Expedited liver allocation in the United States: A critical analysis

Abstract

The fate of donor livers allocated via an out-of-sequence expedited placement (EP) pathway has not been previously examined. We determined the originating and receiving United Network for Organ Sharing (UNOS) regions of all donor livers procured between January 1, 2010 and October 31, 2012 and placed out of sequence with UNOS bypass code 863 (EP attempt) or 898 (miscellaneous). We reviewed the early function of these liver grafts and assessed the effect of EP allocation on wait-listed patients at our center. Registrants at our center were eligible to receive 1298 liver offers during the interval studied: 218 (16.8%) of these liver offers bypassed our center and were allocated to other centers and used in patients lower on the match-run list. During the study interval, 560 livers were allocated in the United States by EP. Regions 1, 5, 7, 9, and 10 used the greatest number of EP-placed grafts. Region 1 (New England) used the greatest proportion of all EP livers (33% of all imported EP livers in the United States, P < 0.001 versus all other regions). Graft function data were available for 560 livers placed by EP: 491 (88%) of these grafts were functioning at a mean of 399.5 days after transplantation. In conclusion, the transplantation of livers allocated by means of an expedited refusal code is asymmetric across regions and, in some instances, results in the bypassing of patients with higher wait-list priority but without notification of the bypassed center. Short-term graft function after EP allocation is excellent. Policies governing EP allocation should be created in order to improve access to available organs.

Pediatric discard risk index for predicting pediatric liver allograft discard

“…Many have pointed out that the current state of expedited marginal liver allocation lacks transparency and uniformity. There is significant regional variation, as one analysis demonstrates that Region 1 used 33% of all expedited allografts 18 . In another analysis, 73% of expedited livers were transplanted in 1 of 6 aggressive centers 16 .…”

“…There is significant regional variation, as one analysis demonstrates that Region 1 used 33% of all expedited allografts. 18 In another analysis, 73% of expedited livers were transplanted in 1 of 6 aggressive centers. 16 There is also great variation of expedited allocation by donor-specific areas, suggesting discretion and a lack of uniformity.…”

Competition in liver transplantation: Helpful or harmful?

“…The heavy concentration of nationally placed livers in a few centers suggests the existence of expedited placement (EP) pathways in a small number of transplant centers. Kinkhabwala et al looked at the fate of donor livers allocated via an out‐of‐sequence or EP pathway. The EP pathway is distinct from the standard allocation pathway governed by the fundamental principles enumerated previously.…”

The time to address the gorillas in the room is overdue

“…This includes wait‐list mortality, which, as a percentage of annual wait‐list additions, has not significantly changed, and frustration over our inability to serve patients who are desperately ill . In this issue of Liver Transplantation , Kinkhabwala et al analyze Organ Procurement and Transplantation Network (OPTN) data on expedited placement (EP) liver allograft codes by correlating the region of EP allograft origination, the region of EP allograft transplantation, the recipient MELD score at OLT, and early EP allograft function. The authors keenly integrate these data with their own wait‐list mortality data during the study period to infer that inequity in US allocation practice has denied their patients an opportunity for OLT and call for additional regulatory oversight.…”

“…Kinkhabwala et al have clearly identified the consequences of the 2 gorillas in the room and have challenged our community. Definitive actions by the transplant community to correct allocation inequity while stimulating utilization are possible and should be prioritized.…”