Changing Landscape of Open Offers in Liver Transplantation in the Machine Perfusion Era: Exposure, Equity, and Economics

IF 1.9 4区医学 Q2 SURGERY Clinical Transplantation Pub Date : 2024-10-26 DOI:10.1111/ctr.70012

Chase J. Wehrle, Abby Gross, Sami Fares, Jiro Kusakabe, Esteban Calderon, Kumaran Shanmugarajah, Melis Uysal, Christina M. Fleischer, Erlind Allkushi, Jesse D. Schold, Mazhar Khalil, Alejandro Pita, Masato Fujiki, Andrea Schlegel, Charles Miller, Koji Hashimoto, Glenn K. Wakam

{"title":"Changing Landscape of Open Offers in Liver Transplantation in the Machine Perfusion Era: Exposure, Equity, and Economics","authors":"Chase J. Wehrle, Abby Gross, Sami Fares, Jiro Kusakabe, Esteban Calderon, Kumaran Shanmugarajah, Melis Uysal, Christina M. Fleischer, Erlind Allkushi, Jesse D. Schold, Mazhar Khalil, Alejandro Pita, Masato Fujiki, Andrea Schlegel, Charles Miller, Koji Hashimoto, Glenn K. Wakam","doi":"10.1111/ctr.70012","DOIUrl":null,"url":null,"abstract":"<div>\n \n \n <section>\n \n <h3> Background</h3>\n \n <p>Open offers (OOs) in liver transplantation (LT) result from bypassing the traditional allocation system. Little is known about the trends of OOs or the differences in donor/recipient characteristics compared to traditionally placed organs. We aim to quantify modern practices regarding OOs and understand NMP's impact, focusing on social determinants of health (SDH), cost, and graft-associated risk.</p>\n </section>\n \n <section>\n \n <h3> Methods</h3>\n \n <p>LTs from 1/1/2018 to 12/31/2023 at a single center were included. NMP was implemented on 10/1/2022. The CDC (centers for disease control)-validated social vulnerability index (SVI) and donor risk index (DRI) were calculated. Comprehensive complications index (CCI), Clavien-Dindo grades, patient and graft survival, and costs of transplantation were included.</p>\n </section>\n \n <section>\n \n <h3> Results</h3>\n \n <p>1162 LTs were performed; 193 (16.8%) from OOs. OOs were more common in the post-NMP era (26.5% vs. 13.3%, <i>p</i> < 0.001). Pre-NMP, patients receiving OOs had longer waitlist times (118 vs. 69 days, <i>p</i> < 0.001), lower MELDs (17 vs. 25 points, <i>p</i> < 0.001), and riskier grafts (DRI = 1.8 vs. 1.6, <i>p</i> = 0.004) compared to standard offers. Post-NMP, recipients receiving OOs demonstrated no difference in waitlist time (27 vs. 20 days, <i>p</i> = 0.21) or graft risk (DRI = 2.03 vs. 2.23, <i>p</i> = 0.17). OO recipient MELD remained lower (16 vs. 22, <i>p</i> < 0.001). OO recipients were more socially vulnerable (SVI), pre-NMP (0.41 vs. 0.36, <i>p</i> = 0.004), but less vulnerable after NMP (0.23 vs. 0.36, <i>p</i> = 0.019). Despite increased graft risk, pre-NMP OO-LTs were less expensive in the 90-day global period ($154 939 vs. $178 970, <i>p</i> = 0.002) and the 180-days pre-/post-LT ($208 807 vs. $228 091, <i>p</i> = 0.021). Cost trends remained similar with NMP.</p>\n </section>\n \n <section>\n \n <h3> Conclusion</h3>\n \n <p>OOs are increasingly utilized and may be appealing due to demonstrated cost reductions even with NMP. Although most OO-related metrics in our center remain similar before and after machine perfusion, programs should take caution that increasing use does not worsen organ access for socially vulnerable populations.</p>\n </section>\n </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"38 10","pages":""},"PeriodicalIF":1.9000,"publicationDate":"2024-10-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/ctr.70012","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Clinical Transplantation","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1111/ctr.70012","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"SURGERY","Score":null,"Total":0}

引用次数: 0

Abstract

Background

Open offers (OOs) in liver transplantation (LT) result from bypassing the traditional allocation system. Little is known about the trends of OOs or the differences in donor/recipient characteristics compared to traditionally placed organs. We aim to quantify modern practices regarding OOs and understand NMP's impact, focusing on social determinants of health (SDH), cost, and graft-associated risk.

Methods

LTs from 1/1/2018 to 12/31/2023 at a single center were included. NMP was implemented on 10/1/2022. The CDC (centers for disease control)-validated social vulnerability index (SVI) and donor risk index (DRI) were calculated. Comprehensive complications index (CCI), Clavien-Dindo grades, patient and graft survival, and costs of transplantation were included.

