Access to Deceased Donor Liver Grafts in Argentina
Nicolás Goldaracena, MD; Lucas McCormack, MD
Liver Surgery and Transplantation Unit, Hospital Alemán of Buenos Aires, Buenos Aires,
Argentina
Short title: Organ allocation in Argentina
Correspondence:
Professor Lucas McCormack, MD.
Chief of Liver Surgery and Transplantation Unit at Hospital Alemán of Buenos Aires.
Av. Pueyrredón 1640. (1118AAT) Ciudad Autónoma de Buenos Aires, Argentina
Phone: +54 11 4827 7000, Fax: +54 11 4827 7014
Email: lmccormack@hospitalaleman.com
Abstract
Liver transplantation (LT) is a successful and well-established therapy for patients
with end-stage liver disease. The scarcity of organs for LT is the most important factor
leading to deaths of patients on waiting lists worldwide. Therefore, the equitable allocation
of donor organs to patients on the waiting list is crucial.
Liver allocation policy in Argentina was initially based on a patient’s location of
care and time on the waiting list. In July 2005, Argentina was the first country after US to
adopt the MELD system for LT. Implementation of the MELD scoring system improved
organ allocation but, unfortunately, this new policy led to a significant increase in waiting
list mortality compared with the pre-MELD era. Using the MELD system, patients with
low MELD scores had the lowest probability to be transplanted, yet those with T2 stage
HCC excessively benefited. Socio-economical factors and differences in the US and
Argentina´s health systems may explain why patient survival on the Argentinean waiting
list was adversely affected. An analysis of specific variables including cultural, logistic and
socio-economical factors would help in optimizing the principles of justice and equity in
each country adopting this objective but not perfect the allocation system.
Introduction
Liver Transplant (LT) is a successful and well-established therapy for patients with
end-stage liver disease. Unfortunately, the scarcity of organs for LT is the most important
factor leading to deaths of patients on waiting lists worldwide (1). If a shortage of liver
grafts did not exist, organ allocation would be much less of a problem. In this complex
scenario, equitable allocation of donor organs to patients on the waiting list (WL) is crucial.
Clearly, any effort to optimize organ allocation should be accompanied by similar efforts to
increase the number of organ donors (2-4).
In Argentina, the first liver transplant was performed by a group led by Eduardo de
Santibañes in January 1988. Initially, as in most countries, liver allocation policy was based
on patient’s location of care and time on the waiting list. In July 2005, Argentina was the
first country that followed the US in adopting the MELD score to guide allocation for
patients requiring LT. The MELD score replaced the subjective criteria previouslyt used to
rule the selection of LT candidates in our country. In this review, different allocation
systems used worldwide are described. The regional approach to allocation of donor livers
in the South American region is also described and finally, we specially analyze how the
access to deceased donor organs in Argentina was influenced bythe MELD allocation
system in our country.
What allocation systems have been used?
The ideal allocation system is based on equity and justice with objective parameters
and transparency (5). Since early stages of LT, many allocation policies have been used
worldwide. While most allocate liver organs based on patient´s location of care and time
on the waiting list, others base allocation on more subjective systems where LT centres
became aware of potential donors, decide whether to accept the donation, and chose which
candidate should receive the graft without considering other centres patient´s (3). The latter
liver allocation system allows the transplant centre to assign the donated liver graft to any
waiting candidate on their list while, in other systems, individual grafts are offered to
individual patients. Therefore, organ allocation policies could be categorized mainly in
centre-based systems and patient-based system.
In centre-based systems, liver organs are offered to centres using different policies
(i.e. rotational centres, previous transplant activity, etc) and the centre finally decides what
patient on their waiting list will receive the organ. An example of a centre-based system
was the organ allocation policy utilized in the United Kingdom (UK) where allocation was
based on each centre receiving a portion of the nation’s donor pool. Allocation was based
upon the center’s previous transplant activity. Organ allocation to individual patients
remained at the centre’s discretion. Currently minimal listing criteria are utilized internally
by different UK programmes as tools to help decide which patient receivesan organ (3).
