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J Hepatol. 2014 Feb;60(2):290-7. doi: 10.1016/j.jhep.2013.10.010. Epub 2013 Oct 23.

A method for establishing allocation equity among patients with and without hepatocellular carcinoma on a common liver transplant waiting list.

Author information

  • 1University Hospital of Padua, Italy.
  • 2Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, USA.
  • 3Organs and Tissue Transplant Immunology Unit, Fond. IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
  • 4University Hospital of Padua, Italy. Electronic address:
  • 5Veneto Institute of Oncology IOV - IRCCS, Padua, Italy.
  • 6Surgery and Transplantation, Ospedale Niguarda Ca' Granda, Milan, Italy.
  • 7Hepatology and Gastroenterology, Ospedale Niguarda Ca' Granda, Milan, Italy.
  • 8Gastroenterology and Transplantation Hepatology, Ospedali Riuniti, Bergamo, Italy.
  • 9Liver Transplantation Unit, Fond. IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
  • 10IRCCS San Martino, Genoa, Italy.
  • 11Medical Liver Transplant Unit, University of Udine, Italy.
  • 12Liver Transplantation, IRCCS INT, Milan, Italy.
  • 13Liver Transplantation Unit, Ancona Hospital, Italy.
  • 14Liver Transplantation Unit, Verona Hospital, Italy.

Erratum in

  • J Hepatol. 2014 Jun;60(6):1336. Multiple investigator names added.



The current organ allocation system for liver transplantation (LT) creates an imbalance between patients with and without hepatocellular carcinoma (HCC). We describe a model designed to re-establish allocation equity among patient groups using transplant benefit as the common endpoint.


We enrolled consecutive adult patients entering the waiting list (WL group, n=2697) and undergoing LT (LT group, n=1702) during the period 2004-2009 in the North Italy Transplant program area. Independent multivariable regressions (WL and LT models) were created for patients without HCC and for those with stage T2 HCC. Monte Carlo simulation was used to create distributions of transplant benefit, and covariates such as Model for End-stage Liver Disease (MELD) and alpha-fetoprotein (AFP) were combined in regression equations. These equations were then calibrated to create an "MELD equivalent" which matches HCC patients to non-HCC patients having the same numerical MELD score.


Median 5 year transplant benefit was 15.12 months (8.75-25.35) for the non-HCC patients, and 28.18 months (15.11-36.38) for the T2-HCC patients (p<0.001). Independent predictors of transplant benefit were MELD score (estimate=0.89, p<0.001) among non-HCC patients, and MELD (estimate=1.14, p<0.001) and logAFP (estimate=-0.46, p<0.001) among HCC patients. The equation "HCC-MELD"=1.27∗MELD - 0.51∗logAFP+4.59 calculates a numerical score for HCC patients, whereby their transplant benefit is equal to that of non-HCC patients with the same numerical value for MELD.


We describe a method for calibrating HCC and non-HCC patients according to survival benefit, and propose that this method has the potential, if externally validated, to restore equity to the organ allocation system.


AFP; CI; CR; Cirrhosis; Clinical decision making; HBV; HCC; HCV; HR; Hepatocellular carcinoma; INR; IQR; LT; Liver Transplantation; Liver transplantation; MELD; NITp; North Italy Transplant program; Surgical oncology; WL; alpha-fetoprotein; competing risk; confidence interval; hazard ratio; hepatitis B virus; hepatitis C virus; hepatocellular carcinoma; international normalized ratio; interquartile range; model for end-stage liver disease; waiting list

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