Jon J Snyder

University of Minnesota Duluth, Duluth, Minnesota, United States

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Publications (114)677.52 Total impact

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    ABSTRACT: Background and objectives: In December of 2014, the Organ Procurement and Transplant Network implemented a new Kidney Allocation System (KAS) for deceased donor transplant, with increased priority for highly sensitized candidates (calculated panel-reactive antibody [cPRA] >99%). We used a modified version of the new KAS to address issues of access and equity for these candidates. Design, setting, participants, & measurements: In a simulation, 10,988 deceased donor kidneys transplanted into waitlisted recipients in 2010 were instead allocated to candidates with cPRA≥80% (n=18,004). Each candidate's unacceptable donor HLA antigens had been entered into the allocation system by the transplant center. In simulated match runs, kidneys were allocated sequentially to adult ABO identical or permissible candidates with cPRA 100%, 99%, 98%, etc. to 80%. Allocations were restricted to donor/recipient pairs with negative virtual crossmatches. Results: The simulation indicated that 2111 of 10,988 kidneys (19.2%) would have been allocated to patients with cPRA 100% versus 74 of 10,988 (0.7%) that were actually transplanted. Of cPRA 100% candidates, 74% were predicted to be compatible with an average of six deceased donors; the remaining 26% seemed to be incompatible with every deceased donor organ that entered the system. Of kidneys actually allocated to cPRA 100% candidates in 2010, 66% (49 of 74) were six-antigen HLA matched/zero-antigen mismatched (HLA-A, -B, and -DR) with their recipients versus only 11% (237 of 2111) in the simulation. The simulation predicted that 10,356 of 14,433 (72%) candidates with cPRA 90%-100% could be allocated an organ compared with 7.3% who actually underwent transplant. Conclusions: Data in this simulation are consistent with early results of the new KAS; specifically, nearly 20% of deceased donor kidneys were (virtually) compatible with cPRA 100% candidates. Although most of these candidates were predicted to be compatible with multiple donors, approximately one-quarter are unlikely to receive a single offer.
    No preview · Article · Feb 2016 · Clinical Journal of the American Society of Nephrology
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    ABSTRACT: Background: In December 2014, a new national deceased donor kidney allocation policy was implemented, which allocates kidneys in the top 20% of the kidney donor profile index to candidates in the top 20% of expected survival. We examined the cost implications of this policy change. Methods: A Markov model was applied to estimate differences in total lifetime cost of care and quality-adjusted life years (QALY). Results: Under the old allocation policy, average lifetime outcomes per listed patient discounted to 2012 US dollars were US $342 799 and 5.42 QALY, yielding US $63 775 per QALY gained. Under the new policy, average lifetime cost was reduced by US $2090 and lifetime QALYs increased by 0.03. Thus, the new policy improved on the old policy by producing more QALYs at lower cost. The present value of total lifetime cost savings from the policy change is estimated to be US $271 million in the first year and US $55 million in subsequent years. The higher transplant rates and allograft survival expected for candidates in the top 20% of expected survival would decrease costs by reducing time on dialysis. Most cost savings are expected to accrue to Medicare, and most increased access to transplant is expected in private payer populations. Conclusions: The new allocation policy was found to be dominant over the old policy because it increases QALYs at lower cost.
    No preview · Article · Jan 2016 · Transplantation
  • Article: Liver
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    ABSTRACT: The median waiting time for patients with MELD ≥ 35 decreased from 18 days in 2012 to 9 days in 2014, after implementation of the Share 35 policy in June 2013. Similarly, mortality among candidates listed with MELD ≥ 35 decreased from 366 per 100 waitlist years in 2012 to 315 in 2014. The number of new active candidates added to the pediatric liver transplant waiting list in 2014 was 655, down from a peak of 826 in 2005. The number of prevalent candidates (on the list on December 31 of the given year) continued to decline, 401 active and 173 inactive. The number of deceased donor pediatric liver transplants peaked at 542 in 2008 and was 478 in 2014. The number of living donor liver pediatric transplants was 52 in 2014; most were from donors closely related to the recipients. Graft survival continued to improve among pediatric recipients of deceased donor and living donor livers.
