Dec. 16, 2020
At many medical centers, patients with end-stage liver disease who have relatively lower MELD scores are deemed noncompetitive for deceased donor liver transplant and are at risk of dying without ever receiving an organ. With nearly 13,000 patients awaiting liver transplant, there isn't capacity or organ supply, and livers are allocated to the sickest patients on the transplant list.
At Mayo Clinic in Phoenix/Scottsdale, Arizona, however, the scenario is unique: The liver transplant surgical team has implemented a comprehensive approach that allows surgeons to offer transplant more quickly at one of the lowest Model for End-Stage Liver Disease (MELD) scores nationally.
How Mayo Clinic in Arizona provides transplants for patients with lower MELD scores
Several reasons account for the ability to provide transplants more quickly to patients with lower MELD scores, notes Bashar A. Aqel, M.D., Gastroenterology and Hepatology at Mayo Clinic in Arizona, including:
- The ability to expand the donor pool while sustaining excellent outcomes
- Patients' willingness to live in or relocate to Phoenix/Scottsdale
- An experienced liver transplant surgical team with an aggressive organ procurement strategy
MELD scores may not provide the whole picture
With a 6-40 range, a patient with a 40 MELD score has only 10% odds of being alive in 90 days, making transplant more likely. "In the organ shortage setting, however, this scoring system disadvantages some patients who have severe complications impacting their quality of life, yet MELD scores too low to receive a transplant quickly," says Dr. Aqel. "They may have liver cancer, bleeding complications, fluid buildup around the lungs or abdomen, or debilitating confusion and encephalopathy."
Observing discrepancies between patients' MELD scores and functional status, the liver transplant surgical team used a unique multidisciplinary approach that allows donor pool expansion to include extended criteria donation, such as hepatitis C infection and donations after cardiac death. The expansion ensures organ allocation to the most suitable patients on the transplant list based on multiple variables. This approach has allowed significantly higher transplant rates, translating into greater chance for transplant, shorter waitlist time (three months on average) and the ability to provide transplants to needy patients with lower MELD scores.
Dr. Aqel notes patients with relatively low MELD scores are waitlisted for years at other medical centers. At Mayo Clinic in Arizona, however, the program has provided transplants for almost everyone in need.
Outcomes tell the story
Despite extended criteria, liver use and donor pool expansion offering patients with lower MELD scores opportunities ― the median at-transplant MELD score is 23 at Mayo Clinic in Arizona, one of the lowest nationally ― outcomes have been stellar, says Dr. Aqel. In the Scientific Registry of Transplant Recipients, liver transplant results for Mayo Clinic in Arizona rank No. 1; the program leads the U.S. in volumes and outcomes. Patients receive deceased donor transplants faster, one-year patient and graft survival is the highest nationwide, and risk of dying while waitlisted is one of the lowest in the country. "These outcomes are precisely what patients seek," says Dr. Aqel. The median hospital stay post-transplant is five to six days versus the transplant center national average of 10 days.
Urgency of using extended criteria organs
Dr. Aqel indicates extended criteria organs, especially for patients at high risk with lower MELD score, increase liver supply, accelerating time to transplant. He also explains how the liver transplant surgical team expedited end-stage liver disease transplants for a large health care system's patients: Despite average 20 to 25 MELD scores, patients waited two to three years for transplant at large Southwestern centers. After an agreement with Mayo Clinic in Arizona and patient relocation to Phoenix/Scottsdale, recipients at a 23 median MELD score now wait approximately three months for transplant. Less ideal liver use for transplant contributes to this reduced wait time.
Hepatitis C-positive livers exemplify extended criteria organs used for transplant at Mayo Clinic in Arizona. Dr. Aqel and the liver transplant surgical team transplant hepatitis C-positive livers ― previously not used in the absence of recipients with active hepatitis C on the transplant list ― offering therapy proved 95% effective post-transplant.
In the November 2020 issue of Journal of Hepatology, Dr. Aqel and colleagues published multicenter observational study results of liver transplant in recipients receiving grafts from HCV-seropositive donors; investigators found excellent short-term outcomes, and patients received transplants much faster compared with regional and national averages.
When to refer patients with end-stage liver disease
Generally, the liver transplant program at Mayo Clinic in Arizona encourages patients and providers to refer early for transplantation. Though MELD scores 15 and higher are reasonable to initiate referral, Dr. Aqel encourages lower MELD score referrals if patients are struggling with significant complications. The program's capability for speed and timely referral from other physicians allow transplant before patients are too ill.
"Imagine if a patient is sick in the ICU," says Dr. Aqel. "We've done those transplants, but we really want to transplant right when the patient needs it and is in shape to recover. That's why I encourage providers to refer patients early rather than late." Upon referral, relocation to Phoenix/Scottsdale, even temporarily, is key, as it enables rapid travel to the hospital when an organ is ready. Physicians also may contact Mayo Clinic in Arizona regarding dual listings.
Mayo Clinic Transplant Center performs more liver transplants than any program in the country. The three Mayo Clinic sites share similar protocols, serving patients with liver disease in three different regions across the U.S. The liver transplant program at Mayo Clinic in Jacksonville, Florida, adopted a methodology like the policy at Mayo Clinic in Arizona, using extended criteria organs and allowing lower MELD score transplants. Transplant program leaders at Mayo Clinic in Rochester, Minnesota, are pursuing living donation to broaden transplant opportunity.
Managing complications during transplant wait
During transplant waitlist time, care for patients with liver disease can be rife with complications. Adverse medication reactions, comorbidities and even accidents can make care challenging. "Patients with liver disease are complex, requiring a lot of attention and effort managing complications while awaiting transplant," says Dr. Aqel. He explains that Mayo Clinic's transplant program is available to help referring physicians with such complexities, essentially comanaging complications.
To access consult and refer a patient, contact Mayo Clinic Medical Professionals Provider Relations.
For more information
MELD score (Model For End-Stage Liver Disease) (12 and older). MDCalc.
Scientific Registry of Transplant Recipients.
Aqel B, et al. Outcomes following transplantation of HCV-seropositive livers to HCV-seronegative recipients. Journal of Hepatology. 2020. In press.