Decision making in liver transplantation-Limited application of the liver donor risk index

Abstract

Introduction The liver donor risk index (LDRI), originally developed in 2006 by Feng et. al and since modified, is a method of evaluating liver grafts from deceased donors by determining the relative risk of graft failure post transplantation. Methods Online and paper surveys sent to liver transplant physicians asking about their attitudes and practices regarding decision-making in liver transplantation and the role of LDRI. Results 147 of 401 (37%) eligible respondents returned partial or complete surveys. The majority of the respondents were male (116/134 or 87%) and practiced in academic medical centers (128/138 or 93%). Transplant coordinators initially contacted the candidate with an offer in 81% of programs. Eighty-eight of 143 (62%) respondents reported that they were very familiar with LDRI, but the vast majority (114/137 or 83%) rarely or never discuss the concept of LDRI with their patients. A majority of respondents (96/132 or 73%) believe that LDRI does not adequately describe a liver’s relative risk of graft failure and that there are factors that make LDRI potentially misleading (122/138 or 88%). Nevertheless, 60 of 130 (46%) believe that LDRI would increase/improve shared decision making. Discussion The LDRI has not been widely adopted because of concerns that 1) it does not accurately reflect post-transplant survival; 2) it excludes relevant donor and recipient factors, and 3) it is too complicated for candidates to grasp. There is a need to improve it or to develop other decision making tools to help promote shared decision making. There is also great diversity in how liver offers are made to ambulatory candidates, and how transplant programs address a candidate’s refusal. Research is needed to determine evidence-based best practice.

Changes in Discard Rate After the Introduction of the Kidney Donor Profile Index (KDPI)

“…Introducing a change in clinical practice has been long known to be challenging for various reasons including physician resistance or incomplete understanding (17,18), and KDPI might not have been an exception. This explanation is also supported by a survey (19) on liver transplant surgeons’ attitudes toward the Liver Donor Risk Index (LDRI), which is analogous to KDRI for liver donors: 73% of liver transplant surgeons surveyed believed that LDRI does not adequately describe donor-associated risk and 83% rarely or never discussed LDRI with their patients. Additionally, given the association between KDPI and discard, the factors constituting KDPI could have already been affecting discard practice, and KDPI may have not provided much additional information.…”

Impact of dynamic changes in MELD score on survival after liver transplantation – a Eurotransplant registry analysis

“…Donor‐derived risk scores, however, showed weak correlations when tested in different populations and might not be able to correctly predict graft survival . A recent analysis showed that, while numerous risk indices have been published, they are not frequently used in daily practice .…”

Combined effect of donor and recipient risk on outcome after liver transplantation: Research of the Eurotransplant database

“…We think that this new DRM is more complete than previous models because it contains all relevant factors that have (significant) impact on outcome after LT. Although a recent study described the limited use of the DRI in the Organ Procurement and Transplantation Network (OPTN), the most important issues named are addressed by the new DRM model . Next to the creation of the DRM, the ET‐DRI was validated in this new cohort, confirming its correlation with outcome after LT in the Eurotransplant region.…”