Overriding this centre-based allocation in the UK is a national super urgent scheme with
specified criteria. In this system time on the super urgent list influences allocation. This
centre-based organ allocation system has been used in many countries such as UK,
Switzerland, Spain, Portugal, Norway and Sweden among others (6).
At present, there is a common belief that liver allocation policies should use
objective medical criteria based on the severity of liver disease to prioritize waiting
candidates. Objective criteria are required to ensure equity and justice in organ allocation.
Consequently, the Model for End-Stage Liver Disease (MELD) system was introduced as a
tool for allocation. The MELD score aims to stratify recipients by their disease severity.
This estimates the 3-month probability of death on the WL.
This system is an objective score based on pre-transplant laboratory data that
include: serum creatinine level, total bilirubin level and international normalized ratio
(INR). The MELD-based allocation policy was designed prospectively using validated
predictive models and employing a continuous scale in contrast to the previous subjective
systems (7-9). The MELD is an example of a patient-based system, where the centre is
obligated to consider an organ for a single patient and if the centre declinesthe offer, the
organ is offered to the next available patient in the WL regardless of the centre they belong
to.
Several criticisms have been raised against the MELD allocation system. Some
patients are quite ill despite a low MELD score. Furthermore serious conditions such as
intractable pruritus, encephalopathy, refractory ascites or recurrent bacterial cholangitis
have no influence on allocation(10). Some investigators have suggested that low serum Na
in patients with refractory ascites or hepatorenal syndrome should be included in the
MELD score to better assess transplant need (11, 12). The reliability of the MELD score is
further affected by variability between laboratory methods in determination of the INR and
patients requiring anticoagulants. The latter will increase the MELD score ad overestimate
the severity of liver disease (13). The MELD score proved to be a robust marker of early
mortality across a wide spectrum of causes of cirrhosis. However, the severity of illness in
patients with cholestatic diseases such as primary and secondary biliary cirrhosis is often
underestimated. Finally, although the implementation of the MELD-based allocation
system for liver transplantation has reduced mortality on the WL in US, this has not been
validated in other countries so far (14).
How is the regional situation of Latin America? The transplantation activity in
Argentina
Many issues have been clearly documented in the transplantation laws of most
South-American countries. These include issues such as brain death diagnosis criteria, the
type of consent for retrieval, the concept of altruistic living related donation, restrictions for
living unrelated donation, medical criteria for allocation and a clear prohibition of organ
commercialization. In Argentina, the presumed consent for retrieval was initiated in 2006
but donor relatives are consulted systematically before donation proceeds. Unfortunately,
family refusal is the most important limitation for cadaveric donation in our country
reaching 51% of all potential donors in the period 2009-2010 (15).
The organ donation rate in Latin America had a continuous increment throughout
the last decade reaching a rate of 7.1 per million population (PMP) in 2010 (Figure 1) (15).
Argentina had a donation rate that stayed above the average in Latin America throughout
most of the decade. In 2010, the organ donation rates had a large variation among countries
(Figure 2). The rates were fromPuerto Rico (25.9 PMP), Uruguay (15.2 PMP) and
Argentina (14.5 PMP).
The number of LT performed in Latin America has grown constantly over the last
decade (Figure 3) (15). In Argentina, the total number of patients on the waiting list and the
number of LT performed increased so that 626 patients were on the national waiting list
and 276 cadaveric donor LT were performed during 2010 (Figure 4) (15). The transplant
activity related to live donation LT was stable for pediatric recipients (around 10% of all
LT). But the number of adult living donor recipients has dropped dramatically and
currently is only performed sporadically in Argentina (i.e. only 6 adults patients were
transplanted using live donors in 2010). A recent analysis of MELD scoring in Argentina
showed that the overall access of non emergent adult candidates to cadaveric LT was 41%
and less than 1% to live donor LT. In the last two years, the gap between the number of
patients on the waiting list and the number of deceased donors has significantly increased.