    No preview · Article · Jan 2016 · American Journal of Transplantation
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    ABSTRACT: SRTR uses data collected by OPTN to calculate metrics such as donation/conversion rate, organ yield, and rate of organs recovered for transplant but not transplanted. In 2014, 9252 eligible deaths were reported by organ procurement organizations, a slight increase from 8944 in 2012, and the donation/conversation rate was 73.4 eligible donors per 100 eligible deaths, a slight increase from 71.3 in 2013. Some metrics show variation across organ procurement organizations, suggesting that sharing best practices could lead to gains in efficiency and organ retrieval.
    No preview · Article · Jan 2016 · American Journal of Transplantation
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    ABSTRACT: Background: For recipients of liver transplants for hepatocellular carcinoma (HCC), HCC recurrence after transplantation remains a major concern. Sirolimus, an immunosuppressant with anti-carcinogenic properties, may reduce HCC recurrence and improve survival. Methods: The U.S. Scientific Registry of Transplant Recipients was linked to pharmacy claims. For liver recipients transplanted for HCC, Cox regression was used to estimate associations of early sirolimus use with recurrence, cancer-specific mortality, and all-cause mortality adjusting for recipient ethnicity, calendar year of transplant, total tumor volume, alpha-fetoprotein, transplant center size, use of IL-2 induction therapy, and allocated and calculated model for end-stage liver disease score. We performed stratified analyses among recipients who met Milan criteria, among those without renal failure, among those with deceased liver donors, by age at transplantation, and by tumor size. Results: Among the 3,936 included HCC liver transplants, 234 (6%) were sirolimus users. In total, there were 242 recurrences and 879 deaths, including 261 cancer-related deaths. All-cause mortality was similar in sirolimus users and non-users (adjusted hazard ratio [HR] =1.01, 95%CI=0.73-1.39). HCC recurrence and cancer-specific mortality rates appeared lower in sirolimus users, but associations were not statistically significant (recurrence HR=0.86, 95%CI=0.45-1.65; cancer-specific mortality HR=0.80, 95%CI=0.43-1.50). Among recipients >55 years old, associations were suggestive of better outcomes for sirolimus users (all-cause mortality HR=0.62, 95%CI=0.38-1.01; recurrence HR=0.52, 95%CI=0.19-1.44; cancer-specific mortality HR=0.34, 95%CI=0.11-1.09), while among recipients ≤55 years old, sirolimus users had worse outcomes (all-cause mortality HR=1.76, 95%CI=1.12-2.75; recurrence HR=1.49, 95%CI=0.62-3.61; cancer-specific mortality HR=1.54, 95%CI=0.71-3.32). Conclusions: Among HCC liver recipients overall, sirolimus did not appear beneficial in reducing all-cause mortality. However, there were suggestions of reductions in recurrence and cancer-specific mortality, and effects appeared to be modified by age at transplantation. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Liver Transplantation
  • Article: Pancreas
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    ABSTRACT: Even though pancreas transplant numbers have steadily declined over the past decade, new listings increased in 2014 compared with the previous year, notably for pancreas transplant alone (PTA) and simultaneous pancreas-kidney transplant. The number of new PTAs also increased over the past two years. Whether this is a sustainable trend remains to be seen. Significant events in 2014 included implementation of a new pancreas allocation system and development of a proposed uniform definition of pancreas graft failure. Meanwhile, overall pancreas transplant rates and outcomes continued to improve. Substantial decline in pancreas after kidney transplants remains a serious concern. SRTR has not published pancreas graft failure data in the program-specific reports for the past two years. While this will not change in the near future, the acceptance of a uniform definition of graft failure is a crucial first step toward resuming graft failure reporting. Continued improvements and innovation, both surgical and immunological, will be critical to keep pancreas transplant as a viable option for treatment of insulin-dependent diabetes. As alternative therapies for diabetes such as islet transplant and artificial pancreas are evolving, improved outcomes with minimizations of complications are more important than ever.
    No preview · Article · Jan 2016 · American Journal of Transplantation
  • Article: Kidney
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    ABSTRACT: Kidney transplant provides significant survival, cost, and quality-of-life benefits over dialysis in patients with end-stage kidney disease, but the number of kidney transplant candidates on the waiting list continues to grow annually. By the end of 2014, nearly 100,000 adult candidates and 1500 pediatric candidates were waiting for kidney transplant. Not surprisingly, waiting times also continued to increase, along with the number of adult candidates removed from the list due to death or deteriorating medical condition. Death censored graft survival has increased after both living and deceased donor transplants over the past decade in adult recipients. The majority of the trends seen over the past 5 years continued in 2014. However, the new allocation system was implemented in late 2014, providing an opportunity to assess changes in these trends in the coming years.
