Impact of the new MELD-based allocation system on waiting list and post-transplant survival-a cohort analysis using the French national CRISTAL database

Concerns related to equity and efficacy of our previous center-based allocation system have led us to introduce a patient-based allocation system called the "Liver Score" that incorporates the model for end-stage liver disease (MELD) score. The main objective of this study was to compare waitlist and post-transplant survivals before and after implementation of the "Liver Score" using the French transplant registry (period before: 2004-2006 and period after: 2007-2012). Patients transplanted during the second period were sicker and had a higher MELD. One-year waitlist survival (74% vs. 76%; P = 0.8) and 1-year post-transplant survival (86.3% vs. 85.7%; P = 0.5) were similar between the 2 periods. Cirrhotic recipients with MELD >= 35 had lower 1-year post-transplant survival compared to those with MELD <35 (74.8% vs. 86.3%; P < 0.01), mainly explained by their higher intubation and renal failure rates. The MELD showed a poor discriminative capacity. In cirrhotic recipients with MELD >= 35, patients presenting 2 or 3 risk factors (dialysis, intubation, or infection) had a lower 1-year survival compared to those with none of these risk factors (61.2% vs. 92%; P < 0.01). The implementation of the MELD-based allocation system has led to transplant sicker patients with no impact on waitlist and post-transplant survivals. Nevertheless, selection of patients with MELD >= 35 should be completed to allow safe transplantation.