The survival benefit of deceased donor liver transplantation using MELD 3.0: A contemporary analysis

The decision to proceed with liver transplant (LT) must account for the risk of death without LT and the likelihood of survival after, a concept known as "survival benefit." A 2005 study suggested that deceased donor LT (DDLT) survival benefit is achieved at a MELD score of 15, a threshold that persists today. This study reassesses that threshold in the context of MELD 3.0. Data from all adults listed for primary single-organ LT in the UNOS/OPTN registry (January 1, 2021-March 31, 2023) were analyzed. Those undergoing living donor LT were excluded. Using sequential stratification, Cox regression models comparing mortality between LT recipients and waitlist candidates estimated hazard ratios across MELD 3.0 subgroups. Among 21,594 LT candidates (median MELD 3.0, 22, IQR 16-30), LT recipients had a 95% lower adjusted mortality risk than waitlisted candidates (HR 0.05, 95% CI 0.04-0.07, p<0.001). This survival benefit varied by MELD 3.0 score, with an advantage emerging at MELD 3.0 ≥12. At MELD 3.0 of 12-14, DDLT reduced mortality by 46% (HR 0.54, 95% CI 0.30-0.96, p=0.04), while no significant survival benefit was seen below MELD 3.0 of 12, largely due to high post-LT mortality. In this analysis of UNOS/OPTN data, DDLT conferred a survival benefit at MELD 3.0 scores ≥12, revising the historical threshold of 15. However, MELD 3.0 alone does not capture the full complexity of LT candidacy. Factors such as refractory ascites, hepatic encephalopathy, frailty, and poor quality of life should also be considered when considering LT for the individual patient.