All analyses were performed using R statistical package, version 4.2.0, for macOS ( ), and statistical significance was set at P < 0.05.Īs shown in Supplementary Table 1, among the 2,353 eligible patients, 1,441 (60.0%) and 942 (40.0%) were waitlisted for LT before (2005.06–2016.05) and after MELD scoring was implemented (2016.06–2021.12). The results from the formula was divided by the number of total 90-day mortality was regarded as reducible wait-list mortality by MELD3.0. First, the possible increased number of LT was calculated with following formula: ∑, the sum of multiplying the difference of DDLT likelihood between different MELD3.0 strata, within the same MELD strata (P B – P A), and the number of deceased patients up-categorized by MELD3.0 (N B-A). 2 using a sub-cohort of patients who were wait-listed during post-MELD era and did not received LDLT within 90 days. To estimate the possible impact of MELD3.0 on the waitlist, we calculated reducible waitlist mortality by the method previously suggested by Kim et al. The mean gain of points by using MELD3.0 was compared with the Student’s t-test. 13 In addition, predictive powers for 90-day mortality of MELD and MELD3.0 were evaluated with calibration plots, which were constructed by smoothing curves from the observed and predicted risk of deaths per decile. Model performance for mortality was compared between MELD and MELD3.0 by calculating Harrel’s C index with a test of statistical difference. Mortality during the 90 days after waitlisting was evaluated using a Kaplan–Meier curve with the log-rank test, stratified by the MELD and MELD3.0 groups. 12 Finally, 2,353 eligible patients were included in the analysis ( Supplementary Fig. Although patients with hepatocellular carcinoma (HCC) fulfilling the Milan criteria received additional MELD points (+4 for MELD ≤ 13, +5 for MELD 14–20, and being assigned 25 points for MELD 21–25) after the MELD era, we did not exclude these patients because additional MELD points might not considerably affect the rate of DDLT in Korea, where patients with MELD < 25 had a very low possibility of DDLT. Exclusion criteria were as follows: 1) age < 18 years at the first waitlisting, 2) prior organ transplantation history or waitlisting for LT, 3) listed for multiorgan transplantation other than liver and kidney, and 4) missing data. The patient list, demographics, and date of death or LT were retrieved from Korean Network for Organ Sharing (KONOS) and merged with institutional data on laboratory results that were necessary for the calculation of MELD and MELD3.0. We performed a retrospective observational study with data from patients who were registered for the approval of LT between June 2005 and December 2021 at Severance Hospital, Korea. 11 This study thus attempted to validate the applicability of MELD3.0 to reduce LT waitlist mortality in Korea. 10 To overcome this organ shortage, living donor liver transplantation (LDLT) is predominant in Korea, with 74.4% of total liver transplantations performed with living donors in 2020. 9 As of 2020, 61% of Korean DDLTs have been performed in patients with an emergency status of 1 or MELD ≥ 38. 8 However, Korea suffers from a more severe organ shortage than Western countries, with 7.62 brain-dead liver donations per 1 million people per year. Korea applied the MELD allocation system in June 2016, which resulted in reduced waitlist mortality from 57.4 to 52.7 deaths per 100 person-years. They reviewed its applicability, but no study has assessed its accuracy across the diversity of liver transplant (LT) circumstances in various countries. 6 developed MELD3.0, which reflects the relationship between sex and the mortality of low albumin due to ascites. 5 Moreover, there is a need to consider liver failure complications such as ascites and encephalopathy, which are difficult to objectify. 4 In addition, disparities in liver allocation between sexes has been reported in several countries due to overestimated kidney function in women. 2, 3 However, the accuracy of the MELD score for predicting waitlist mortality has been questioned due to recent changes in the characteristics and improvement in treatment of end-stage liver disease. In 2016, UNOS reapplied the score, which added Na to the existing MELD as a liver allocation policy, thereby reducing waiting mortality and increasing the equity of organ use. 1 MELD has been used worldwide since it was adopted by United Network for Organ Sharing (UNOS) as an organ allocation policy in 2002. The model for end-stage liver disease (MELD) is a tool developed for organ allocation in deceased donor liver transplantation (DDLT) based on predicted mortality.
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