The MELD system and liver transplant waiting- list mortality in developing countries: lessons learned from Sao Paulo, Brazil

Objective: The MELD system has not yet been tested as an allocation tool for liver transplantation in the developing countries. In 2006, MELD (Model for End-stage Liver Disease) was launched as a new liver allocation system in Sao Paulo, Brazil. This study was designed to assess the results of the new allocation policy on waiting list mortality. Methods: The State of Sao Paulo liver transplant database was retrospectively reviewed from July 2003 through July 2009. Patients were divided into those who were transplanted before - (Pre-MELD Group) and those who were transplanted after (post-MELD Group) the implementation of the MELD system. Only adult liver transplant candidates were included. Waiting list mortality was the primary endpoint. Results: The unadjusted death rate in waiting list decreased significantly after the implementation of the MELD system (from 91.2 to 33.5/1,000 patients per year; p<0.0001). Multivariate analysis showed a significant drop in risk of waiting list death for post-MELD patients (HR 0.34; p<0.0001). Currently, 48% of patients are transplanted within 1-year of listing (versus 23% in the pre-MELD era; p<0.0001). Patient and graft survival did not change with MELD implementation. Conclusion: There was a reduction in waiting time and list mortality after implementation of the MELD system in Sao Paulo. Patients listed in the post-MELD era had a significant reduction in risk for the waiting list mortality. There were no changes in post-transplant outcomes. MELD can be successfully utilized for liver transplant allocation in developing countries.