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Endo Y, Sasaki K, Munir MM, Woldesenbet S, Tsilimigras DI, Katayama E, Yang J, Limkemann A, Schenk A, Washburn K, Pawlik TM. Effect of the opioid crisis on the liver transplantation donor pool: A national analysis. Clin Transplant 2024; 38:e15290. [PMID: 38545890 DOI: 10.1111/ctr.15290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/22/2024] [Accepted: 03/03/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Over the last decade there has been a surge in overdose deaths due to the opioid crisis. We sought to characterize the temporal change in overdose donor (OD) use in liver transplantation (LT), as well as associated post-LT outcomes, relative to the COVID-19 era. METHODS LT candidates and donors listed between January 2016 and September 2022 were identified from the Scientific Registry of Transplant Recipients database. Trends in LT donors and changes related to OD were assessed pre- versus post-COVID-19 (February 2020). RESULTS Between 2016 and 2022, most counties in the United States experienced an increase in overdose-related deaths (n = 1284, 92.3%) with many counties (n = 458, 32.9%) having more than a doubling in drug overdose deaths. Concurrently, there was an 11.2% increase in overall donors, including a 41.7% increase in the number of donors who died from drug overdose. In pre-COVID-19 overdose was the 4th top mechanism of donor death, while in the post-COVID-19 era, overdose was the 2nd most common cause of donor death. OD was younger (OD: 35 yrs, IQR 29-43 vs. non-OD: 43 yrs, IQR 31-56), had lower body mass index (≥35 kg/cm2, OD: 31.2% vs. non-OD: 33.5%), and was more likely to be HCV+ (OD: 28.9% vs. non-OD: 5.4%) with lower total bilirubin (≥1.1 mg/dL, OD: 12.9% vs. non-OD: 20.1%) (all p < .001). Receipt of an OD was not associated with worse graft survival (HR .94, 95% CI .88-1.01, p = .09). CONCLUSIONS Opioid deaths markedly increased following the COVID-19 pandemic, substantially altering the LT donor pool in the United States.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Kazunari Sasaki
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Jason Yang
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Ashley Limkemann
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Austin Schenk
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Kenneth Washburn
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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Adjei M, Wisel SA, Yang JD, Nissen NN, Kim IK, Steggerda JA. Implications of drug intoxication on donor utilization and outcomes in liver transplantation. Clin Transplant 2024; 38:e15276. [PMID: 38454610 DOI: 10.1111/ctr.15276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/27/2024] [Accepted: 02/17/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION This study evaluates the implications of drug intoxication (DI) on donor utilization and outcomes in liver transplantation (LT). METHODS The UNOS STAR database was evaluated for all potential donors and adult, first-time, whole LT between 2005 and 2019. Logistic regression analyses evaluated liver utilization; proportional hazards modeling assessed risk of 1-year graft loss. RESULTS A total of 132 783 potential donors (10 205, 7.7% from DI), and 90 612 adult LT were identified (7490, 8.3% from DI). DI donors had median age 32 years (IQR 26-40 years, p < .001), were 42.6% female (n = 4346), and 15.5% were DCD donors (n = 1583). Utilization of DI donors changed over time, such that by 2015-2019 they were the most likely donor cause of death (COD) to be utilized. Among LT recipients, there were insignificant differences (<2% variance) in age, gender, ethnicity, and etiology of liver disease according to donor COD. Recipients with MELD scores >30 more frequently received grafts from donors with trauma (23.8%) and DI (21.8%) versus cardiovascular (20.0%) and CVA/stroke (19.9%, p < .001). Among DBD donors, DI-COD was associated with superior 1-year graft survival compared to donors from trauma (HR 1.172, 95% CI 1.057-1.300) and CVA/stroke (HR 1.404, 95% CI 1.264-1.561, p < .001). Donor COD was not significantly associated with 1-year graft loss among DCD donors. CONCLUSIONS There is an increased likelihood of donor utilization when COD is drug overdose and an increased likelihood of 1-year graft survival compared to donors from trauma, CVA/stroke, and other COD.
