Optimization of Donor-Recipient match and identification of the futile match cutoff. A national italian study on liver transplantation.

Intentional matching of liver transplant donor-recipient risk factors, supported by D-MELD (donor age × biochemical MELD), could offer a new therapeutic strategy with effects on survival. As yet, an extensive stratification of cases according to the futile transplant principle using a continous quantitative parameter has not been performed. To stratify the prognosis according to donor-recipient match and assess the predictive role of D-MELD together with covariates, a database detailing 5946 liver transplants performed in 21 Italian Centers (2002–2009) was analyzed. Primary endpoint was to evaluate the prognostic power of D-MELD and covariates in terms of 3-year patient survival. The futile-transplant cutoff (life-expectancy <50% at 5 years) was investigated. The database was divided into a training and a validation set. The adequacy of fit for both sets was tested using Hosmer-Lemeshow and C-statistics. Cases were stratified in ten D-MELD deciles. Significant differences among D-MELD deciles allowed regrouping them in three D-MELD classes (A <338, B 338–1628, C >1628). D-MELD classes were used for regression analyses. At 3 years, the odds ratio (OR) for death is 2.03 (95% CI 1.44–2.85) in D-MELD class C versus class B (reference). The OR is 0.40 (95% CI 0.24– 0.66) in D-MELD class A versus class B. Other significant covariates were HCV status (OR = 1.42; 95% CI 1.11–1.81), HBV status (OR = 0.69; 95% CI 0.51–0.93), re-transplant status (OR = 1.82; 95% CI 1.16– 2.67) and low-volume transplant Center (OR = 1.48; 95% CI 1.11– 1.99). Results were confirmed by Cox regressions. The “futilematch cutoff” was identified only in HCV patients (D-MELD=1750, p < 0.001).Assuming the same high D-MELD value, an organ from an elderly donor is likely to fail in an old recipient or in an HCV recipient but not in an HBV recipient. The identification of predictive factors (D-MELD class and covariates) and the introduction of the futile cutoff may lead to formulate new organ-allocation policies. The futile matches should be proibited by national allocation rules. Fatal allocation of high-risk organs to high-risk patients should be avoided. Organs from young donors should not be allocated to recipients with a low biochemical MELD without additional risk factors.