Split‐Liver Allocation: An Underused Opportunity to Expand Access to Liver Transplantation

Ge, Jin; Lai, Jennifer C.

doi:10.1002/lt.25458

Cited by 11 publications

(14 citation statements)

References 8 publications

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“…( 16 ) Expansion of SLT therefore represents a great opportunity to reduce disparities in access to organs not only for children but also for women. ( 4,5 )…”

Section: Discussionmentioning

confidence: 99%

Survival Benefit of Split‐Liver Transplantation for Pediatric and Adult Candidates

et al. 2022

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Patient and graft survival are similar following whole-liver transplantations (WLTs) versus split-liver transplantations (SLTs) among pediatric and adult recipients, yet SLTs are rarely used. We sought to determine the survival benefit associated with accepting a splittable graft offer for SLT versus declining and waiting for a subsequent offer using 2010 to 2018 Scientific Registry of Transplant Recipients (SRTR) data on 928 pediatric and 1814 adult liver transplantation candidates who were ever offered a splittable graft. We compared eventual mortality, regardless of subsequent transplants, between those patients who accepted versus declined a split liver offer with adjustments for Pediatric End-Stage Liver Disease/Model for End-Stage Liver Disease (MELD) scores, diagnosis, and weight among pediatric candidates and matching for MELD score, height, and offer among adult candidates. Among pediatric candidates ≤7 kg, split liver offer acceptance versus decline was associated with a 63% reduction in mortality (adjusted hazard ratio [aHR], 0.17 0.37 0.80 [P = 0.01]; 93.1% versus 84.0% 1-year survival after decision). Within 1 year of decline for those ≤7 kg, 6.4% died and 31.1% received a WLT. Among pediatric candidates >7 kg, there was no significant difference associated with acceptance of a split liver offer (aHR, 0.63 1.07 1.82 [P = 0.81]; 91.7% versus 94.4% 1-year survival after decision). Within 1 year of decline for those >7 kg, 1.8% died and 45.8% received a WLT. Among adult candidates, split liver offer acceptance was associated with a 43% reduction in mortality (aHR, 0.39 0.57 0.83 [P = 0.005]; 92.2% versus 84.4% 1-year survival after decision). Within 1 year of decline for adult candidates, 7.9% died and 39.3% received a WLT. Accepting split liver offers for SLT could significantly improve survival for small children and adults on the waiting list.

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“…( 16 ) Expansion of SLT therefore represents a great opportunity to reduce disparities in access to organs not only for children but also for women. ( 4,5 )…”

Section: Discussionmentioning

confidence: 99%

Survival Benefit of Split‐Liver Transplantation for Pediatric and Adult Candidates

et al. 2022

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“…20,30 However, this technique has historically been considered higher risk and is not routinely performed at all transplant centers in the United States. 20,30 UNOS is currently studying whether to move to a continuous distribution method of organ allocation. 33 Candidate height is proposed to be included.…”

Section: Discussionmentioning

confidence: 99%

“…The authors recommended that pediatric donor livers that do not find a pediatric recipient locally, regionally, or nationally, should be preferentially offered to women 25 . Increasing rates of split LT (single donor liver used for two recipients) has also been proposed as a mechanism for improving LT rates in short stature candidates 20,30 . However, this technique has historically been considered higher risk and is not routinely performed at all transplant centers in the United States 20,30 …”

Section: Discussionmentioning

confidence: 99%

“…However, they do not address the availability of smaller organs in the donor pool. To address this issue, some have proposed prioritizing pediatric livers to women and offering women size-reduced or split LT. 20,25,30 Ge et al found that women who received pediatric donor first offers had lower waitlist mortality than women who received adult donor offers first. 25 The authors recommended that pediatric donor livers that do not find a pediatric recipient locally, regionally, or nationally, should be preferentially offered to women.…”

Section: Discussionmentioning

confidence: 99%

“…However, studies correcting for these serum creatinine and MELD score differences have not fully accounted for greater waitlist mortality in women 13,19 . Sex differences in size‐appropriate organs may play a significant role in women's increased waitlist mortality 11,13,20,21 . Most deceased donor livers come from men, leading to technical challenges using these organs in smaller individuals, such as women 22,23,24 .…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Awarding additional MELD points to the shortest waitlist candidates improves sex disparity in access to liver transplant in the United States

Bernards

Lee

Leung

et al. 2022

American Journal of Transplantation

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Since the introduction of the MELD‐based allocation system, women are now 30% less likely than men to undergo liver transplant (LT) and have 20% higher waitlist mortality. These disparities are in large part due to height differences in men and women though no national policies have been implemented to reduce sex disparities. Patients were identified using the Scientific Registry of Transplant Recipients (SRTR) from 2014 to 2019. Patients were categorized into five groups by first dividing into thirds by height then dividing the shortest third into three groups to capture more granular differences in the most disadvantaged patients (<166 cm). We then used LSAM to model waitlist outcomes in five versions of awarding additional MELD points to shorter candidates compared to current policy. We identified two proposed policy changes LSAM scenarios that resulted in improvement in LT and death percentage for the shortest candidates with the least negative impact on taller candidates. In conclusion, awarding an additional 1–2 MELD points to the shortest 8% of LT candidates would improve waitlist outcomes for women. This strategy should be considered in national policy allocation to address sex‐based disparities in LT.

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Graft Survival and Segment Discards Among Split‐Liver and Reduced‐Size Transplantations in the United States From 2008 to 2018

et al. 2021

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Split-liver transplantation has allocation advantages over reduced-size transplantation because of its ability to benefit 2 recipients. However, prioritization of split-liver transplantation relies on the following 3 major assumptions that have never been tested in the United States: similar long-term transplant recipient outcomes, lower incidence of segment discard among splitliver procurements, and discard of segments among reduced-size procurements that would be otherwise "transplantable." We used United Network for Organ Sharing Standard Transplant Analysis and Research data to identify all split-liver (n = 1831) and reduced-size (n = 578) transplantation episodes in the United States between 2008 and 2018. Multivariable Cox proportional hazards modeling was used to compare 7-year all-cause graft loss between cohorts. Secondary analyses included etiology of 30-day all-cause graft loss events as well as the incidence and anatomy of discarded segments. We found no difference in 7-year all-cause graft loss (adjusted hazard ratio [aHR], 1.09; 95% confidence interval [CI], 0.82-1.46) or 30-day all-cause graft loss (aHR, 1.13; 95% CI, 0.70-1.80) between split-liver and reduced-size cohorts. Vascular thrombosis was the most common etiology of 30-day all-cause graft loss for both cohorts (56.4% versus 61.8% of 30-day graft losses; P = 0.85). Finally, reduced-size transplantation was associated with a significantly higher incidence of segment discard (50.0% versus 8.7%) that were overwhelmingly right-sided liver segments (93.6% versus 30.3%). Our results support the prioritization of split-liver over reduced-size transplantation whenever technically feasible.

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Split‐Liver Allocation: An Underused Opportunity to Expand Access to Liver Transplantation

Cited by 11 publications

References 8 publications

Survival Benefit of Split‐Liver Transplantation for Pediatric and Adult Candidates

Survival Benefit of Split‐Liver Transplantation for Pediatric and Adult Candidates

Awarding additional MELD points to the shortest waitlist candidates improves sex disparity in access to liver transplant in the United States

Graft Survival and Segment Discards Among Split‐Liver and Reduced‐Size Transplantations in the United States From 2008 to 2018

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