In Eurotransplant, relatively more females than males die while waiting for liver transplantation, and relatively fewer females undergo transplantation. With adult liver transplantation candidates listed between 2007 and 2019 (n = 21 170), we study whether sex disparity is inherent to the model for end-stage liver disease (MELD) scoring system, or the indirect result of a small candidate body size limiting access to transplantation. Cox proportional hazard models are used to quantify the direct effect of sex on waitlist mortality, independent of the effect of sex through MELD scores, and the direct effect of sex on the transplantation rate, independent of the effect of sex through MELD and candidate body size. Adjusted waitlist mortality hazard ratios (HRs) for female sex are insignificant (HR: 1.03, 95% CI: 0.88-1.20). We thus lack evidence that MELD systematically underestimates waitlist mortality rates for females. Transplantation rates are 25% lower for females than males in unadjusted analyses (HR: 0.74, 95% CI: 0.71-0.77), but HRs become insignificant with adjustment for mediators (HR: 0.98, 95% CI: 0.93-1.04), most importantly candidate body size. Sex disparity in Eurotransplant thus appears to be largely a consequence of lower transplantation rates for females, which are explained by sex differences in body size.

BACKGROUND: Eurotransplant liver transplant candidates are prioritized by Model for End-stage Liver Disease (MELD), a 90-day waitlist survival risk score based on the INR, creatinine and bilirubin. Several studies revised the original MELD score, UNOS-MELD, with transplant candidate data by modelling 90-day waitlist mortality from waitlist registration, censoring patients at delisting or transplantation. This approach ignores biomarkers reported after registration, and ignores informative censoring by transplantation and delisting.
METHODS: We study how MELD revision is affected by revision from calendar-time cross-sections and correction for informative censoring with inverse probability censoring weighting (IPCW). For this, we revised UNOS-MELD on patients with chronic liver cirrhosis on the Eurotransplant waitlist between 2007 and 2019 (n = 13,274) with Cox models with as endpoints 90-day survival (a) from registration and (b) from weekly drawn calendar-time cross-sections. We refer to the revised score from cross-section with IPCW as DynReMELD, and compare DynReMELD to UNOS-MELD and ReMELD, a prior revision of UNOS-MELD for Eurotransplant, in geographical validation.
RESULTS: Revising MELD from calendar-time cross-sections leads to significantly different MELD coefficients. IPCW increases estimates of absolute 90-day waitlist mortality risks by approximately 10 percentage points. DynReMELD has improved discrimination over UNOS-MELD (delta c-index: 0.0040, p < 0.001) and ReMELD (delta c-index: 0.0015, p < 0.01), with differences comparable in magnitude to the addition of an extra biomarker to MELD (delta c-index: ± 0.0030).
CONCLUSIONS: Correcting for selection bias by transplantation/delisting does not improve discrimination of revised MELD scores, but substantially increases estimated absolute 90-day mortality risks. Revision from cross-section uses waitlist data more efficiently, and improves discrimination compared to revision of MELD exclusively based on information available at listing.

UNASSIGNED: The time from dialysis onset to enrollment on the kidney waiting list (listing time) is a crucial step on the path to receiving a kidney allograft; however, this process has received very little research attention in the Eurotransplant (ET) area.
UNASSIGNED: We retrospectively analyzed data from the German transplantation registry, including patients who were on the waiting list for a first kidney transplant in Germany between 2006 and 2016. Listing time was evaluated using a mixed linear model. The outcomes on the kidney waiting list were assessed using competing risk analyses.
UNASSIGNED: We assessed a total of 43,955 patients. Listing occurred at a higher pace in patients receiving living donor transplantations (median 0.4 years from dialysis onset) than in deceased donor transplantations (Eurotransplant Kidney Allocation System [ETKAS] 1.1 years, European Senior Program [ESP] 1.4 years, Acceptable Mismatch program 1.3 years), with 28.5% of living donor transplantations performed preemptively. There was only modest variation in listing time between the transplant centers. Patients with a history of viral infection, high immunization; hemodialysis patients; and patients with a higher body mass index (BMI) had a delayed listing process. Two of 3 patients listed in the ETKAS, excluding those with potential bonus points (pediatric, other organ transplantations), were eventually transplanted. Older patients, male patients, patients with blood type O, and patients with diabetic nephropathy as the underlying renal disease had the highest risk not to proceed to transplantation.
UNASSIGNED: Although long waiting times remain the biggest hurdle for transplantation in Germany, there is ample room for improvement of the listing process.

