OPTN/SRTR 2020 Annual Data Report: COVID

A change of heart: Preliminary results of the US 2018 adult heart allocation revision.

Maximizing donors' gifts: A comparison of actual and expected solid organ yield among VCA donors.

Our aim was to evaluate liver transplant outcomes involving donors with high macrosteatosis grafts in the obese modern liver transplant recipient population. A high-steatosis graft was defined as donor graft macrosteatosis ≥30% on biopsy. Recipient obesity was defined as body mass index (BMI) >35 adjusted for ascites. Raw and adjusted recipient liver transplant survival were evaluated and compared between 4 cohorts: (1) high-steatosis graft in high-BMI recipient; (2) low-steatosis graft in high-BMI recipient; (3) high-steatosis graft in normal-BMI recipient; and (4) low-steatosis graft in normal-BMI recipient. After adjustment for multiple factors, recipient high-BMI remained an independent predictor of posttransplant mortality at 30 days (P < 0.0001) and persisted at 1 year (P = 0.009). A high-steatosis graft was the strongest independent predictor of mortality at 30 days (hazard ratio 2.05, 1.66-2.53; P < 0.0001) and that effect was diminished but persistent at 1 year (1.27, 1.10-1.46; P = 0.001). Recipient high-BMI and a high-steatosis graft are both significant independent and equally powerful predictors of mortality after modern liver transplant. High-steatosis grafts transplanted into obese recipients have the highest mortality. The increase in mortality associated with a high-steatosis graft into a normal-BMI recipient is similar in magnitude to a low-steatosis graft placed into a high-BMI recipient.

Liver transplantation for alcoholic hepatitis in the United States: Excellent outcomes with profound temporal and geographic variation in frequency.

Utilizing High-Risk Kidneys-Risks, Benefits, and Unintended Consequences?

Objectives: 1)To evaluate liver allograft utilization, as determined by allograft availability, origin, and failure probability estimates utilizing the liver donor risk index (LDRI). 2) Correlate allograft utilization with waitlist mortality. Methods: A Scientific Registry of Transplant Recipients (SRTR) search of adult (age>18years), initial transplant, liver allograft only US recipients from 01/01/03 through 12/31/12 identified 44686 transplant procedures. Origin was categorized as local (LCL), regional (RGN), or national (NTL) by Organ Procurement and Transplant Network (OPTN) classification and LDRI calculated. Allograft availability, donor classification as donation after brain death (DBD) or donation after cardiac death (DCD), and waitlist mortality were integrated through separate SRTR queries. Results: Consented DBD and DCD donors significantly increased over the study period (p<0.01); however, the probabilities of a consented DBD or DCD donor yielding a transplanted liver allograft have declined from a peak of 89% and 44% in 2007 to a decade low 84% and 38%; respectively (p<0.05). LCL allograft utilization has increased while NTL utilization has significantly declined. Median LDRI decreased in 4 of 11 OPTN regions (mean: 5%) while increasing in 6 regions (mean: 8% [ p=NS]). LCL and RGN median LDRI were not significantly different over the study period while NTL median LDRI significantly decreased (p<0.05). Waitlist mortality, as defined by candidates removed for death or too ill for transplantation has not improved. Conclusion: Significant increases in consented DBD and DCD liver allograft donors have not yielded equivalent increases in transplant activity or decreased waitlist mortality due to stagnant allograft acceptance practices and lower utilization of high-risk allografts.

The authors, from well-respected and accomplished liver transplant centers in Houston and San Antonio, write of the geographic disparities and deceased donor liver transplantation within United Network for Organ Sharing region 4.1 They note significant differences in Model for End-Stage Liver Disease scores at liver transplant for non–status 1 candidates, importantly point to data showing greater risk of being delisted, and point out that the risk of being delisted is directly proportional to the donor service area (DSA) size and varies among the four DSAs. Regrettably, this analysis is incomplete and perhaps disingenuous. First, the time period covered in this data analysis precedes the implementation of the mandatory share 15 rule, which may well have a significant impact both in region 4 and nationally on transplant rates and may obviate the differences within DSAs. Second, the authors advocate for increased intraregional sharing of liver allografts, yet they are the same group who brought this issue before the liver intestine committee at the United Network for Organ Sharing, which prompted Scientific Registry of Transplant Recipients modeling of broader geographic sharing within region 4. The Scientific Registry of Transplant Recipients modeling data, which these authors chose not to present, showed no benefit in overall mortality (pretransplant and posttransplant) with broader regional sharing within region 4. Finally, and perhaps most importantly, their analysis completely omits the primary reason for differential delisting rates within region 4: a sharp difference in donor organ acceptance rates within the adult liver transplant centers of region 4. In fact, in some of the DSAs with the lowest delisting rates, the organ acceptance rates are some of the highest in the country and clearly higher than those in the DSAs in which delisting rates are not as favorable. The authors, to their credit, address an important topic. They should be encouraged to present all of the data that are pertinent to the analysis. Marlon F. Levy M.D., F.A.C.S. [email protected]*, * Transplant Services, Baylor University Medical Center, Dallas, TX.

Kidney transplant (KT) directors are general surgeons or urologists. All KT centers must meet established performance standards. However, it has not been established if general surgery and urology led programs have disparate outcomes. Transplant outcomes and donor-recipient characteristics by director training were investigated. Organ Procurement and Transplantation Network (OPTN) directory, program websites were analyzed for surgical director demographics. Scientific Registry of Transplant Recipients (SRTR) 1-year kidney survival and deceased donor (DD) wait-time rankings were evaluated. A retrospective analysis of 142157 KT recipients from 2010 to 2019 was performed using the United Network for Organ Sharing (UNOS) database. One hunderd and seventy three (90.6%) KT programs were led by general surgeons. There were no significant differences in gender, ethnicity, region, credentials, or fellowship completion. Recipients undergoing KT with urology led programs were older (P=.002) and had longer wait-times (P<.001). These centers used higher KDPI (.47vs. .45, P<.001) and higher HLA mismatch (3.92vs. 3.89, P=.02) kidneys. Urology led centers utilized living donors less frequently (32.1%vs. 35.8%, P<.001) and had longer CIT (15.44vs. 12.21, P<.001). Both had similar SRTR ranking of 1-year survival and DD wait-time. Most directors were general surgeon. Patient outcomes did not differ by transplant director training. Urologists represent a viable option for KT leadership and recruitment should be encouraged.

Expanding the kidney donor pool: Ethical and medical considerations

US Transplant Policy Should Strengthen Bridges, Not Build Walls.

IntroductionThe Association of Maternal & Child Health Programs (AMCHP) and the Association of State and Territorial Health Officials (ASTHO) launched the PRISM (Promoting Innovation in State and Territorial MCH Policymaking) Learning Community, funded by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). The goal of PRISM was to build state and territorial health agency program and policy-making capacity to address substance use and mental health in the maternal and child health (MCH) population. Expanding access to care and treatment for perinatal substance use disorders (SUD) emerged as the issue of greatest need for state teams.MethodsThe PRISM Learning Community consisted of three major components: (1) intensive capacity building for cross-agency state teams, which involved action planning, peer-to-peer learning, and technical assistance; (2) programming to inform the MCH field broadly about innovations in perinatal SUD policy and practice; and (3) a program evaluation involving pre-, mid-, and post-assessments and follow-up key informant interviews with state teams. This manuscript is not based on clinical study or patient data, therefore IRB approval was not required.ResultsStates reported that their knowledge of perinatal SUDs increased and their cross-agency partnerships were strengthened as a result of their participation in PRISM. States identified four key priorities for their continued work: to improve multisector collaborations, to institute equitable SUD screening practices for pregnant people, to strengthen the perinatal behavioral health workforce, and to enhance Medicaid coverage for perinatal SUD prevention and treatment services. The need to respond to urgent demands of COVID-19 and the stigma associated with perinatal SUDs were the most significant barriers to advancing state action plan goals.DiscussionSince 2018, the PRISM project has supported nine jurisdictions across two cohorts. Participation in PRISM advanced state policies and programs to improve perinatal SUD care through capacity building, technical assistance, and virtual programming. Findings and lessons learned from PRISM may inform the activities of other states seeking to address perinatal substance use disorders.

Background: There are known disparities in waitlist outcomes by race and sex among patients bridged to heart transplant (BTT) with durable mechanical circulatory support (MCS). With the increasing use of temporary MCS devices (tMCS), we examined waitlist and post-transplant outcomes of patients who had BTT with tMCS. Methods: Data from the United Network for Organ Sharing (UNOS) database was used to identify patients BTT with tMCS between 2008 and 2018. Patients were stratified by race and sex. Primary outcomes were waitlist mortality within 1 year of listing and 1 year post-transplant mortality among those who successfully reached transplant. Survival was examined with the Kaplan Meier method and Cox proportional hazard modeling. Results: A total of 997 patients received tMCS as BTT, including 606 white, 203 Black, 119 Hispanic, 56 Asian, 13 other race, and 302 (30%) female patients. Baseline hemodynamics were comparable among groups. Waitlist mortality within 1 year of listing was 35.8% overall and similar for all races (p=0.418) and both sexes (p=0.617). Among those who successfully reached transplant, there were no differences in 1 year post-transplant survival by race (p=0.722) or sex (p= 0.475). On multivariable Cox proportional hazard modeling, neither race nor sex was associated with waitlist or post-transplant mortality (p=NS). Level of education (&lt;high school) was independently associated with 1 year waitlist mortality (HR 1.49, 95% CI 1.06 - 2.06). History of diabetes (HR 1.38, 95% CI 1.07-1.74) and post-transplant dialysis (HR 1.66, 95% CI 1.18-2.29) were associated with 1 year post transplant mortality. Conclusions: Unlike in BTT with durable MCS, we did not find differences in outcomes associated with race and sex among patients BTT with tMCS. Given the sharp increase in tMCS use after the 2018 U.S. allocation change, it will be important to closely monitor that access to transplantation and outcomes of BTT with tMCS patients continue to be equitable.

Effects of race-neutral estimated glomerular filtration rate policies on access to kidney transplantation.

Does the UNOS Heart Transplant Allocation System Favor Men Over Women?

The Collaborative Innovation and Improvement Network (COIIN): Effect on donor yield, waitlist mortality, transplant rates, and offer acceptance.