Results

1162 LTs were performed; 193 (16.8%) from OOs. OOs were more common in the post-NMP era (26.5% vs. 13.3%, p < 0.001). Pre-NMP, patients receiving OOs had longer waitlist times (118 vs. 69 days, p < 0.001), lower MELDs (17 vs. 25 points, p < 0.001), and riskier grafts (DRI = 1.8 vs. 1.6, p = 0.004) compared to standard offers. Post-NMP, recipients receiving OOs demonstrated no difference in waitlist time (27 vs. 20 days, p = 0.21) or graft risk (DRI = 2.03 vs. 2.23, p = 0.17). OO recipient MELD remained lower (16 vs. 22, p < 0.001). OO recipients were more socially vulnerable (SVI), pre-NMP (0.41 vs. 0.36, p = 0.004), but less vulnerable after NMP (0.23 vs. 0.36, p = 0.019). Despite increased graft risk, pre-NMP OO-LTs were less expensive in the 90-day global period ($154 939 vs. $178 970, p = 0.002) and the 180-days pre-/post-LT ($208 807 vs. $228 091, p = 0.021). Cost trends remained similar with NMP.

Conclusion

OOs are increasingly utilized and may be appealing due to demonstrated cost reductions even with NMP. Although most OO-related metrics in our center remain similar before and after machine perfusion, programs should take caution that increasing use does not worsen organ access for socially vulnerable populations.

Abstract Image

查看原文

微信好友朋友圈 QQ好友复制链接

本刊更多论文

机器灌注时代肝移植公开报价的变化：曝光、公平和经济学。

背景：肝移植（LT）中的开放供体（OO）是绕过传统分配系统的结果。与传统的器官分配相比，人们对开放供体的趋势或供体/受体特征的差异知之甚少。我们旨在量化有关OOs的现代做法并了解NMP的影响，重点关注健康的社会决定因素（SDH）、成本和移植物相关风险：方法：纳入一个中心从 2018 年 1 月 1 日至 2023 年 12 月 31 日的 LT。NMP 于 2022 年 1 月 10 日实施。计算了疾病控制中心（CDC）验证的社会脆弱性指数（SVI）和供体风险指数（DRI）。综合并发症指数（CCI）、Clavien-Dindo分级、患者和移植物存活率以及移植成本也包括在内：结果：共进行了 1162 例 LT，其中 193 例（16.8%）来自 OO。OOs 在后 NMP 时代更为常见（26.5% 对 13.3%，P < 0.001）。与标准方案相比，NMP 前接受 OOs 的患者等待时间更长（118 天 vs. 69 天，p < 0.001），MELD 更低（17 分 vs. 25 分，p < 0.001），移植物风险更高（DRI = 1.8 vs. 1.6，p = 0.004）。NMP 后，接受 OO 的受者在等待时间（27 天 vs. 20 天，p = 0.21）或移植物风险（DRI = 2.03 vs. 2.23，p = 0.17）方面没有差异。OO 受体的 MELD 值仍然较低（16 对 22，p < 0.001）。OO 受体在 NMP 前的社会脆弱性（SVI）较高（0.41 对 0.36，p = 0.004），但在 NMP 后的社会脆弱性较低（0.23 对 0.36，p = 0.019）。尽管移植物风险增加，但 NMP 前的 OO-LT 在全球 90 天（154 939 美元对 178 970 美元，p = 0.002）和 LT 前后 180 天（208 807 美元对 228 091 美元，p = 0.021）的费用较低。费用趋势与 NMP 相似：结论：OO 的使用率越来越高，即使使用 NMP 也能降低成本，因此可能很有吸引力。尽管在我们的中心，大多数 OO 相关指标在机器灌注前后保持相似，但项目应注意的是，越来越多地使用 OO 不会使社会弱势群体获得器官的情况恶化。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

求助全文

约1分钟内获得全文去求助

来源期刊

Clinical Transplantation 医学-外科

CiteScore

3.70

自引率

4.80%

发文量

286

审稿时长

2 months

期刊介绍： Clinical Transplantation: The Journal of Clinical and Translational Research aims to serve as a channel of rapid communication for all those involved in the care of patients who require, or have had, organ or tissue transplants, including: kidney, intestine, liver, pancreas, islets, heart, heart valves, lung, bone marrow, cornea, skin, bone, and cartilage, viable or stored. Published monthly, Clinical Transplantation’s scope is focused on the complete spectrum of present transplant therapies, as well as also those that are experimental or may become possible in future. Topics include: Immunology and immunosuppression; Patient preparation; Social, ethical, and psychological issues; Complications, short- and long-term results; Artificial organs; Donation and preservation of organ and tissue; Translational studies; Advances in tissue typing; Updates on transplant pathology;. Clinical and translational studies are particularly welcome, as well as focused reviews. Full-length papers and short communications are invited. Clinical reviews are encouraged, as well as seminal papers in basic science which might lead to immediate clinical application. Prominence is regularly given to the results of cooperative surveys conducted by the organ and tissue transplant registries. Clinical Transplantation: The Journal of Clinical and Translational Research is essential reading for clinicians and researchers in the diverse field of transplantation: surgeons; clinical immunologists; cryobiologists; hematologists; gastroenterologists; hepatologists; pulmonologists; nephrologists; cardiologists; and endocrinologists. It will also be of interest to sociologists, psychologists, research workers, and to all health professionals whose combined efforts will improve the prognosis of transplant recipients.