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,\r\nsupported by D-MELD (donor age × biochemical MELD), could offer\r\na new therapeutic strategy with effects on survival. As yet, an\r\nextensive stratification of cases according to the futile transplant\r\nprinciple using a continous quantitative parameter has not been\r\nperformed.\r\nTo stratify the prognosis according to donor-recipient match and\r\nassess the predictive role of D-MELD together with covariates, a\r\ndatabase detailing 5946 liver transplants performed in 21 Italian\r\nCenters (2002–2009) was analyzed. Primary endpoint was to\r\nevaluate the prognostic power of D-MELD and covariates in terms of\r\n3-year patient survival. The futile-transplant cutoff (life-expectancy\r\n<50% at 5 years) was investigated. The database was divided into\r\na training and a validation set. The adequacy of fit for both sets\r\nwas tested using Hosmer-Lemeshow and C-statistics. Cases were\r\nstratified in ten D-MELD deciles.\r\nSignificant differences among D-MELD deciles allowed regrouping\r\nthem in three D-MELD classes (A <338, B 338–1628, C >1628).\r\nD-MELD classes were used for regression analyses. At 3 years, the\r\nodds ratio (OR) for death is 2.03 (95% CI 1.44–2.85) in D-MELD\r\nclass C versus class B (reference). The OR is 0.40 (95% CI 0.24–\r\n0.66) in D-MELD class A versus class B. Other significant covariates\r\nwere HCV status (OR = 1.42; 95% CI 1.11–1.81), HBV status (OR = 0.69;\r\n95% CI 0.51–0.93), re-transplant status (OR = 1.82; 95% CI 1.16–\r\n2.67) and low-volume transplant Center (OR = 1.48; 95% CI 1.11–\r\n1.99). Results were confirmed by Cox regressions. The “futilematch\r\ncutoff” was identified only in HCV patients (D-MELD=1750,\r\np < 0.001).Assuming the same high D-MELD value, an organ from an elderly\r\ndonor is likely to fail in an old recipient or in an HCV recipient\r\nbut not in an HBV recipient. The identification of predictive factors\r\n(D-MELD class and covariates) and the introduction of the futile\r\ncutoff may lead to formulate new organ-allocation policies. The\r\nfutile matches should be proibited by national allocation rules.\r\nFatal allocation of high-risk organs to high-risk patients should\r\nbe avoided. Organs from young donors should not be allocated to\r\nrecipients with a low biochemical MELD without additional risk\r\nfactors.