Med 348: 818–825
Trotter JF, Brimhall B, Arjal R, Phillips C (2004) Specific laboratory methodologies achieve higher model for endstage liver disease (MELD) scores for patients listed for liver transplantation. Liver Transpl 10: 995–1000
Trotter JF, Olson J, Lefkowitz J et al. (2007) Changes in international normalized ratio (INR) and model for endstage liver disease (MELD) based on selection of clinical laboratory. AM J Transplant 7: 1624–1628
Wiesner RH, McDiarmid SV, Kamath PS et al. (2001) MELD and PELD: application of survival models to liver allocation. Liver Transpl 7: 567–580
Wiesner R, Edwards E, Kamath P (2001) Mayo end-stage liver disease model (MELD) score predicts liver transplant waiting list mortality: Implications for liver allocation policy. Transplantation [Suppl 1] 71: 461
Wiesner R, Edwards E, Freeman R et al. (2003) Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology 124: 91–96
Verdonk RC, Berg AP van den, Slooff MJ et al. (2007) Liver transplantation: an update. Neth J Med 65: 372–380
Interessenkonflikt
Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Jung, G., Encke, J., Schmidt, J. et al. Model for end-stage liver disease. Chirurg 79, 157–163 (2008). https://doi.org/10.1007/s00104-008-1463-4
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00104-008-1463-4