    No preview · Article · Jan 2016 · American Journal of Transplantation
  • Article: Intestine
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    ABSTRACT: Intestine and intestine-liver transplant plays an important role in the treatment of intestinal failure, despite decreased morbidity associated with parenteral nutrition. In 2014, 210 new patients were added to the intestine transplant waiting list. Among prevalent patients on the list at the end of 2014, 65% were waiting for an intestine transplant and 35% were waiting for an intestine-liver transplant. The pretransplant mortality rate decreased dramatically over time for all age groups. Pretransplant mortality was highest for adult candidates, at 22.1 per 100 waitlist years compared with less than 3 per 100 waitlist years for pediatric candidates, and notably higher for candidates for intestine-liver transplant than for candidates for intestine transplant without a liver. Numbers of intestine transplants without a liver increased from a low of 51 in 2013 to 67 in 2014. Intestine-liver transplants increased from a low of 44 in 2012 to 72 in 2014. Short-gut syndrome (congenital and other) was the main cause of disease leading to both intestine and intestine-liver transplant. Graft survival improved over the past decade. Patient survival was lowest for adult intestine-liver recipients and highest for pediatric intestine recipients.
    No preview · Article · Jan 2016 · American Journal of Transplantation
  • Article: Heart
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    ABSTRACT: As the number of candidates listed for heart transplant continues to rise, it is encouraging that the number of heart transplants also continues to rise steadily each year. Evaluation of waitlist activity demonstrates a growing number of adult candidates removed from the list due to undergoing transplant, but also growing numbers of adult candidates added to the list over the past 3 years. In 2014, 2679 heart transplants were performed, an increase of 28.4% since 2003, and the number of people living with a transplanted heart continued to increase. The number of new pediatric candidates added to the heart transplant waiting list increased to 593 in 2014. The number of pediatric heart transplants performed each year increased from 293 in 2003 to 410 in 2014. Almost 60% of pediatric candidates waiting on December 31, 2014, had been waiting for less than 1 year, compared with 43.0% in 2004. Among pediatric patients who underwent transplant in 2008-2012, overall cumulative incidence of death at 1, 3, and 5 years was 9.2%, 14.7%, and 18.3%, respectively.
    No preview · Article · Jan 2016 · American Journal of Transplantation
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    ABSTRACT: Background: Solid organ transplant recipients have heightened risk for diffuse large B-cell lymphoma (DLBCL). The role of donor-recipient HLA mismatch and recipient HLA type on DLBCL risk are not well established. Methods: We examined 172 231 kidney, heart, pancreas, and lung recipients transplanted in the United States between 1987 and 2010, including 902 with DLBCL. Incidence rate ratios (IRRs) were calculated using Poisson regression for DLBCL risk in relation to HLA mismatch, types, and zygosity, adjusting for sex, age, race/ethnicity, year, organ, and transplant number. Results: Compared with recipients who had 2 HLA-DR mismatches, those with zero or 1 mismatch had reduced DLBCL risk, (zero: IRR, 0.76, 95% confidence interval [95% CI], 0.61-0.95; one: IRR, 0.83; 95% CI, 0.69-1.00). In stratified analyses, recipients matched at either HLA-A, -B, or -DR had a significantly reduced risk of late-onset (>2 years after transplantation), but not early-onset DLBCL, and there was a trend for decreasing risk with decreasing mismatch across all 3 loci (P = 0.0003). Several individual recipient HLA-A, -B, -C, -DR, and -DQ antigens were also associated with DLBCL risk, including DR13 (IRR, 0.74; 95% CI, 0.57-0.93) and B38 (IRR, 1.48; 95% CI, 1.10-1.93), confirming prior findings that these 2 antigens are associated with risk of infection-associated cancers. Conclusions: In conclusion, variation in HLA is related to susceptibility to DLBCL, perhaps reflecting intensity of immunosuppression, control of Epstein-Barr virus infection among transplant recipients or chronic immune stimulation.
