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

Objective: The MELD system has not yet been tested as an allocationtool for liver transplantation in the developing countries. In 2006,MELD (Model for End-stage Liver Disease) was launched as a newliver allocation system in São Paulo, Brazil. This study was designedto assess the results of the new allocation policy on waiting listmortality. Methods: The State of São Paulo liver transplant databasewas 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-MELDGroup) the implementation of the MELD system. Only adult livertransplant candidates were included. Waiting list mortality was theprimary endpoint. Results: The unadjusted death rate in waiting listdecreased significantly after the implementation of the MELD system(from 91.2 to 33.5/1,000 patients per year; p<0.0001). Multivariateanalysis showed a significant drop in risk of waiting list death forpost-MELD patients (HR 0.34; p<0.0001). Currently, 48% of patientsare transplanted within 1-year of listing (versus 23% in the pre-MELDera; p