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Heiden BT, Yang Z, Bai YZ, Yan Y, Chang SH, Park Y, Colditz GA, Dart H, Hachem RR, Witt CA, Vazquez Guillamet R, Byers DE, Marklin GF, Pasque MK, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Development and validation of the lung donor (LUNDON) acceptability score for pulmonary transplantation. Am J Transplant 2023; 23:540-548. [PMID: 36764887 PMCID: PMC10234600 DOI: 10.1016/j.ajt.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 01/04/2023]
Abstract
There is a chronic shortage of donor lungs for pulmonary transplantation due, in part, to low lung utilization rates in the United States. We performed a retrospective cohort study using data from the Scientific Registry of Transplant Recipients database (2006-2019) and developed the lung donor (LUNDON) acceptability score. A total of 83 219 brain-dead donors were included and were randomly divided into derivation (n = 58 314, 70%) and validation (n = 24 905, 30%) cohorts. The overall lung acceptance was 27.3% (n = 22 767). Donor factors associated with the lung acceptance were age, maximum creatinine, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, mechanism of death by asphyxiation or drowning, history of cigarette use (≥20 pack-years), history of myocardial infarction, chest x-ray appearance, bloodstream infection, and the occurrence of cardiac arrest after brain death. The prediction model had high discriminatory power (C statistic, 0.891; 95% confidence interval, 0.886-0.895) in the validation cohort. We developed a web-based, user-friendly tool (available at https://sites.wustl.edu/lundon) that provides the predicted probability of donor lung acceptance. LUNDON score was also associated with recipient survival in patients with high lung allocation scores. In conclusion, the multivariable LUNDON score uses readily available donor characteristics to reliably predict lung acceptability. Widespread adoption of this model may standardize lung donor evaluation and improve lung utilization rates.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yun Zhu Bai
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yikyung Park
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hank Dart
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | | | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
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Abstract
BACKGROUND Quality in kidney transplantation is measured using 1-year patient and graft survival. Because 1-year patient and graft survival exceed 95%, this metric fails to measure a spectrum of quality. Textbook outcomes (TO) are a composite quality metric offering greater depth and resolution. We studied TO after living donor (LD) and deceased donor (DD) kidney transplantation. STUDY DESIGN United Network for Organ Sharing data for 69,165 transplant recipients between 2013 and 2017 were analyzed. TO was defined as patient and graft survival of 1 year or greater, 1-year glomerular filtration rate of greater than 40 mL/min, absence of delayed graft function, length of stay of 5 days or less, no readmissions during the first 6 months, and no episodes of rejection during the first year after transplantation. Bivariate analysis identified characteristics associated with TO, and covariates were incorporated into multivariable models. Five-year conditional survival was measured, and center TO rates were corrected for case complexity to allow center-level comparisons. RESULTS The national average TO rates were 54.1% and 31.7% for LD and DD transplant recipients. The hazard ratio for death at 5 years for recipients who did not experience TO was 1.92 (95% CI 1.68 to 2.18, p ≤ 0.0001) for LD transplant recipients and 2.08 (95% CI 1.93 to 2.24, p ≤ 0.0001) for DD transplant recipients. Center-level comparisons identify 18% and 24% of centers under-performing in LD and DD transplantation. High rates of TO do not correlate with transplantation center volume. CONCLUSION Kidney transplant recipients who experience TO have superior long-term survival. Textbook outcomes add value to the current standards of 1-year patient and graft survival.
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Batra RK, Mulligan DC. Current status: meeting the regulatory goals of your liver transplant program. Curr Opin Organ Transplant 2021; 26:146-151. [PMID: 33650996 DOI: 10.1097/mot.0000000000000869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The regulatory framework set by the Organ Procurement and Transplantation Network (OPTN) and Center for Medicare and Medicaid Services (CMS) for practice of liver transplantation in US is periodically updated and risk adjusted. Therefore, it is prudent for transplant centers to know the rules of engagement as it pertains to their practice. RECENT FINDINGS OPTN besides providing the regulatory oversight for safe and continued practice of transplant centers, provides necessary tools like: advanced statistical models and technological platforms to aid, and guide transplant centers including the necessary safeguards for high-quality transplant care.CMS regulations although had different thresholds to flag underperformance, often covered common grounds similar to the OPTN, therefore considered duplicative and unnecessary. But with much deliberation and consideration CMS undertook a major overhaul to the final rule for re-approval applications, a giant leap in the positive direction for transplant innovation and growth. SUMMARY The duplicative regulatory framework of OPTN and CMS has although achieved the goal of improving 1-year patient outcomes, it has proven costly in terms of slowing innovation, increasing organ discard and stunting growth of transplant volume. But the new updates in effect and also in the pipeline are a long-awaited opportunity for waiting transplant patients.
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Affiliation(s)
- Ramesh K Batra
- Yale University School of Medicine, Director, Liver Transplant Program
| | - David C Mulligan
- Yale University School of Medicine, Chair, Division of Transplantation and Immunology, Yale New Haven Hospital, New Haven, Connecticut, USA
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Peters TG, Bragg-Gresham JL, Klopstock AC, Roberts JP, Chertow G, McCormick F, Held PJ. Estimated impact of novel coronavirus-19 and transplant center inactivity on end-stage renal disease-related patient mortality in the United States. Clin Transplant 2021; 35:e14292. [PMID: 33749935 PMCID: PMC8250232 DOI: 10.1111/ctr.14292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/10/2021] [Accepted: 03/14/2021] [Indexed: 12/24/2022]
Abstract
To predict whether the COVID‐19 pandemic and transplant center responses could have resulted in preventable deaths, we analyzed registry information of the US end‐stage renal disease (ESRD) patient population awaiting kidney transplantation. Data were from the Organ Procurement and Transplantation Network (OPTN), the US Centers for Disease Control and Prevention, and the United States Renal Data System. Based on 2019 OPTN reports, annualized reduction in kidney transplantation of 25%–100% could result in excess deaths of wait‐listed (deceased donor) transplant candidates from 84 to 337 and living donor candidate excess deaths from 35 to 141 (total 119–478 potentially preventable deaths of transplant candidates). Changes in transplant activity due to COVID‐19 varied with some centers shutting down while others simply heeded known or suspected pandemic risks. Understanding potential excess mortality for ESRD transplant candidates when circumstances compel curtailment of transplant activity may inform policy and procedural aspects of organ transplant systems allowing ways to best inform patients and families as to potential risks in shuttering organ transplant activity. Considering that more than 700 000 Americans have ESRD with 100 000 awaiting a kidney transplant, our highest annual estimate of 478 excess total deaths from postponing kidney transplantation seems modest.
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Affiliation(s)
- Thomas G Peters
- Department of Surgery, University of Florida, Jacksonville, FL, USA
| | | | - Annie C Klopstock
- Department of Economics, San Diego State University, San Diego, CA, USA
| | - John P Roberts
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Glenn Chertow
- Department of Medicine - Med/Nephrology, Stanford University, Stanford, CA, USA
| | | | - Philip J Held
- Department of Medicine - Med/Nephrology, Stanford University, Stanford, CA, USA
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