    No preview · Article · Dec 2015 · Transplantation
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    ABSTRACT: Among patients with ESRD, cancer risk is affected by kidney dysfunction and by immunosuppression after transplant. Assessing patterns across periods of dialysis and kidney transplantation may inform cancer etiology. We evaluated 202,195 kidney transplant candidates and recipients from a linkage between the Scientific Registry of Transplant Recipients and cancer registries, and compared incidence in kidney function intervals (time with a transplant) with incidence in nonfunction intervals (waitlist or time after transplant failure), adjusting for demographic factors. Incidence of infection-related and immune-related cancer was higher during kidney function intervals than during nonfunction intervals. Incidence was most elevated for Kaposi sarcoma (hazard ratio [HR], 9.1; 95% confidence interval (95% CI), 4.7 to 18), non-Hodgkin's lymphoma (HR, 3.2; 95% CI, 2.8 to 3.7), Hodgkin's lymphoma (HR, 3.0; 95% CI, 1.7 to 5.3), lip cancer (HR, 3.4; 95% CI, 2.0 to 6.0), and nonepithelial skin cancers (HR, 3.8; 95% CI, 2.5 to 5.8). Conversely, ESRD-related cancer incidence was lower during kidney function intervals (kidney cancer: HR, 0.8; 95% CI, 0.7 to 0.8 and thyroid cancer: HR, 0.7; 95% CI, 0.6 to 0.8). With each successive interval, incidence changed in alternating directions for non-Hodgkin's lymphoma, melanoma, and lung, pancreatic, and nonepithelial skin cancers (higher during function intervals), and kidney and thyroid cancers (higher during nonfunction intervals). For many cancers, incidence remained higher than in the general population across all intervals. These data indicate strong short-term effects of kidney dysfunction and immunosuppression on cancer incidence in patients with ESRD, suggesting a need for persistent cancer screening and prevention.
    No preview · Article · Nov 2015 · Journal of the American Society of Nephrology
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    ABSTRACT: Background: Ventricular assist devices (VADs) have improved survival among end-stage heart disease patients. Since 2002, heart transplant candidates with VADs have been afforded 30 days of elective time at the highest urgency category (Status 1A) under Organ Procurement and Transplantation Network (OPTN) policy. We aimed to determine the effect of increasing elective time at the highest urgency category for heart transplant candidates with VADs. This analysis was requested by OPTN during its evaluation of heart allocation policy. Methods: We simulated several allocation schemes wherein elective Status 1A time was increased to 45, 60, and 90 days; results were compared with a baseline simulation of 30 days and with the actual observed heart transplant waiting list cohort. Results: The simulations showed that increasing elective Status 1A time for candidates with VADs did not substantially change waiting list mortality overall or for sub-groups of concern, which were candidates with VADs listed at a lower-urgency category (Status 1B), those with with VAD complications, total artificial heart, or intraaortic balloon pump support; or those with extracorporeal membrane oxygenation. Across the different time allowances, the average post-transplant death rate remained stable. It also remained stable for recipients previously listed as Status 1A or 1B categories for VAD and for recipients with VAD complications or an intraaortic balloon pump at transplant, on extracorporeal membrane oxygenation, and those without devices. Conclusions: Our results suggest that increasing time in the highest urgency category for candidates with VADs would not improve waiting list mortality or post-transplant outcomes for heart transplant candidates overall. © 2015 International Society for Heart and Lung Transplantation.
    No preview · Article · Oct 2015
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    ABSTRACT: Solid organ transplant recipients, who are medically immunosuppressed to prevent graft rejection, have increased melanoma risk, but risk factors and outcomes are incompletely documented. We evaluated melanoma incidence among 139,991 non-Hispanic white transplants using linked U.S. transplant-cancer registry data (1987-2010). We used standardized incidence ratios (SIRs) to compare incidence to the general population, and incidence rate ratios (IRRs) from multivariable Poisson models to assess risk factors. Separately, we compared post-melanoma survival among transplant recipients (N=182) and non-recipients (N=131,358) using multivariable Cox models. Among transplant recipients, risk of invasive melanoma (N=519) was elevated (SIR=2.20, 95%CI 2.01-2.39), especially for regional stage tumors (SIR=4.11, 95%CI 3.27-5.09). Risk of localized tumors was stable over time after transplantation, but higher with azathioprine maintenance therapy (IRR=1.35, 95%CI 1.03-1.77). Risk of regional/distant stage tumors peaked within 4 years following transplantation and increased with polyclonal antibody induction therapy (IRR=1.65, 95%CI 1.02-2.67). Melanoma-specific mortality was higher among transplant recipients than non-recipients (HR 2.98, 95%CI 2.26-3.93). Melanoma exhibits increased incidence and aggressive behavior under transplant-related immunosuppression. Some localized melanomas may result from azathioprine, which acts synergistically with ultraviolet radiation, while T-cell depleting induction therapies may promote late stage tumors. Our findings support sun safety practices and skin screening for transplant recipients.Journal of Investigative Dermatology accepted article preview online, 13 August 2015. doi:10.1038/jid.2015.312.
