Innovative approaches increase access to liver transplant for patients with low MELD scores

Historically, in any transplant program worldwide, patients had to be extremely sick and have a high Model for End-stage Liver Disease (MELD) score to receive a liver transplant. However, often the MELD score does not represent how sick the patient truly is.

For example, patients may have ascites for which they undergo regular paracentesis. But because their MELD score is very low, they could wait a long time for a liver transplant from a deceased donor. In addition to ascites, other complications of liver disease that can cause patients to be much sicker than what their MELD score represents include hepatocellular carcinoma, primary sclerosing cholangitis and hepatic encephalopathy.

“Over the last several years, and particularly in 2024, our team has worked tirelessly to increase access to liver transplant for patients, even though their MELD score may be low,” says Sumeet Asrani, MD, MSc, Chief of Hepatology and Liver Transplantation at Baylor Scott & White Annette C. and Harold C. Simmons Transplant Institute. “This includes a wide range of innovative approaches, including living donor liver transplant, the safe use of organs that may have not been considered in the past and new donor organ preservation technologies. All of these approaches have been instrumental to achieving our goal of increasing access for patients without compromising safety and their wellbeing.”

One of the quickest ways for a patient with a low MELD score to receive a liver transplant is through living donor liver transplant. Living donor liver transplantation offers immediate organ availability and is a planned procedure, which can avoid the progression of the recipient’s disease. In addition, a living donor liver is the best quality liver, which often leads to improved outcomes.

“We have the largest experience in North America with robotic donor hepatectomies, which is definitely the future for living donor liver transplant,” says Amar Gupta, MD, FACS, FRCS(C), Surgical Director of Liver Transplantation, Baylor University Medical Center at Dallas (Baylor Dallas). “Living liver donors just want to save a life, and it is our goal to minimize their pain, scarring and recovery time.”

BSW Simmons Transplant Institute has been a leader in Texas in the use of DCD (donation after cardiac death) organs. Several new technologies are available to increase opportunities to use liver grafts from DCD donors. These include normothermic regional perfusion (NRP), normothermic machine perfusion (NMP) and hypothermic oxygenated machine perfusion (HOPE). According to Anji Wall, MD, PhD, FACS, an abdominal transplant surgeon on the medical staff at Baylor Dallas, each technology has advantages and disadvantages in terms of quality improvement, functional assessment, and financial viability.

“In our practice, we have focuses mainly on the utilization of NRP, which is in situ oxygenated perfusion of the organs that is used for transplantation during the donor operation,” Dr. Wall says. “The advantage of this technology is that it immediately reconditions the organs. In liver transplantation, NRP is associated with higher graft utilization rates, as well as better outcomes, particularly with respect to ischemic type biliary lesions, namely ischemic cholangiopathy.

“What we have been able to do with NRP is utilize liver grafts with longer times during which the organs are not perfused in the dying process, as well as grafts from older donors with more comorbidities,” Dr. Wall continues. “Because these grafts are not used by other centers, we can transplant patients who have lower priority on the waiting list, but are experiencing complications from their liver disease and need transplantation. And, while DCD grafts have historically been considered of lower quality than donation after brain death grafts, that is no longer the case in our practice. We consider them to be the same, and are having similar outcomes. Our data shows we are not compromising on recipient outcomes, despite extending our donor acceptance criteria.”

Overall, the BSW Simmons transplant team has significantly changed their approach to how they look at donors. They made the decision that a more concerted effort to thoroughly evaluate potential livers could result in an increased supply of organs.

“In the past, when a donor’s clinical history was communicated to us, and there were some worrisome words or other information, we might decline the organ right away,” Dr. Gupta says. “But now we take a look at the gross appearance of the liver and take a biopsy, which is an objective and truthful evaluation of the organ. We have found livers that had bad donor stories, but turned out to be good organs. By being more aggressive and putting in the time and effort, we are able to transplant patients who would not get usable organ offers because they are so far down on the list.”

At Baylor Scott & White All Saints Medical Center – Fort Worth (BSW Fort Worth), the focus also is on using livers that have been on NRP or other pumps as much as possible. “From a quality standpoint, what we are trying to do is optimize donor organs so that we increase access without compromising quality,” says Shivang Mehta, MD, a transplant hepatologist on the medical staff at BSW Fort Worth and Medical Director of Quality. “We have found outcomes are better when we incorporate this new technology.”

Dr. Asrani concludes, “Managing liver patients is a difficult and complex process because many need a transplant but often the opportunities are limited,” Dr. Asrani says. “Now, with our aggressive and proactive approach, we are able to choose from a menu of options so that our patients get transplanted safely with excellent outcomes.”