BACKGROUND: Liver transplantation is the only promising treatment for end-stage liver disease and patients with hepatocellular carcinoma. However, too many organs are rejected for transplantation.
METHODS: We analyzed the factors involved in organ allocation in our transplant center and reviewed all livers that were declined for transplantation. Reasons for declining organs for transplantation were categorized as major extended donor criteria (maEDC), size mismatch and vascular problems, medical reasons and risk of disease transmission, and other reasons. The fate of the declined organs was analyzed.
RESULTS: 1086 declined organs were offered 1200 times. A total of 31% of the livers were declined because of maEDC, 35.5% because of size mismatch and vascular problems, 15.8% because of medical reasons and risk of disease transmission, and 20.7% because of other reasons. A total of 40% of the declined organs were allocated and transplanted. A total of 50% of the organs were completely discarded, and significantly more of these grafts had maEDC than grafts that were eventually allocated (37.5% vs. 17.7%, p < 0.001).
CONCLUSIONS: Most organs were declined because of poor organ quality. Donor-recipient matching at time of allocation and organ preservation must be improved by allocating maEDC grafts using individualized algorithms that avoid high-risk donor-recipient combinations and unnecessary organ declination.

Liver transplantation (LT) is the only definitive treatment to cure hepatocellular carcinoma (HCC) in cirrhosis. Waiting-list candidates are selected by the model for end-stage liver disease (MELD). However, many indications are not sufficiently represented by labMELD. For HCC, patients are selected by Milan-criteria: Milan-in qualifies for standard exception (SE) and better organ access on the waiting list; while Milan-out patients are restricted to labMELD and might benefit from extended criteria donor (ECD)-grafts. We analyzed a cohort of 102 patients (2011−2020). Patients with labMELD (no SE, Milan-out, n = 56) and matchMELD (SE-HCC, Milan-in, n = 46) were compared. The median overall survival was not significantly different (p = 0.759). No difference was found in time on the waiting list (p = 0.881), donor risk index (p = 0.697) or median costs (p = 0.204, EUR 43,500 (EUR 17,800−185,000) for labMELD and EUR 30,300 (EUR 17,200−395,900) for matchMELD). Costs were triggered by a cut-off labMELD of 12 points. Overall, the deficit increased by EUR 580 per labMELD point. Cost drivers were re-operation (p < 0.001), infection with multiresistant germs (p = 0.020), dialysis (p = 0.017), operation time (p = 0.012) and transfusions (p < 0.001). In conclusion, this study demonstrates that LT for HCC is successful and cost-effective in low labMELD patients independent of Milan-criteria. Therefore, ECD-grafts are favorized in Milan-out HCC patients with low labMELD.

This study aimed to identify cutoff values for donor risk index (DRI), Eurotransplant (ET)-DRI, and balance of risk (BAR) scores that predict the risk of liver graft loss. MEDLINE and Web of Science databases were searched systematically and unrestrictedly. Graft loss odds ratios and 95% confidence intervals were assessed by meta-analyses using Mantel-Haenszel tests with a random-effects model. Cutoff values for predicting graft loss at 3 months, 1 year, and 3 years were analyzed for each of the scores. Measures of calibration and discrimination used in studies validating the DRI and the ET-DRI were summarized. DRI ≥ 1.4 (six studies, n = 35 580 patients) and ET-DRI ≥ 1.4 (four studies, n = 11 666 patients) were associated with the highest risk of graft loss at all time points. BAR > 18 was associated with the highest risk of 3-month and 1-year graft loss (n = 6499 patients). A DRI cutoff of 1.8 and an ET-DRI cutoff of 1.7 were estimated using a summary receiver operator characteristic curve, but the sensitivity and specificity of these cutoff values were low. A DRI and ET-DRI score ≥ 1.4 and a BAR score > 18 have a negative influence on graft survival, but these cutoff values are not well suited for predicting graft loss.

Heart transplantation (HTx) represents optimal care for advanced heart failure. Left ventricular assist devices (LVADs) are often needed as a bridge-to-transplant (BTT) therapy to support patients during the wait for a donor organ. Prolonged support increases the risk for LVAD complications that may affect the outcome after HTx.
A total of 342 patients undergoing HTx after LVAD as BTT in a 10-year period in two German high-volume HTx centres were retrospectively analysed. While 73 patients were transplanted without LVAD complications and with regular waiting list status (T, n = 73), the remaining 269 patients were transplanted with high urgency status (HU) and further divided with regard to the observed leading LVAD complications (infection: HU1, n = 91; thrombosis: HU2, n = 32; stroke: HU3, n = 38; right heart failure: HU4, n = 41; arrhythmia: HU5, n = 23; bleeding: HU6, n = 18; device malfunction: HU7, n = 26). Postoperative hospitalization was prolonged in patients with LVAD complications. Analyses of perioperative morbidity revealed no differences regarding primary graft dysfunction, renal failure, and neurological events except postoperative infections. Short-term survival, as well as Kaplan-Meier survival analysis, indicated comparable results between the different study groups without disadvantages for patients with LVAD complications.
Left ventricular assist device therapy can impair the outcome after HTx. However, the occurrence of LVAD complications may not impact on outcome after HTx. Thus, we cannot support the prioritization or discrimination of HTx candidates according to distinct mechanical circulatory support-associated complications. Future allocation strategies have to respect that device-related complications may define urgency but do not impact on the outcome after HTx.