Allocation of deceased liver grafts in Argentina: before and after the MELD score
In contrast to other countries, all patients in Argentina are listed in a “unique
national” waiting list, and thus, there is no allocation of organs from deceased donors to
regional or LT-centers. On our national liver WL, we differentiate between two major
categories: emergency and elective candidates. Emergency status receives top priority on
the WL and includes: fulminant liver failure, primary non-function of the graft or vascular
complications after LT requiring re-transplantation in the first 7 postoperative days. Before
2005, the non-emergency patients who required continuous intensive care received first
priority (i.e. Urgency A). Organ allocation was then prioritized to patients requiring
continuous hospitalization (i.e. Urgency B), and finally to patients who were cared for at
home (i.e. Electives). As the waiting list continued to grow, waiting time became a major
factor in determining who received a donor organ in each category of urgency.
In July 2005 all LT candidates listed in Argentina were re-categorized using the
MELD score for organ allocation Thus, non-emergent patients who need a LT are
stratified numerically using the MELD score . These patients were identified as elective
among a unique national LT waiting list. Of all elective patients listed under the MELD
system, laboratory values are regularly updated depending on the patient’s medical
condition or the MELD score as follows: every 7 days for patients with MELD points >20,
every 30 days for MELD points 15–19, every 3 months for MELD points 11–14 and every
12 months for MELD points <10 (14). When the MELD score may not estimate the
severity of illness, each centre can request an Experts Committee for additional “priority”
points. Medical conditions which qualify for additional MELD points include: familial
amyloidotic polyneuropathy (16 points) and hepatopulmonary syndrome (20 points). A T2
hepatocellular carcinoma (HCC) defined as 1tumor of 2–5 cm or 2 or 3 tumors < 3 cm in
diameter (Milan criteria) according to pre-operative imaging receives 22 points. Similar to
US practice, patients with a MELD score of 22 as a result of the pre-transplant diagnosis of
T2 HCC receive an additional point for every 3 months on the waiting list.
Each centre can also request additional points for other conditions that diminish
quantity or quality of life but are not included in the MELD score. These include
conditions such as: encephalopathy, hyponatremia, refractory ascites, symptomatic
polycystic liver disease, recurrent biliary sepsis, refractory variceal bleeding and severe
pruritus or recurrent bacterial cholangitis,. Each of these conditions is considered
individually by a panel of experts to determine if the requested points are appropriate.
The panel uses medical evidence from the literature or expert opinions to decide if patients
receive the extra-points.
The MELD Exceptions Experts Committee is comprised of five liver transplants
specialists (minimum two surgeons and two hepatologists) representing different accredited
LT programmes from the country. Every year, three Committee members are replaced by
experts from other centres (16). Each LT centre must request additional points by sending
a letter signed by the LT programme director explaining the case and a signed copy of the
laboratory values and imaging reports. All the requests are reviewed in a blinded fashion by
a minimum of two experts and in cases of disagreement a third person is consulted. A
response must be sent to the LT programme requesting the extra points within 48hs.
What was the impact of the MELD allocation system in Argentina?
The implementation of organ allocation using the MELD scoreimproved organ
allocation in compared to the previous subjective system. The INCUCAI (Instituto
Nacional Central Único Coordinador de Ablación e Implante) created a modern centralized
electronic database for collecting data from each patient on the national waiting list. This
provided transparency to the allocation system.
A four year study involving a cohort of 1773 adult patients listed for LT in
Argentina (150 emergent and 1623 elective) reported the first experience outside US using
MELD scores for allocation (17). In this cohort, 141/ 1623 (8.6%) patients had upgraded
MELD scores due to for the following conditions: 2 Familial Amyloidotic Polyneuropathy,
6 Hepatopulmonary syndrome, 111 T2 HCC and 22 other reasons not included in the
official national regulation. In Argentina, adult elective patients had a median time in the
LT waiting list of 155 days (IQR= 40- 519) with an overall access to deceased donors of
41%. As expected, the median waiting time increased inversely with the MELD score
reaching a median time of 440 days for the group with <10 points (17).
Unfortunately, the implementation of the MELD system led to a significant increase
in waiting list mortality compared with the pre-MELD era (14, 18). While the mortality of
emergent patients remained equal in both periods, the mortality rate in elective candidates
increased significantly from 10.4% in the pre-MELD to 14.8% in the MELD era. As
expected, mortality rate during the MELD era in emergency patients was significantly
higher compared with elective patients (24.7% vs. 14.8%, p<0.002) (17).
The new “sickest first” policy meant that most deceased donor LT were performed
in patients with high MELD scores. With scores ≥18 the probability of receiving a liver
remained over 50%. Patient death on the waiting list became more frequent r in low MELD
candidates (i.e. <10 MELD points). These patients had the lowest probability to be
transplanted and more than a 4 fold risk of dying while waiting for a liver. The subgroup
with MELD scores <10 points (n= 433) had a lower probability of being transplanted with a
deceased donor(3%) among all the subgroups of elective patients. When the probability of
being transplanted is compared with the probability of dying while waiting for a liver;
patients with a MELD score <18 points had higher probability of dying waiting for
transplantation compared to receiving a deceased liver graft (16.2% vs. 10%; p<0.01) (17).
It is possible that socio-economical factors and differences in the US and the
Argentinean health systems (e.g. regional vs. national allocation system, lack of
homogeneous distribution of LT centers among the country, larger geographical distances
from patient location to LT center, etc.) explain the differences in wait list mortality
Studies that focus upon the reason for rather than rates of mortality on the waiting list in
both countries may help to clarify these contradictory experiences.
An important finding of this study is that patients with presumed T2 stage HCC
excessively benefit from additional MELD exception points. This subgroup benefited from
more accessto deceased donor LT. There was a depreciable drop-out rate due to tumor
progression and the lowest mortality rate compared with other subgroups of patients
stratified according to their MELD scores on the waiting list. This shorter waiting time for
patients with T2 HCC caused a significant reduction in adult live donor LT application in
Argentina compared with the pre-MELD era.
In the MELD era, there were only few adult live donor LTs performed and none of
them for patients with T2 HCC. In order to provide equity in the allocation system, these
data raise the question whether the priority points for patient with T2 HCC should be
reduced. The same question has been raised in the US. Further multidisciplinary discussion
is urgently needed to discuss how to incorporate principles of justice into the allocation of
deceased donor livers without compromising the survival of patients without early stage
liver cancer who were listed for LT in Argentina.
Postoperative outcome and long-term survival are not prospectively recorded by the
INCUCAI so far and, unfortunately, the survival benefit of allocation systems that use
MELD scores is unpredictable in Argentina. To date the survival benefit using MELDbased allocation has been validated only in US (14). A negative survival benefit has been
demonstrated for candidates with MELD scores below 15who received high risk donor
organs (18, 19). Clearly, the North-American experience cannot be extrapolated to other
countries as Argentina where most patients are dying with low MELD score but need a LT.
Perhaps many financial, logistic and structural limitations existing in developing countries
explain why the experience from North-America was not observed in our country.
Probably, some modifications the MELD system is required and adaptation should be
made to this novel and promising policy in order to accommodate the special conditions in
each country.
The National MELD Exceptions Experts Committee activity in Argentina
There were a total of 234/ 1623 (14.4%) requests to the r MELD Exceptions Experts
Committee in a period of almost 4 years. This constitutes more than 14% of the cases of
adult patients listed for LT. In these cases the LT team decided that the calculated MELD
score did not properly reflect the need of LT and therefore, priority points were requested.
In 189/234 cases the requests were based upon patient having one of the standard
conditions included in the regulations outlined above. However, additional points were
adjudicated in only 119 cases (62%) as follows: 2 Familial Amyloidotic Polyneuropathy, 6
Hepatopulmonary syndrome and 111 presumed T2 HCC.
In the subgroup of patients with high suspicion of T2 HCC, 94 underwent deceased
LT (probability to be transplant= 84.2%). A whole-liver explants examination was
performed to assess discrepancy with preoperative tumor diagnosis and pathological
staging. When 94 pathology reports were reviewed, the diagnosis of HCC was incorrect in
21/94 (22%) cases and T2 HCC was confirmed in only 41/94 patients (diagnostic accuracy=
43%).
Preoperative imaging underestimated tumor extension in 23 cases (T3 stage HCC)
but overestimated the tumor size in 9 patients (T1 stage HCC). In 70/189 (37%) cases the
request was denied for patients with presumed T2 HCC. From this subgroup, only 42
patients underwent LT (probability to be transplant = 60%). Pathology reports of the
explanted livers were available in 40/42 transplanted candidates. We found that 18 had no
HCC; none had T1 HCC, 11 (26.1%) had T2 HCC and 11 patients had T3 HCC. This
showed that the Experts Committee incorrectly denied requests in 26.1% of the patients in
whom the preoperative imaging detected T2 HCC. There was a consequent increase in the
mortality and due to a reduced probability of transplantation in these candidates. These
results showed a very low positive predictive value with a low diagnostic accuracy rate for
T2 HCC.
These errors risk the principles of equity and justice that should guide liver
allocation. Perhaps, the creation of an Experts Radiologist Committee would improve the
low diagnostic accuracy for T2 HCC. Currently in Argentina, the quality of imaging
employed for each center is not monitored. This may account for some of the error rate in
diagnosis. Major efforts should be made to implement uniform methods of diagnosis and
definitions of disease. This is an important vehicle to to ensure optimal health care delivery
and prevent unfair listing and management of patients considered for LT (20). Furthermore,
as tumor staging plays a critical role in obtaining points for allocation, it is the key to
ensuring that all patients will be managed according to the same measurements using the
same tools with the same criteria and modern technology. Thus, while allocation to HCC
patients based upon the stage of disease may appear to offer a balanced distribution of
organs, the wide inter-center variability in our country suggests that there are additional
factors to consider. It is the role of the national Ministry of Health and the INCUCAI to
ensure that all patients are staged according to the same methodology to avoid inequity on
the national liver WL (20, 21).
On the other hand, 45/234 patients requested the Experts Committee opinion for
special situations that were not included in the standard regulation. Surprisingly, additional
points were adjudicated in only 17/37 (37%) of cases and denied in the remaining.
Recurrent cholangitis and post-transplant complications were the most frequent arguments
that the Committee awarded extra-MELD points. Inversely, the most frequent cases denied
additional points by the Experts Committee that are not part of the standard regulation
were: the presence of hepatorenal syndrome with ascites and edema, severe malnutrition
and the hepatic encephalopathy alone or associated with intractable gastrointestinal
bleeding.
Unfortunately, allocation remains unclear for all the conditions wherethe MELD
score does not estimate the risk of mortality(5, 10-12, 14, 22). Ideally, medical decisions of
the magnitude of organ allocation would be made with the highest quality clinical evidence
available in the literature. However, an adequate amount of evidence is often not available
and many of the conditions that could affect mortality occur so infrequently that the
development of clinical studies focusing on these issues may never be possible. In this
context, prioritization policy in Argentina relies on the subjective opinion of a minimum of
2 experts. Other well-defined endpoints that are measured by objective variables should be
developed for such conditions that were not included in the regulation.
Conclusions
The new MELD-based allocation system has been adopted in Argentina. However,
the mortality rate of elective patients on the waiting list increased after MELD
implementation. Most of the increased mortality is in patients with low MELD scores on
the national waiting list. The MELD exceptions are frequently requested and most
receiving priority points for T2HCC unfairly benefited by radiological imaging limitations.
Improvement in imaging modalities and the use of better diagnostic criteria are urgently
required to improve diagnosis and staging of HCC in Argentina. The activity of the
National Experts may benefit from oversight. The Committee needs to provide feedback to
the transplant community and to guarantee high standards of excellence for liver allocation
in our country. Further investigations focused on the strict analysis of specific variables
including cultural, logistic and socio-economical factors inherent to developing and
developed countries would help in optimizing the principles of justice and equity in each
country individually.
References
1.
Adam R, Hoti E. Liver transplantation: the current situation. Semin Liver Dis
2009;29(1):3-18.
2.
McCormack L, Petrowsky H, Jochum W, Mullhaupt B, Weber M, Clavien PA. Use
of severely steatotic grafts in liver transplantation: a matched case-control study. Ann Surg
2007;246(6):940-6; discussion 946-8.
3.
McCormack L, Dutkowski P, El-Badry AM, Clavien PA. Liver transplantation
using fatty livers: always feasible? J Hepatol 2011;54(5):1055-62.
4.