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Affiliation(s)
- Michie Adjei
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Steven A Wisel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ju Dong Yang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nicholas N Nissen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Irene K Kim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Justin A Steggerda
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Bekki Y, Myers B, Tomiyama K, Imaoka Y, Akabane M, Kwong AJ, Melcher ML, Sasaki K. Decreased Utilization Rate of Grafts for Liver Transplantation After Implementation of Acuity Circle-based Allocation. Transplantation 2024; 108:498-505. [PMID: 37585345 DOI: 10.1097/tp.0000000000004751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
BACKGROUND The allocation system for livers began using acuity circles (AC) in 2020. In this study, we sought to evaluate the impact of AC policy on the utilization rate for liver transplantation (LT). METHODS Using the US national registry data between 2018 and 2022, LTs were equally divided into 2 eras: pre-AC (before February 4, 2020) and post-AC (February 4, 2020, and after). Deceased potential liver donors were defined as deceased donors from whom at least 1 organ was procured. RESULTS The annual number of deceased potential liver donors increased post-AC (from 10 423 to 12 259), approaching equal to that of new waitlist registrations for LT (n = 12 801). Although the discard risk index of liver grafts was comparable between the pre- and post-AC eras, liver utilization rates in donation after brain death (DBD) and donation after circulatory death (DCD) donors were lower post-AC ( P < 0.01; 79.8% versus 83.4% and 23.7% versus 26.0%, respectively). Recipient factors, ie, no recipient located, recipient determined unsuitable, or time constraints, were more likely to be reasons for nonutilization after implementation of the AC allocation system compared to the pre-AC era (20.0% versus 12.3% for DBD donors and 50.1% versus 40.8% for DCD donors). Among non-high-volume centers, centers with lower utilization of marginal DBD donors or DCD donors were more likely to decrease LT volume post-AC. CONCLUSIONS Although the number of deceased potential liver donors has increased, overall liver utilization among deceased donors has decreased in the post-AC era. To maximize the donor pool for LT, future efforts should target specific reasons for liver nonutilization.
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Affiliation(s)
- Yuki Bekki
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Bryan Myers
- Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Koji Tomiyama
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Yuki Imaoka
- Division of Abdominal Transplant, Department of Surgery, Stanford University, Palo Alto, CA
| | - Miho Akabane
- Division of Abdominal Transplant, Department of Surgery, Stanford University, Palo Alto, CA
| | - Allison J Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Marc L Melcher
- Division of Abdominal Transplant, Department of Surgery, Stanford University, Palo Alto, CA
| | - Kazunari Sasaki
- Division of Abdominal Transplant, Department of Surgery, Stanford University, Palo Alto, CA
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Bruix J. A history of the treatment of primary liver cancer. Clin Liver Dis (Hoboken) 2024; 23:e0147. [PMID: 38707239 PMCID: PMC11068144 DOI: 10.1097/cld.0000000000000147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/23/2023] [Indexed: 05/07/2024] Open
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Stewart D, Hasz R, Lonze B. Beyond donation to organ utilization in the USA. Curr Opin Organ Transplant 2023; 28:197-206. [PMID: 36912063 DOI: 10.1097/mot.0000000000001060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
PURPOSE OF REVIEW The deceased donor organ pool has broadened beyond young, otherwise healthy head trauma victims. But an abundance of donated organs only benefits patients if they are accepted, expeditiously transported and actually transplanted. This review focuses on postdonation challenges and opportunities to increase the number of transplants through improved organ utilization. RECENT FINDINGS We build upon recently proposed changes in terminology for measuring organ utilization. Among organs recovered for transplant, the nonuse rate (NUR REC ) has risen above 25% for kidneys and pancreata. Among donors, the nonuse rate (NUR DON ) has risen to 40% for livers and exceeds 70% for thoracic organs. Programme-level variation in offer acceptance rates vastly exceeds variation in the traditional, 1-year survival benchmark. Key opportunities to boost utilization include donation after circulatory death and hepatitis C virus (HCV)+ organs; acute kidney injury and suboptimal biopsy kidneys; older and steatotic livers. SUMMARY Underutilization of less-than-ideal, yet transplant-worthy organs remains an obstacle to maximizing the impact of the U.S. transplant system. The increased risk of inferior posttransplant outcomes must always be weighed against the risks of remaining on the waitlist. Advanced perfusion technologies; tuning allocation systems for placement efficiency; and data-driven clinical decision support have the potential to increase utilization of medically complex organs.
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Affiliation(s)
- Darren Stewart
- Department of Surgery, NYU Langone Health, New York, New York
| | - Richard Hasz
- Gift of Life Donor Program, Philadelphia, Pennsylvania, USA
| | - Bonnie Lonze
- Department of Surgery, NYU Langone Health, New York, New York
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Bhattacharya D, Aronsohn A, Price J, Lo Re V. Hepatitis C Guidance 2023 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection. Clin Infect Dis 2023:ciad319. [PMID: 37229695 DOI: 10.1093/cid/ciad319] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/11/2023] [Accepted: 05/23/2023] [Indexed: 05/27/2023] Open
Abstract
The Infectious Diseases Society of America and the American Association for the Study of Liver Diseases have collaboratively developed evidence-based guidance regarding the diagnosis, management, and treatment of hepatitis C virus (HCV) infection since 2013. A panel of clinicians and investigators with extensive infectious diseases or hepatology expertise specific to HCV infection periodically review evidence from the field and update existing recommendations or introduce new recommendations as evidence warrants. This update focuses on changes to the guidance since the previous 2020 published update, including ongoing emphasis on recommended universal screening; management recommendations for incomplete treatment adherence; expanded eligibility for simplified chronic HCV infection treatment in adults with minimal monitoring; updated treatment and retreatment recommendations for children as young as 3 years old; management and treatment recommendations in the transplantation setting; and screening, treatment, and management recommendations for unique and key populations.
