In the US, the MELD model gives exception points of 22 to HCC cases within Milan. This escalates every 3 months as long as pt has remained within Milan i.e. 25, 28 etc.... The Non-HCC case does not have the advantage of this same escalation. The system is working for the HCC patient but perhaps not for the non-HCC patient. Can we devise a system that works equally well for Non-HCC patient without significantly lowering the success chances for the HCC patients?
Very difficult unless the donor pool is expanded. Nevertheless, the advantage of HCC seems that they have more MELD points with otherwise more liver reserve. For a non-HCC to reach same score means their disease is more advanced and probably decompensated with ascites
Or EVs. An option would be to give more points to patients with recurrent acute esophageal bleeding or refractory ascites. These have an impact on mortality and are not considered in the MELD calculation. But again, for that you need more livers.
thank-you for your response and I agree with your reasoning. What if when Non-HCC patient gets to a immediate life threatening MELD for two consecutive weeks i.e. 28(not transient). They begin to automatically move up every 3 months as does the HCC patient until they get to MELD 40.
This topic was the subject of a presentation by Julie Heimbach of the Mayo Clinic at the WTC meeting in San Francisco this last week. One allocation proposal that has been suggested is for the HCC patients not to accrue additional MELD points for the first 6 months that they are listed. However it does appear that the whole issue of redistricting is going to be addressed first.
This is because 90% HCC cases are already cirrhotic and HCC further push them towards early transplant which is not the case with non HCC cases who may or may not be cirrhotics. Also donor pool is important. Escalation of points may be given wider interval while for non HCC cases apart from MELD score other factors like resistant ascites, recurrent GI bleed or encephalopathy, inserted TIPSS may be given priority for transplant
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