![]() However, a-fetoprotein levels may have some prognostic value in the context of longitudinal changes (eg, doubling of levels among patients listed or being considered for liver transplant). Currently, there are no specific cutoffs for a-fetoprotein, and, in my opinion, a single value may not be very important. The current guidelines from the American Association for the Study of Liver Diseases do not recommend the use of a-fetoprotein for screening, but this test likely does have some prognostic value in patients who have confirmed HCC. RW The role of a-fetoprotein in patients with HCC is controversial because the prognostic value of this laboratory test is still not completely known. H&O Does a patient’s α-fetoprotein level justify a change in MELD score? Given this imbalance, allocation policies may be revisited to try to better equalize distribution of organs, but regardless of which policies are used, some groups will benefit more than others. Thus, there is an imbalance between the number of patients who need a transplant and the number of organs available to be transplanted. The issue of prioritization is very tricky because a limited number of organs are available, the number of donor organs is not expected to increase significantly in the near term, and the number of patients being listed may be increasing. Current modifications to the MELD exception policy for HCC attempt to address this issue, and future studies will need to evaluate the impact of these changes on liver transplant waitlist outcomes among patients with and without HCC in the United States. When MELD exception points were first granted to patients with HCC, several studies showed that these patients were overprioritized, meaning that they had much lower waitlist mortality compared with patients with decompensated liver disease. ![]() RW I think that the answer to this question cannot be determined yet. H&O Do you think that patients with HCC are still overprioritized, or are they underprioritized now? The impact of this revision on waitlist outcomes among patients with and without HCC remains to be seen. Therefore, in 2015, the MELD exception policy for HCC was modified to include a 6-month waiting period prior to receiving MELD exception points. However, many studies have suggested that patients with HCC are overprioritized with the MELD exception policy. To improve prognostication, MELD exception points are given, which increases the chances of receiving a liver transplant. For conditions such as HCC, the biological MELD score may not accurately capture the patient’s mortality risk given that the degree of hepatic dysfunction may not be very severe even though HCC increases near-term mortality. The concept of the MELD exception point system is to better capture an individual’s mortality risk. RW Patients who meet certain criteria, such as having hepatocellular carcinoma (HCC), are given MELD exception points (ie, extra points) to increase their priority for receiving a liver transplant. H&O Within the current allocation system, how does hepatocellular carcinoma factor into the MELD score? The Share 35 policy expands the geographic area of organ sharing for patients with MELD scores of 35 or greater before organs are offered to patients with lower MELD scores. Recent changes to the allocation system have attempted to allow broader access to liver transplantation among those with the highest MELD scores. ![]() The algorithm for organ distribution is complex, but the concept is that organs that become available are generally offered to patients within the same region as the donor, starting with the most urgent patients first. All revisions of the MELD score aim to improve the accuracy of determining prognosis and, thus, priority for liver transplantation. The MELD score is calculated from a patient’s serum bilirubin level, international normalized ratio, and serum creatinine level, whereas the MELD-Na score is a recently adopted, modified MELD score that incorporates serum sodium. This allocation system uses objective measures based upon laboratory tests (ie, MELD and MELD-Na scores) to determine the severity of liver disease. The overarching goal is to provide liver transplants first to the sickest patients, who are the ones in greatest need. RW The current allocation system for patients with chronic liver disease is based upon patients’ Model for End-Stage Liver Disease (MELD) score and allocates organs across 11 geographic regions in the United States. H&O How are donor livers currently allocated to patients in need of a transplant? Clinical Advances in Hematology & Oncologyĭivision of Gastroenterology and Hepatology ![]()
0 Comments
Leave a Reply. |
Details
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |