Liver transplant center variability in accepting organ offers and its impact on patient survival

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• 作者：David S. Goldberg¹ ; ² ; ³ ; ^{david.goldberg@uphs.upenn.edu" class="auth_mail" title="E-mail the corresponding author} ; Benjamin French² ; ³ ; James D. Lewis¹ ; ² ; ³ ; Frank I. Scott¹ ; ² ; Ronac Mamtani⁴ ; Richard Gilroy⁵ ; Scott D. Halpern² ; ³ ; ⁶ ; Peter L. Abt⁷
• 关键词：OPTN ; Organ Procurement and Transplantation Network ; MELD ; Model for End-Stage Liver Disease ; UNOS ; United Network for Organ Sharing ; HCC ; hepatocellular carcinoma ; DRI ; donor risk index ; LSAM ; Liver Simulated Allocation Model
• 刊名：Journal of Hepatology
• 出版年：2016
• 出版时间：April 2016
• 年：2016
• 卷：64
• 期：4
• 页码：843-851
• 全文大小：873 K

文摘

Despite an allocation system designed to give deceased-donor livers to the sickest patients, many transplantable livers are declined by U.S. transplant centers. It is unknown whether centers vary in their propensities to decline organs for the highest priority patients, and how these decisions directly impact patient outcomes.

Methods

We analyzed Organ Procurement and Transplantation Network (OPTN) data from 5/1/07-6/17/13, and included all adult liver-alone waitlist candidates offered an organ that was ultimately transplanted. We evaluated acceptance rates of liver offers for the highest ranked patients and their subsequent waitlist mortality.

Results

Of the 23,740 unique organ offers, 8882 (37.4%) were accepted for the first-ranked patient. Despite adjusting for organ quality and recipient severity of illness, transplant centers within and across geographic regions varied strikingly (p <0.001) in the percentage of organ offers they accepted for the highest priority patients. Among all patients ranked first on waitlists, the adjusted center-specific organ acceptance rates ranged from 15.7% to 58.1%. In multivariable models, there was a 27% increased odds of waitlist mortality for every 5% absolute decrease in a center’s adjusted organ offer acceptance rate (adjusted OR: 1.27, 95% CI: 1.20–1.32). However, the absolute difference in median 5-year adjusted graft survival was 4% between livers accepted for the first-ranked patient, compared to those declined and transplanted at a lower position.

Conclusion

There is marked variability in center practices regarding accepting livers allocated to the highest priority patients. Center-level decisions to decline organs substantially increased patients’ odds of dying on the waitlist without a transplant.