    No preview · Article · Aug 2015 · Journal of Investigative Dermatology
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    ABSTRACT: Created by the US National Organ Transplant Act in 1984, the Scientific Registry of Transplant Recipients (SRTR) is obligated to publicly report data on transplant program and organ procurement organization performance in the United States. These reports include risk-adjusted assessments of graft and patient survival, and programs performing worse or better than expected are identified. The SRTR currently maintains 43 risk adjustment models for assessing posttransplant patient and graft survival and, in collaboration with the SRTR Technical Advisory Committee, has developed and implemented a new systematic process for model evaluation and revision. Patient cohorts for the risk adjustment models are identified, and single-organ and multiorgan transplants are defined, then each risk adjustment model is developed following a prespecified set of steps. Model performance is assessed, the model is refit to a more recent cohort before each evaluation cycle, and then it is applied to the evaluation cohort. The field of solid organ transplantation is unique in the breadth of the standardized data that are collected. These data allow for quality assessment across all transplant providers in the United States. A standardized process of risk model development using data from national registries may enhance the field.
    No preview · Article · Aug 2015 · Transplantation
  • N Salkowski · J J Snyder · B L Kasiske

    No preview · Article · Jun 2015 · American Journal of Transplantation
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    ABSTRACT: Concerns have been raised that optimized redistricting of liver allocation areas might have the unintended result of shifting livers from better-performing to poorer-performing OPOs. We used the Liver Simulated Allocation Model to simulate a 5-year period of liver sharing within either 4 or 8 optimized districts. We investigated whether each OPO's net liver import under redistricting would be correlated with two OPO performance metrics (observed to expected liver yield and liver donor conversion ratio), along with two other potential correlates (eligible deaths and incident listings above MELD 15). We found no evidence that livers would flow from better-performing OPOs to poorer-performing OPOs in either redistricting scenario. Instead, under these optimized redistricting plans, our simulations suggest that livers would flow from OPOs with more-than-expected eligible deaths toward those with fewer-than-expected eligible deaths, and that livers would flow from OPOs with fewer-than-expected incident listings to those with more-than-expected incident listings, the latter a pattern already established in the current allocation system. Redistricting liver distribution to reduce geographic inequity is expected to align liver allocation across the country with the distribution of supply and demand, rather than transferring livers from better-performing OPOs to poorer-performing OPOs. This article is protected by copyright. All rights reserved. © 2015 American Association for the Study of Liver Diseases.
    No preview · Article · May 2015 · Liver Transplantation
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    ABSTRACT: Bending the cost curve in medical expenses is a high national priority. The relationship between cost and kidney allograft failure has not been fully investigated in the United States. Using Medicare claims from the United States Renal Data System, we determined costs for all adults with Medicare coverage who underwent kidney transplant January 1, 2007, to June 30, 2009. We compared relative cost (observed/expected payment) for year 1 after transplantation for all transplant centers, adjusting for recipient, donor, and transplant characteristics, region, and local wage index. Using program-specific reports from the Scientific Registry of Transplant Recipients, we correlated relative cost with observed/expected allograft failure between centers, excluding small centers. Among 19,603 transplants at 166 centers, mean observed cost per patient per center was $65,366 (interquartile range, $55,094-$71,624). Mean relative cost was 0.99 (±0.20); mean observed/expected allograft failure was 1.03 (±0.46). Overall, there was no correlation between relative cost and observed/expected allograft failure (r = 0.096, P = 0.22). Comparing centers with higher than expected costs and allograft failure rates (lower performing) and centers with lower than expected costs and failure rates (higher-performing) showed differences in donor and recipient characteristics. As these characteristics were accounted for in the adjusted cost and allograft failure models, they are unlikely to explain the differences between higher- and lower-performing centers. Further investigations are needed to determine specific cost-effective practices of higher- and lower-performing centers to reduce costs and incidence of allograft failure.