McCormack L, Quiñonez E, Ríos MM, Capitanich P, Goldaracena N, Cabo JK, et
al. Rescue policy for discarded liver grafts: a single-centre experience of transplanting
livers ‘that nobody wants’. Hpb 2010;12(8):523-530.
5.
Freeman RB, Jamieson N, Schaubel DE, Porte RJ, Villamil FG. Who should get a
liver graft? J Hepatol 2009;50(4):664-73.
6.
Dutkowski P, Oberkofler CE, Béchir M, Müllhaupt B, Geier A, Raptis DA, et al.
The model for end-stage liver disease allocation system for liver transplantation saves lives,
but increases morbidity and cost: a prospective outcome analysis. Liver Transplantation
2011;17(6):674-684.
7.
Cholongitas E, Marelli L, Shusang V, Senzolo M, Rolles K, Patch D, et al. A
systematic review of the performance of the model for end-stage liver disease (MELD) in
the setting of liver transplantation. Liver Transpl 2006;12(7):1049-61.
8.
Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, et
al. A model to predict survival in patients with end-stage liver disease. Hepatology
2001;33(2):464-70.
9.
Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to
predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.
Hepatology 2000;31(4):864-71.
10.
Wiesner RH. Patient selection in an era of donor liver shortage: current US policy.
Nat Clin Pract Gastroenterol Hepatol 2005;2(1):24-30.
11.
Ruf AE, Kremers WK, Chavez LL, Descalzi VI, Podesta LG, Villamil FG. Addition
of serum sodium into the MELD score predicts waiting list mortality better than MELD
alone. Liver Transplantation 2005;11(3):336-343.
12.
Samuel D. MELD-Na as a prognostic score for cirrhotic patients: Hyponatremia and
ascites are back in the game. J Hepatol 2009;50(4):836-8.
13.
Trotter JF, Olson J, Lefkowitz J, Smith AD, Arjal R, Kenison J. Changes in
international normalized ratio (INR) and model for endstage liver disease (MELD) based
on selection of clinical laboratory. Am J Transplant 2007;7(6):1624-8.
14.
Freeman RB, Wiesner RH, Edwards E, Harper A, Merion R, Wolfe R. Results of
the first year of the new liver allocation plan. Liver Transpl 2004;10(1):7-15.
15.
Sociedad de Trasplante de America Latina y Caribe. In: Available at:
www.stalyc.net. Accessed: July 30, 2011.
16.
McCormack L, Gadano A, Lendoire J, Quinonez E, Imventarza O, Andriani O, et
al. Model for end-stage liver disease exceptions committee activity in Argentina: does it
provide justice and equity among adult patients waiting for a liver transplant? HPB
(Oxford) 2010;12(8):531-7.
17.
McCormack L, Gadano A, Lendoire J, Imventarza O, Andriani O, Gil O, et al.
Model for end-stage liver disease-based allocation system for liver transplantation in
Argentina: does it work outside the United States? HPB (Oxford) 2010;12(7):456-64.
18.
Merion RM, Schaubel DE, Dykstra DM, Freeman RB, Port FK, Wolfe RA. The
survival benefit of liver transplantation. Am J Transplant 2005;5(2):307-13.
19.
Perkins JD, Halldorson JB, Bakthavatsalam R, Fix OK, Carithers RL, Jr., Reyes JD.
Should liver transplantation in patients with model for end-stage liver disease scores <or=
14 be avoided? A decision analysis approach. Liver Transpl 2009;15(2):242-54.
20.
Freeman RB, Jr., Gish RG, Harper A, Davis GL, Vierling J, Lieblein L, et al. Model
for end-stage liver disease (MELD) exception guidelines: results and recommendations
from the MELD Exception Study Group and Conference (MESSAGE) for the approval of
patients who need liver transplantation with diseases not considered by the standard MELD
formula. Liver Transpl 2006;12(12 Suppl 3):S128-36.
21.
Varela M, Forner A, Bruix J. Diagnosis and staging of hepatocellular carcinoma
prior to transplantation: expertise or failure. Liver Transpl 2006;12(10):1445-7.
22.
