Source General Surgery and Transplantation Unit, Department of Surgery, "A. Gemelli" Hospital, Catholic University, Rome, Italy Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgical and Gastroenterological Sciences, University of Padua, Padua, Italy General Surgery and Liver Transplantation Unit, "S.Giovanni Battista" Hospital, University of Turin, Turin, Italy Hepatobiliary Surgery and Liver Transplantation Unit, "Niguarda" Hospital, Milan, Italy General Surgery III Liver and Lung Transplantation, "Ospedali Riuniti", Bergamo, Italy Liver and Multivisceral Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy Liver Unit, Department of Surgery, National Cancer Institute, IRCCS Foundation, Milan, Italy General Surgery ad Transplantation Unit, Department of Surgery, "Tor Vergata" University Hospital, Rome, Italy General Surgery and Liver Transplantation Unit, IRCCS Foundation, "Maggiore" Hospital, Milan, Italy Liver Transplantation Unit, Department of General Surgery and Transplantation, "Umberto I" Hospital, "La Sapienza" University, Rome Liver and Multiorgan Transplantation Unit, Department of General Surgery, "S. Orsola" Hospital, University of Bologna, Bologna, Italy General Surgery and Liver Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy Abdominal Transplantation Surgery, IsMeTT-UPMC, Palermo, Italy Epidemiology and Biostatistics Unit, Institute of Hygiene, Catholic University, Rome, Italy Multivisceral Transplantation Unit, Department of Surgical and Gastroenterological Sciences, University of Padua, Padua, Italy Delegate of the European Liver and Intestine Transplantation Association (ELITA) Gastroenterology Unit, Department of Internal Medicine, Catholic University, Rome, Italy Delegate of the Italian Association for the Study of the Liver (AISF).

Donor-recipient match is a matter of debate in liver transplantation. D-MELD (donor age × recipient biochemical model for end-stage liver disease [MELD]) and other factors were analyzed on a national Italian database recording 5946 liver transplants. Primary endpoint was to determine factors predictive of 3-year patient survival. D-MELD cutoff predictive of 5-year patient survival <50% (5yrsPS<50%) was investigated. A prognosis calculator was implemented (http://www.D-MELD.com). Differences among D-MELD deciles allowed their regrouping into three D-MELD classes (A < 338, B 338-1628, C >1628). At 3 years, the odds ratio (OR) for death was 2.03 (95% confidence interval [CI], 1.44-2.85) in D-MELD class C versus B. The OR was 0.40 (95% CI, 0.24-0.66) in class A versus class B. Other predictors were hepatitis C virus (HCV; OR = 1.42; 95% CI, 1.11-1.81), hepatitis B virus (HBV; OR = 0.69; 95% CI, 0.51-0.93), retransplant (OR = 1.82; 95% CI, 1.16-2.87) and low-volume center (OR = 1.48; 95% CI, 1.11-1.99). Cox regressions up to 90 months confirmed results. The hazard ratio was 1.97 (95% CI, 1.59-2.43) for D-MELD class C versus class B and 0.42 (95% CI, 0.29-0.60) for D-MELD class A versus class B. Recipient age, HCV, HBV and retransplant were also significant. The 5yrsPS<50% cutoff was identified only in HCV patients (D-MELD ≥ 1750). The innovative approach offered by D-MELD and covariates is helpful in predicting outcome after liver transplantation, especially in HCV recipients.