The Heart Donor Score (HDS) predicts donor organ discard for medical reasons and survival after heart transplantation (HTX) in the Eurotransplant allocation system. Our aim was to adapt the HDS for application in the United Network for Organ Sharing (UNOS) registry. To adjust for differences between the Eurotransplant and UNOS registries, the \"adapted HDS\" was created (aHDS) by exclusion of the covariates \"valve function,\" \"left-ventricular hypertrophy,\" and exclusion of \"drug abuse\" from the variable \"compromised history.\" Two datasets were analyzed to evaluate associations of the aHDS with donor organ discard (n = 70 948) and survival (n = 19 279). The aHDS was significantly associated with donor organ discard [odds ratio 2.72, 95% confidence interval (CI) 2.68-2.76, P < 0.001; c-statistic: 0.937). The score performed comparably in donors <60 and ≥60 years of age. The aHDS was a significant predictor of survival as evaluated by univariate Cox proportional hazards analysis (hazard ratio 1.04, 95% CI 1.01-1.07, P = 0.023), although the association lost significance in a multivariable model. The aHDS predicts donor organ discard. Negative effects of most aHDS components on survival are likely eliminated by highly accurate donor selection processes.

The author concludes lessons learned from Hungary joining Eurotransplant five years ago through the more than half a century history of the Hungarian organ transplantation. The result of the stepwise evolution is that today\'s transplantation activity can be measured by a European benchmark. In comparison to the era before the membership, there are 40% more transplantations in the country. First the numbers of the living donor kidney transplantations significantly raised, followed by the organs transplanted from brain-dead donors: kidney, heart, pancreas, then liver and finally also lung. The ratio of the multiorgan donors changed from about 40% to more than 70%. A reassuring solution was found for the high urgent cases, for the paediatric transplants and for the highly immunized patients, who would have been in a desperate situation without Eurotransplant, but now every Hungarian end-stage organ failure patient has similar chances for getting a potential life-saving organ as their former luckier West-European counterparts. Orv Hetil. 2018; 159(42): 1695-1699.
Absztrakt: Az öt éve történt Eurotransplant-csatlakozás tanulságait vizsgálja a szerző a magyarországi szervátültetések több mint fél évszázados történetén keresztül. A fokozatos fejlődés eredményezte azt a helyzetet, melynek során ma európai mércével mérhető transzplantációs aktivitást jegyezhetünk. A csatlakozás előtti állapothoz képest körülbelül 40%-kal több átültetés történik hazánkban. Elsőként jelentősen megemelkedett az élődonoros veseátültetések száma, majd ezt követte az agyhalottakból származó szervek transzplantációinak szignifikáns emelkedése a vese, a szív, a hasnyálmirigy, majd a máj és végül a tüdő vonatkozásában is. Az úgynevezett ’multiorgan’ (többszervi) donorok aránya a korábbi 40%-ról 70% fölé emelkedett. Megnyugtató megoldás született a sürgősségi szervátültetések, a gyermektranszplantációk és az immunizált betegek vonatkozásában is, akik az Eurotransplant-csatlakozás nélkül reménytelen helyzetben volnának, így viszont minden magyar végstádiumú szervelégtelenségben szenvedő beteg ugyanolyan eséllyel kaphat adott esetben életmentő szervet, mint a korábban szerencsésebb helyzetben lévő nyugat-európai társaik. Orv Hetil. 2018; 159(42): 1695–1699.

In this article, I critically examine the principle of national solidarity in organ sharing across national borders. More specifically, I analyse the policy foundations of solidarity in the transnational allocation of organs and its implementation in the system of national balance points adopted in Europe. I argue that the system of national balance points is based on statist collectivism and therefore is oriented more toward collective, rather than individual welfare. The same collective welfare rationale is also evident from leading policy statements about self-sufficiency in organ donation that seem to assume that cross-border organ sharing can be wrong if collective welfare is violated. This collectivist system of organ sharing can produce unjust results to individual candidates for organ transplantation. I propose several measures to reform the existing solidarity-based framework for the procurement and allocation of organs in order to balance the collective and the individual welfare of the donors and recipients of organs. I also discuss the implications of adopting that proposal.