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":"机器灌注时代肝移植公开报价的变化：曝光、公平和经济学。","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":"{\"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}","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}
Changing Landscape of Open Offers in Liver Transplantation in the Machine Perfusion Era: Exposure, Equity, and Economics
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.
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.
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