    No preview · Article · Apr 2015 · Transplantation
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    ABSTRACT: There have been few prospective controlled studies of kidney donors. Understanding the pathophysiologic effects of kidney donation is important for judging donor safety and improving our understanding of the consequences of reduced kidney function in chronic kidney disease. Prospective, controlled, observational cohort study. 3-year follow-up of kidney donors and paired controls suitable for donation at their donor's center. Kidney donation. Medical history, vital signs, glomerular filtration rate, and other measurements at 6, 12, 24, and 36 months after donation. At 36 months, 182 of 203 (89.7%) original donors and 173 of 201 (86.1%) original controls continue to participate in follow-up visits. The linear slope of the glomerular filtration rate measured by plasma iohexol clearance declined 0.36±7.55mL/min per year in 194 controls, but increased 1.47±5.02mL/min per year in 198 donors (P=0.005) between 6 and 36 months. Blood pressure was not different between donors and controls at any visit, and at 36 months, all 24-hour ambulatory blood pressure parameters were similar in 126 controls and 135 donors (mean systolic blood pressure, 120.0±11.2 [SD] vs 120.7±9.7mmHg [P=0.6]; mean diastolic blood pressure, 73.4±7.0 vs 74.5±6.5mmHg [P=0.2]). Mean arterial pressure nocturnal dipping was manifest in 11.2% ± 6.6% of controls and 11.3% ± 6.1% of donors (P=0.9). Urinary protein-creatinine and albumin-creatinine ratios were not increased in donors compared with controls. From 6 to 36 months postdonation, serum parathyroid hormone, uric acid, homocysteine, and potassium levels were higher, whereas hemoglobin levels were lower, in donors compared with controls. Possible bias resulting from an inability to select controls screened to be as healthy as donors, short follow-up duration, and dropouts. Kidney donors manifest several of the findings of mild chronic kidney disease. However, at 36 months after donation, kidney function continues to improve in donors, whereas controls have expected age-related declines in function. Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Mar 2015 · American Journal of Kidney Diseases
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    ABSTRACT: Unlabelled: The current system granting liver transplant candidates with hepatocellular carcinoma (HCC) additional Model for End-Stage Liver Disease (MELD) points is controversial due to geographic disparity and uncertainty regarding optimal prioritization of candidates. The current national policy assigns a MELD exception score of 22 immediately upon listing of eligible patients with HCC. The aim of this study was to evaluate the potential effects of delays in granting these exception points on transplant rates for HCC and non-HCC patients. We used Scientific Registry of Transplant Recipients data and liver simulated allocation modeling software and modeled (1) a 3-month delay before granting a MELD exception score of 25, (2) a 6-month delay before granting a score of 28, and (3) a 9-month delay before granting a score of 29. Of all candidates waitlisted between January 1 and December 31, 2010 (n = 28,053), 2773 (9.9%) had an HCC MELD exception. For HCC candidates, transplant rates would be 108.7, 65.0, 44.2, and 33.6 per 100 person-years for the current policy and for 3-, 6-, and 9-month delays, respectively. Corresponding rates would be 30.1, 32.5, 33.9, and 34.8 for non-HCC candidates. Conclusion: A delay of 6-9 months would eliminate the geographic variability in the discrepancy between HCC and non-HCC transplant rates under current policy and may allow for more equal access to transplant for all candidates.
    No preview · Article · Jan 2015 · Hepatology
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    ABSTRACT: While the costs to Medicare of solid organ transplant are varied and considerable, the total Medicare expenditure of $4.4 billion for solid organ transplant recipients was less than 1 remains one of the most cost-effective surgical interventions in medicine. Heart transplant, the most expensive of the major transplants, is likely cost-effective; SRTR has released an Excel-based tool for investigators to use in exploring this question further. It is likely that most solid organ transplants are cost-effective, given the results presented here and the relatively high cost of heart transplant. However, this must be verified with further study.
    No preview · Article · Jan 2015 · American Journal of Transplantation

Publication Stats

6k Citations
677.52 Total Impact Points


  • 2008-2016
    • University of Minnesota Duluth
      • Medical School
      Duluth, Minnesota, United States
  • 2014-2015
    • Washington University in St. Louis
      San Luis, Missouri, United States
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
    • United Network for Organ Sharing
      Ричмонд, Virginia, United States
    • Stanford University
      Stanford, California, United States
  • 2003-2015
    • Minneapolis Medical Research Foundation
      Minneapolis, Minnesota, United States
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States
  • 2012
    • National Institutes of Health
      • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
      Bethesda, MD, United States
  • 2002-2008
    • Hennepin County Medical Center
      Minneapolis, Minnesota, United States