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Release Date:
07/16/2001

Explanations of Proposed Model for End Stage Liver Disease (MELD)

MEMORANDUM

To: Liver transplant candidates and their families
From: Deborah Surlas, RN, Chair, OPTN/UNOS Patient Affairs Committee
Subject: OPTN/UNOS Endorsement of MELD System
Date: July 16, 2001


OPTN/UNOS Board Endorses Further Development of Liver Urgency Scale

UNOS continuously develops new policies and refines other policies to keep up with the medical advances in transplantation and drug therapy. At its June 28-29 meeting, the OPTN/UNOS Board of Directors endorsed further development of the Model for End Stage Liver Disease (MELD) for possible implementation after the Board meeting next November. The organization has been developing the MELD/PELD (Pediatric End Stage Liver Disease) system for over a year. The new policy is expected to save lives on the liver transplant waiting list by prioritizing (ranking) patients by their short-term risk of death without a transplant.

What is the OPTN/UNOS?

The Organ Procurement and Transplantation Network (OPTN) was established by Congress to link all U.S. transplant hospitals and organ procurement organizations and ensure efficient, equitable distribution of donated organs. The U.S. Department of Health and Human Services (HHS) provides oversight of the OPTN through federal regulation and contract with the United Network for Organ Sharing (UNOS).

UNOS is a non-profit medical, scientific, and educational organization of volunteers and staff. Under the OPTN contract, UNOS maintains the nation's organ transplant waiting list. It brings together medical professionals, transplant recipients and donor families to develop organ transplantation and allocation (distribution) policies. There are patient representatives on the Board of Directors and the various committees of the OPTN/UNOS, including the Patient Affairs Committee.

Organ sharing policies constantly change to improve transplantation. Policies are made to benefit every patient equally (justice) and make the best use of limited donor organs (utility). Patients on the waiting list are treated equally regardless of ethnicity, gender, religion, socio-economic status, or history of personal behavior.

What is the current liver allocation (distribution) policy?

There are 4 categories of patients, Status 1, 2A, 2B and 3. A patient's status category is determined by a point system, using objective and subjective factors. Status 1 patients are the most critical. They have fulminant (sudden) liver failure, or their newly transplanted liver did not function. They have a life expectancy of less than 7 days without a liver transplant. This category will remain in place and not be affected by the new system.

Status 2A patients are those who typically have chronic liver disease and are in the hospital's critical care unit with a life expectancy of less than 7 days without a liver transplant, as determined by objective and subjective medical criteria. Status 2B patients typically have chronic liver disease and are becoming more urgently in need of a transplant, but do not meet the criteria for Status 2A.

Status 3 patients also have chronic liver disease and are under continuous medical care, but are not in the hospital, except for possible short stays. These patients do not meet the criteria for Status 2B.

What is the MELD scoring system?

It is a means of giving adult liver candidates a ‘score' (number) based on how urgently they need a liver transplant within the next 3 months. The number is calculated by a formula using routine lab test results that are standardized at all hospitals. This is a much more precise method of ranking patients so that those most in need will be given the highest priority for donated livers, rather than simply allocating them to patients who have waited longer but who may be much more stable. The MELD policy will replace Status 2A, 2B and 3 with a continuous scale.

How will the MELD policy improve on the current policy?

The MELD system, which is based on numerous studies of medical data, is expected to save lives on the waiting list by more accurately determining who is in greatest need of a liver transplant within the next 3 months and giving those patients the highest priority. The MELD system is also based on objective (non-biased) medical criteria.

Who reviewed and approved the MELD system?

Proposals detailing the MELD system have twice been sent out to the general public for their comments. More than a dozen public meetings have been held at which panels of experts debated and refined the system. The various committees of the OPTN/UNOS, including the Patients Affairs and Minority Affairs Committees have given their input and endorsement. The Board of Directors of the OPTN/UNOS, which includes patients, donors, and their families, gives the final approval, subject to oversight by the Department of Health and Human Services.

How will the MELD scoring system help me?

Studies of systems that rank patients by priority, such as the MELD scoring system have suggested that a change to the MELD system will most likely reduce deaths on the liver waiting list. Instead of the current system that ‘lumps' patients together in one of only 3 groups (Status 2A, 2B or 3), the MELD system will give you your own individual urgency status. By going to a more continuous scale, the system will more accurately indicate which patients are most in need. As you become in greater need of a transplant, your MELD score will increase, and you will move up in the ranking, thus receiving greater priority for organ offers.

What will my MELD score be?

Your individual MELD scores will be calculated by inserting your individual lab test results into a formula. As your lab results change, so will your MELD score. Your MELD score can go up and down as you wait for a transplant. As your MELD score increases, these lab tests will be done more frequently. The MELD score can range from 10 (less ill) to 40 (gravely ill).

How will waiting time affect the MELD system?

The MELD system puts emphasis on your need of a liver transplant in the next 3 months. Waiting time will be used as a tiebreaker if two patients with the same MELD score are offered an organ. Under the current system, waiting time is a principal factor in determining who is offered a donated liver. The Institute of Medicine has reported that waiting time is a poor indicator of how urgently a patient needs a liver transplant.

What if I am already on the waiting list?

You will be ‘grand fathered' into the MELD system. You will be given credit for the time you have already been on the list. You will then continue to be ranked according to the severity of your illness, your MELD score.

What about pediatric patients?

Candidates under the age of 18 will be ranked according to the Pediatric End Stage Liver Disease (PELD) scoring system. This system is similar to the MELD, but recognizes the specific needs of children. Pediatric Status 1 will remain in place. Status 2B and 3 will be replaced with the PELD policy. (There is no Status 2A for pediatric patients.)

When will the MELD system go into effect?

The system and computer programming are still being refined. The new system is expected to take effect after final approval at the November 2001 OPTN/UNOS Board of Directors meeting.

What if I have more questions?

If you have any questions or concerns, you should contact your transplant team for further information. You can also visit http://www.unos.org/, http://www.patients.unos.org/, or http://www.optn.org/ on the web.

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