Reassessing the survival benefit of deceased donor liver transplantation – retrospective cohort study

Currently in the United States, deceased donor liver transplant (DDLT) allocation priority is based on the Model for End-Stage Liver Disease including sodium (MELD-Na) score. The United Network for Organ Sharing's "Share-15" policy states that candidates with MELD-Na scores of 15 or greater have priority to receive local organ offers compared to candidates with lower MELD-Na scores. Since the inception of this policy, major changes in the primary etiologies of end-stage liver disease have occurred and previous assumptions need to be recalibrated.We retrospectively analyzed the Scientific Registry of Transplant Recipients database between 2012 and 2021 to determine life years saved by DDLT at each interval of MELD-Na score and the time-to-equal risk and time-to-equal survival versus remaining on the waitlist. We stratified our analysis by MELD exception points, primary disease etiology, and MELD score.On aggregate, compared to remaining on the waitlist, a significant one-year survival advantage of DDLT at MELD-Na scores as low as 12 was found. The median life-years saved at this score after liver transplant was estimated to be greater than 9 years. While the total life years saved were comparable across all MELD-Na scores, the time-to-equal risk and time-to-equal survival decreased exponentially as MELD-Na scores increased.Herein we challenge the perception as to the timing of DDLT and when that benefit occurs. National liver allocation policy is transitioning to a continuous distribution framework and these data will be instrumental to defining the attributes of the continuos allocation score.