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Affiliation(s)
- Debika Bhattacharya
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA
| | - Andrew Aronsohn
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago
| | - Jennifer Price
- Division of Medicine, Department of Gastroenterology and Hepatology, University of California, San Francisco
| | - Vincent Lo Re
- Department of Medicine, Division of Infectious Diseases and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine
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Myers B, Bekki Y, Kozato A, Crismale JF, Schiano TD, Florman S. DCD Hepatitis C Virus-positive Donor Livers Can Achieve Favorable Outcomes With Liver Transplantation and Are Underutilized. Transplantation 2023; 107:670-679. [PMID: 36398318 DOI: 10.1097/tp.0000000000004401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV)-positive donors (antibody-positive [Ab + ] or nucleic acid test positive [NAT + ] donors) have been underutilized. The aim of this study was to evaluate the utilization of livers from HCV-positive with donation after circulatory death (DCD) and to assess outcomes in recipients of these grafts. METHODS Data between 2015 and 2019 were obtained from the United Network for Organ Sharing database. The utilization rates and graft survival among 8455 DCD liver and nonliver donors and 2278 adult DCD liver transplantation (LT) recipients were reviewed on the basis of donor HCV Ab/NAT status. RESULTS The utilization of Ab + /NAT - donors <40 y and Ab + /NAT + donors ≥40 y was low than utilization of HCV-negative donors ( P < 0.001). Multivariate analysis identified HCV status (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.06-2.48 in Ab + /NAT - , and OR, 1.49; 95% CI, 1.09-2.05 in Ab + /NAT + ) as an independent predictor of nonutilization of liver grafts. The rate of significant liver fibrosis was comparable in Ab + /NAT - (3.5%; P = 0.84) but was higher in Ab + /NAT + (8.7%; P = 0.03) than that in Ab - /NAT - donors. Kaplan-Meier survival curves demonstrated comparable 3-y patient survival in recipients of HCV-positive grafts compared with recipients of HCV-negative grafts ( P = 0.63; 85.6% in Ab - /NAT - , 80.4% in Ab + /NAT - , and 88.7% in Ab + /NAT + ). CONCLUSIONS Patient and graft survival rates are similar between HCV-positive and HCV-negative DCD LT. However, HCV-positive donors are particularly underutilized for DCD LT.
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Affiliation(s)
- Bryan Myers
- Division of General Surgery, Department of Surgery, Mount Sinai School of Medicine, New York City, NY
| | - Yuki Bekki
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Akio Kozato
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, NY
| | - James F Crismale
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Thomas D Schiano
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, NY
| | - Sander Florman
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, NY
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Normothermic Regional Perfusion Can Improve Both Utilization and Outcomes in DCD Liver, Kidney, and Pancreas Transplantation. Transplant Direct 2023; 9:e1450. [PMID: 36845854 PMCID: PMC9945290 DOI: 10.1097/txd.0000000000001450] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 02/22/2023] Open
Abstract
Normothermic regional perfusion (NRP) has gained widespread adoption in multiple European countries. The aim of this study was to examine the influence of thoracoabdominal-NRP (TA-NRP) on the utilization and outcomes of liver, kidney, and pancreas transplantation in the United States. Methods Using the US national registry data between 2020 and 2021, donation after circulatory death (DCD) donors were separated into 2 groups: DCD with TA-NRP and without TA-NRP. There were 5234 DCD donors; among them 34 donors were with TA-NRP. After 1:4 propensity score matching, the utilization rates were compared between DCD with and without TA-NRP. Results Although the utilization rates of kidney and pancreas were comparable (P = 0.71 and P = 0.06, 94.1% versus 95.6% and 8.8% versus 2.2%, respectively), that of liver in DCD with TA-NRP was significantly higher (P < 0.001; 70.6% versus 39.0%). Among 24 liver transplantations, 62 kidney transplantations, and 3 pancreas transplantations from DCD with TA-NRP, there were 2 liver grafts and 1 kidney graft that failed within 1 y after transplantation. Conclusions TA-NRP in the United States significantly increased the utilization rate of abdominal organs from DCD donors with comparable outcomes after transplantation. Increasing use of NRP may expand the donor pool without compromising transplant outcomes.
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