Austin MT, Poulose BK, Ray WA, Arbogast PG, Feurer ID, Pinson CW. Model for
end-stage liver disease: did the new liver allocation policy affect waiting list mortality?
Arch Surg 2007;142(11):1079-85.
Figure Legends
Figure 1. Comparison of organ donation rate in Latin America and Argentina in the last
decade. Data expressed in donors per million population (PMP).
Figure 2. National organ donation rates in Latin American countries in 2010. Data
expressed in donors per million population (PMP).
Figure 3. Number of LT performed in Latin America along the decade.
Figure 4. Transplantation activity in Argentina expressed in number of cases by years
including: patients on the national waiting list and deceased donor LT, pediatric and adult
live donor LT performed.
Figure 1.
South America
Argentina
16
14.5
14
12
10.5
10
8
6.8
2.1
12.3
12.4
7.9
6.4
6
4
10.5
11.6
13
3.2
3.8
4.2
2003
2004
5
5.6
5.8
5.9
2006
2007
2008
6.6
7.1
2009
2010
2
0
2001
2002
2005
Figure 2.
30
25.9
25
20
15
10
15.2 14.5
12.5
9.9 9.6
5.4
5
0
3.7 3.5 3.5 3.2 3.2
2.5
1.5 1.1
1
Figure 3.
2500
2181
2058
1889
2000
1688 1728
1524 1513
1500
1316
959
1000
1038
1088
822
664
514
500
369
34
43
114 138
225
0
19911992199319941995199619971998199920002001200220032004200520062007200820092010
Figure 4.
Waiting list
Deceased donor LT
Pediatric Live Donor LT
Adult Live Donor LT
700
626
583
600
500
485
455
449
395
400
354
326
300
276
271
240
166
200
185
192
214
237
225
112
100
19 24
21 24
20 13
23 7
18 7
22 4
31
2
28 5
33 6
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
Questions
1 Which is the most prevalent cause leading to patient deaths on liver transplant
waiting lists?
A) Hepatocellular carcinoma progression
B) Renal disfunction
C) Liver grafts shortage
D) Spontaneus bacterial peritonitis
2
3
4
Which was the first country to adopt MELD allocation policy after the US?
A)
France
B)
Argentina
C)
Brazil
D)
Germany
MELD system is based on:
A)
Bilirrubin, creatinine and INR
B)
Bilirubin, Albumin and INR
C)
Albumin, Platelets and bilirubin
D)
Sodium, Creatinine and INR
Emergency status in Argentina includes:
A)
Fulminant liver failure, graft primary non-function and vascular
complication after LT needing retransplantation within the first 7
postoperative days
B)
Patients with the longest time on waiting list
C)
Patients that fulfil Milan criteria
D)
5
6
Patients with graft rejection
MELD allocation policy started in Argentina in:
A)
2000
B)
2008
C)
2005
D)
1999
Conditions thatqualify for additional MELD pointsare:
A)
Spontaneous bacterial peritonitis
B)
Hepatocellular carcinoma beyond Milan criteria
C)
Amyloidotic polyneuropathy, hepatopulmonary syndrome and T2 stage
hepatocellular carcinoma
D)
7
8
Only T2 stage hepatocellular carcinoma
Implementation of the MELD system in Argentina led to a:
A)
Increment on waiting list mortality compared with the pre-MELD era
B)
Decrease on waiting list mortality compared with the pre-MELD era
C)
Increase in the mortality rate of emergent patients
D)
Increment in the number of donors per year
In Argentina, patients who have the lowest probability to be transplanted are:
A)
Emergent patients
B)
Patients with MELD< 10
C)
Patients with MELD between 10 and 20
D)
Patients with MELD > 20
9
10
Patients with T2 stage HCC in Argentina:
A)
Have the highest mortality rate on the waiting list
B)
Do not receive priority points by the MELD Exceptions Committee
C)
Cannot be transplanted by law
D)
Excessively benefit from the MELD Exception regulation
For patients with MELD score >20, the laboratory values should be updated
A)
Every 3 months
B)
Every 1 month
C)
Every 7 days
D)
Every 12 months
Answers
1) C
2) B
3) A
4) A
5) C
6) C
7) A
8) B
9) D
10) C