Offer patterns of nationally placed livers by donation service area

Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, CA.
Liver Transplantation (Impact Factor: 4.24). 04/2013; 19(4). DOI: 10.1002/lt.23604
Source: PubMed


We previously reported that national liver distribution is highly concentrated among 6 U.S. centers, raising the possibility of expedited placement. Therefore, we evaluated all national offers of nationally placed livers (n=1625) to adult wait-list candidates from 2/05-1/10. We developed a model to predict national utilization pathways; pathways exceeding expected by ≥3 standard errors of the best-fit linear unbiased predictions were defined as "preferred". All 51 donation service areas (DSAs) placed ≥1 liver nationally, but the %/DSA ranged from 1-36%. Of 2830 possible national DSA→center pathways, 87% were utilized. 580(36%) livers were accepted on the first national offer. Four DSAs accounted for 47% of first national offer livers, of which 44% were accepted by a single center. Compared to first offer livers utilizing non-preferred pathways, first offers along a preferred pathway were offered to fewer Status 1 candidates (19 vs. 61%) and had lower median MELD scores (22 vs. 36) [p<0.001]. In conclusion, DSA placement patterns of national livers vary widely, with four DSAs exporting a high proportion of national livers on the first national offer to non-Status 1 candidates with MELD scores less than their local transplant MELD. While this practice may have facilitated liver placement, it raises the possibility of expedience trumping patient need. Here, we propose changes to the national liver distribution system that help balance equity, efficiency, and transparency. © 2013 American Association for the Study of Liver Diseases.

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Available from: Jennifer C Lai, Feb 06, 2015

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    ABSTRACT: The fate of donor livers allocated via an out-of-sequence expedited placement (EP) pathway has not been previously examined. We determined the originating and receiving UNOS Regions of all donor livers procured between 1/1/2010 and 10/31/2012 and placed out-of-sequence using UNOS bypass codes 863 (expedited placement attempt) or 898 (miscellaneous). We reviewed early function of these liver grafts and assessed the effect of EP allocation on wait-listed patients at our center. Registrants at our center were eligible to receive 1298 liver offers during the interval studied: 218 (16.8%) of these liver offers bypassed our center and were allocated to other centers and utilized in patients lower on the match run list. During the study interval, 560 livers were allocated in the U.S. by EP. Regions 1, 5, 9, 7, and 10 utilized the greatest number of EP-placed grafts. Region 1 (New England) utilized the greatest proportion of all EP livers, using 33% of all exported EP livers in the U.S. (p = 0.0002, compared to all other Regions). Graft function data was available for 560 livers placed by EP: 491 (88%) of these grafts were functioning at a mean of 399.5 days post-transplantation. Conclusions: Transplantation of livers allocated by means of an expedited refusal code is asymmetric across regions and in some instances results in bypass of patients with higher waitlist priority but without notification of the bypassed center. Short-term graft function after EP allocation was excellent. Policies governing EP allocation should be created in order to improve access to available organs. Liver Transpl, 2013. © 2013 AASLD.
    No preview · Article · Jul 2013 · Liver Transplantation

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