Should a Lower Quality Organ Go to the Least Sick Patient? Model for End-Stage Liver Disease Score and Donor Risk Index as Predictors of Early Allograft Dysfunction
ABSTRACT There is a global tendency to justify transplanting extended criteria organs (ECD; Donor Risk Index [DRI] ≥ 1.7) into recipients with a lower Model for End-Stage Liver Disease (MELD) score and to transplant standard criteria organs (DRI < 1.7) into recipients with a higher MELD scores. There is a lack of evidence in the current literature to justify this assumption.
A review of our prospectively entered database for donation after brain death (DBD) liver transplantation (n = 310) between January 1, 2006, and September 30, 2010, was performed. DRI was dichotomized as <1.7 and ≥ 1.7. Recipients were divided into 3 strata, those with high (≥ 27), moderate (15-26), and low MELD (<15) scores. The recently validated definition of early allograft dysfunction (EAD) was used. We analyzed EAD and its relation with donor DRI and recipient MELD scores.
The overall incidence of EAD was 24.5%. Mortality in the first 6 months in recipients with EAD was 20% compared with 3.4% for those without EAD (relative risk [RR], 5.56, 95% confidence interval [CI], 1.96-15.73; P < .001). Graft failure rate in the first 6 months in those with EAD was 27% compared with 5.8% for those without EAD (RR, 4.63; 95% CI, 2.02-10.6; P < .001). In patients with low MELD scores, a significantly increased rate of EAD (25%) was seen in patients transplanted with a high DRI liver compared with those transplanted with a low DRI liver (6.25%; P = .012). In moderate and high MELD recipients, there was no significant difference in the rate of EAD in patients transplanted with a high DRI liver (62%) compared with those transplanted with a low DRI liver (59%).
These results suggest that contrary to common belief it is not justified to preferentially allocate organs with higher DRI to recipients with lower MELD scores.
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ABSTRACT: The impact of ischemia/reperfusion injury in the setting of transplantation for hepatocellular carcinoma (HCC) has not been thoroughly investigated. The present study examined data from the Scientific Registry of Transplant Recipients for all recipients of deceased donor liver transplants performed between January 1, 1995 and October 31, 2011. In a multivariate Cox analysis, significant predictors of patient survival included the following: HCC diagnosis (P < 0.01), donation after cardiac death (DCD) allograft (P < 0.001), hepatitis C virus-positive status (P < 0.01), recipient age (P < 0.01), donor age (P < 0.001), Model for End-Stage Liver Disease score (P < 0.001), recipient race, and an alpha-fetoprotein level > 400 ng/mL at the time of transplantation. In order to test whether the decreased survival seen for HCC recipients of DCD grafts was more than would be expected because of the inferior nature of DCD grafts and the diagnosis of HCC, a DCD allograft/HCC diagnosis interaction term was created to look for potentiation of effect. In a multivariate analysis adjusted for all other covariates, this interaction term was statistically significant (P = 0.049) and confirmed that there was potentiation of inferior survival with the use of DCD allografts in recipients with HCC. In conclusion, patient survival and graft survival were inferior for HCC recipients of DCD allografts versus recipients of donation after brain death allografts. This potentiation of effect of inferior survival remained even after adjustments for the inherent inferiority observed in DCD allografts as well as other known risk factors. It is hypothesized that this difference could reflect an increased rate of recurrence of HCC. Liver Transpl 19:1214-1223, 2013. (c) 2013 AASLD.Liver Transplantation 11/2013; 19(11). DOI:10.1002/lt.23715 · 3.79 Impact Factor
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ABSTRACT: Background: Liver organ donor characteristics have a significant impact on graft quality and in turn recipient outcome. In this study, we examined deceased liver donor characteristics and Donor Risk Index (DRI) trends in Canada over the past decade. Methods: Data were extracted from the Canadian Organ Replacement Register (CORR) and Quebec Transplant for the decade (2000-2010). Trends in the DRI and donor characteristics were examined including: age, race, height, cause of death (COD), location, cold ischemia time (CIT), and type of donation. Results: 3745 transplants using deceased liver donors were analyzed. Donor age, proportion of black donors, proportion of cerebrovascular accident as a COD, and proportion of donation after cardiac death (DCD) donors all increased over the aforementioned time period. The proportion of transplants classified geographically as local increased and the CIT for donor livers decreased. Although many of the parameters that adversely affect DRI increased over the study period, the DRI only showed a small significant trend in increasing value. The increase in these parameters has been counteracted by a decrease in modifiable risk factors such as CIT and distance traveled. Recipient 5-year survival rates increased from 71.43% (1999-2001) to 75.5% (2005-2007), however this trend was not significant. Although there was an increase in the utilization of older and DCD donor organs, recipient survival was not compromised. Conclusions: Liver donor demographic trends in Canada suggest an increase in utilization of higher risk donors. However, overall graft quality is not compromised due to a decreasing trend in CIT and increase in local transplants. Better coordination and allocation practices in liver transplantation across Canada minimize the risk for graft failure and results in good recipient outcomes. Liver Transpl , 2013. © 2013 AASLD.Liver Transplantation 11/2013; 19(11). DOI:10.1002/lt.23718 · 3.79 Impact Factor
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ABSTRACT: There are limited data on length of stay (LOS) following liver transplantation (LT), yet this is an important health services metric that directly correlates with early post-LT health care costs. The primary objective of this study was to examine the relationship between early allograft dysfunction (EAD) and LOS after LT. The secondary objective was to identify additional recipient, donor, and operative factors associated with LOS. Adult patients undergoing primary LT over a 32-month period were prospectively examined at a single center. Subjects fulfilling standard criteria for EAD were compared with those not meeting the definition. Variables associated with increased LOS on ordinal logistic regression were identified. Subjects with EAD had longer mean hospital LOS than those without (42.5 ± 38.9 days vs 27.4 ± 31 days; P = .003). Subjects with EAD also had longer mean intensive care LOS (8.61 ± 10.28 days vs 5.45 ± 11.6 days; P = .048). Additional factors significantly associated with LOS included Model for End-Stage Liver Disease (MELD) score, recipient location before LT, and postoperative surgical complications. EAD is associated with longer hospitalization after LT. MELD score, preoperative recipient location, and postoperative complications were significantly associated with LOS. From a cost-containment perspective, these findings have implications on resource allocation.Transplantation Proceedings 01/2013; 45(1):259-64. DOI:10.1016/j.transproceed.2012.07.147 · 0.95 Impact Factor