Brazilian doctors request revision of criteria for liver transplant

Patients in critical condition who have undergone several blood transfusions or previous transplants have a high risk of complications and should not be eligible for transplantation, affirms a study published in Liver Transplantation.

By Karina Toledo

Agência FAPESP – Based on the study published in the June edition of Liver Transplantation, researchers from the Universidade de São Paulo Medical School (FMUSP) have proposed alterations to the national guidelines for liver transplants.

According to Luiz Augusto Carneiro D’Albuquerque, director of the Division of Digestive System Organ Transplants at FMUSP’s Hospital das Clínicas and one of the authors of the article, the results of the study indicate that gravely ill patients who should not be eligible for treatment owing to a high risk of death or other complications are undergoing transplant operations in Brazil.

At the same time, candidates with better chances of survival are dying on the waiting list. Until 2006, explains Carneiro, Brazilian legislation focused on chronological criteria for the distribution of organs, or rather, older people were given priority in the line. In 2007, in the case of livers, the country adopted a system that is used worldwide, known as the Model for End-Stage Liver Disease (MELD). MELD is a mathematical formula that takes into account the results of exams and other patient indicators, allowing doctors to estimate the risk of death if a transplant does not occur in the next three months. The higher the rating is, the greater the priority.

“In Scandinavian countries, for example, transplants are given to patients with an average MELD of 20 to 22. In the United States, the average varies from 20 to 28, and when it passes 36, they believe that is too late to operate,” explained Carneiro.

The average score for transplant patients at HC – the country’s leading facility for such operations – is 34. According to Carneiro, there are frequently cases of patients in Brazil who receive operations with MELD scores of over 40.

“This has a negative impact on the utilization of the organs because there are high retransplantation and mortality rates. We lose approximately 20% to 25% of sick patients after a year, while this rate in Scandinavia is just 8%. Their health system as a whole works better, so patients arrive at the transplant center in better shape,” explained Carneiro.

To evaluate the impact of adopting MELD on the site survival and infection (SSI) rates in Brazil, the researchers analyzed data from 543 patients operated on at HC from 2002 to 2011 – totaling 597 surgeries as a result of retransplants.

According to the results, the use of the MELD score modified the incidence and epidemiology of SSI during the first year of use – the average infection rate in 2002-2006 was 30% compared to 24% in 2007-2011.

“We concluded that the adoption of MELD caused an increase in mortality. The patient profile with complications before 2007 is the same profile of those with complications today. However, we managed to establish some SSI risk factors,” explained Carneiro.

Although the number of patients studied is still not sufficient to establish a cutoff for transplantation, Carneiro believes that patients in a critical condition will not benefit from treatment. The study showed that those at a higher risk of developing SSI are people who have already undergone previous transplants or several blood transfusions.

Other risk factors found, although less significant, were dependence on dialysis, cytomegalovirus infection and a cold ischemia time (the time an organ is preserved on ice) of more than 400 minutes.

Scarcity of organs

According to Carneiro, only a third of patients who need a liver can be operated on at the HC. Currently, there are 140 patients on the hospital’s waiting list. Nationwide, the number reaches 1,240, according to data from the Brazilian Association of Organ Transplants (ABTO).

“We are operating on only the most critical cases because we cannot go against the law. However, to reduce mortality, we have to better select among the ill. The results of this study can provide a basis for the State to review the organ distribution policy. The Health Ministry is expected to release a new ordinance on the topic before October, and we expect it to include these findings in the new norms,” explained Carneiro.

Some of the data were collected through a FAPESP-funded project that was coordinated by Edson Abdala, head of Infectology at the Division of Digestive System Transplants. Other authors of the article also have projects funded by FAPESP. The study was presented during the 40th Continuing Education Course on the Digestive System, Coloproctology, Organ Transplants of the Digestive System and Endoscopy held on July 1-5, 2013, at the Centro de Convenções Rebouças, in São Paulo.

The article “Surgical site infection in liver transplant recipients in the MELD era: Analysis of the epidemiology, risk factors, and outcomes” (doi: 10.1002/lt.23682) can be read at onlinelibrary.wiley.com/doi/10.1002/lt.23682/abstract;jsessionid=7FC41F0EC99BD7F0849018D9767932BD.d01t04.