The Increased Costs of Donation After Cardiac Death Liver Transplantation

Jay, Colleen L.; Lyuksemburg, Vadim; Kang, Raymond; Preczewski, Luke; Stroupe, Kevin T.; Holl, Jane L.; Abécassis, Michaël; Skaro, Anton I.

doi:10.1097/sla.0b013e3181d3d3da

Cited by 95 publications

(87 citation statements)

References 16 publications

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“…Other investigators have also seen significantly higher rates of ischemic cholangiopathy in DCD liver transplant recipients. (4,16,17) For these reasons, many transplant centers have shied away from using DCD livers.…”

Section: Discussionmentioning

confidence: 99%

Liver transplant outcomes using ideal donation after circulatory death livers are superior to using older donation after brain death donor livers

2016

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Multiple reports have demonstrated that liver transplantation following donation after circulatory death (DCD) is associated with poorer outcomes when compared with liver transplantation from donation after brain death (DBD) donors. We hypothesized that carefully selected, underutilized DCD livers recovered from younger donors have excellent outcomes. We performed a retrospective study of the United Network for Organ Sharing database to determine graft survivals for patients who received liver transplants from DBD donors of age 60 years, DBD donors < 60 years, and DCD donors < 50 years of age. Between January 2002 and December 2014, 52,271 liver transplants were performed in the United States. Of these, 41,181 (78.8%) underwent transplantation with livers from DBD donors of age < 60 years, 8905 (17.0%) from DBD donors 60 years old, and 2195 (4.2%) livers from DCD donors < 50 years of age. DCD livers of age < 50 years with < 6 hours of cold ischemia time (CIT) had superior graft survival when compared with DBD livers age 60 years (P < 0.001). In 2014, there were 133 discarded DCD livers; of these, 111 (83.4%) were from donors < age 50 years old. Young DCD donor livers (age < 50 years old) with short CITs yield results better than that seen with DBD livers > 60 years old. Careful donor organ and recipient selection can lead to excellent results, despite previous reports suggesting otherwise. Increased acceptance of these DCD livers would lead to shorter wait list times and increased national liver transplant rates.Liver Transplantation 22 1197-1204 2016 AASLD. There exists a vast disparity between the number of patients on the liver transplant waiting list and the number of available organs.(1-4) One method for increasing the number of transplantable organs has been to use organs from patients who die after circulatory death.(5-9) Accordingly, large increases in the number of transplantable kidneys have resulted from donation after circulatory death (DCD) protocols. However, only modest increases in DCD liver transplantation have been observed. (5,10,11) In fact, only approximately 6% of liver transplants in the United States are performed using DCD livers.(12) This lack of growth in the DCD liver pool is due, in part, to the technical challenges of the operation and concern for postoperative complications such as ischemic cholangiopathy. (5,6) As described by Feng et al., (13) not all donor livers yield equivalent recipient outcomes. Much like livers that are recovered from donation after brain death (DBD) donors, DCD livers carry a spectrum of risk. That is, there are some livers which likely function better than others. It is known that the age of the DCD donor is a risk factor for graft loss when compared with DBD organs, particularly when the DCD donor is >50 years of age. (13,14) In addition, cold ischemia time (CIT) has been shown to have a greater effect on Abbreviations: BMI, body mass index; CIT, cold ischemia time; DBD, donation after brain death; DCD, donation after circulatory death; ICU, intensive ca...

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Section: Discussionmentioning

confidence: 99%

Liver transplant outcomes using ideal donation after circulatory death livers are superior to using older donation after brain death donor livers

2016

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“…It is important to note that patient and graft survival rates were not different between DCD and DBD grafts in the aforementioned study. Similarly, Jay and associates 48 found increased 1-year posttransplant costs for DCD recipients (125% of DBD cost). The cost remained higher in DCD (120% of DBD) transplants despite the exclusion of retransplants, which is a major risk for DCD livers but occurs infrequently.…”

Section: Emre a Eren Et Al/experimental And Clinical Transplantationmentioning

confidence: 99%

Untitled

2016

Exp Clin Transplant

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The supply of liver grafts for treatment of end-stage liver disease continues to fall short of ongoing demands. Currently, most liver transplants originate from donations after brain death. Enhanced utilization of the present resources is prudent to address the needs of the population. Donation after circulatory or cardiac death is a mechanism whereby the availability of organs can be expanded. Donations after circulatory death pose unique challenges given their exposure to warm ischemia. Technical principles of donations after circulatory death procurement and pertinent studies investigating patient outcomes, graft outcomes, and complications are highlighted in this review. We also review associated risk factors to suggest potential avenues to achieve improved outcomes and reduced complications. Future considerations and alternative techniques of organ preservation are discussed, which may suggest novel strategies to enhance preservation and donor expansion through the use of marginal donors. Ultimately, without effective measures to bolster organ supply, donations after circulatory death should remain a consideration; however, an understanding of inherent risks and limitations is necessary.

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“…Relevant to this investigation, Jay and coworkers estimated direct medical care costs based on inpatient and outpatient care for 28 DCD and 198 DBD liver recipients. 30 They found that the mean 1-year posttransplant costs were higher for DCD recipients (124.9% DBD costs; P = .04; 95% CI = 102%-151%). Furthermore, the increased DCD costs persisted (125.2% DBD costs; P = .009; 95% CI = 106%-144%) after adjustment for recipient characteristics (age, sex, race, body mass index, Model For End-Stage Liver Disease [MELD] score, hepatitis C, hepatocellular carcinoma, and medical status).…”

Section: Donation After Cardiac Death Costs and Resource Utilizationmentioning

confidence: 99%

“…6,[12][13][14][16][17][18]25,[28][29][30] Foley and coworkers 13 reported that rates of overall biliary complications (DCD, 47%; DBD, 26%; P < .01) and IC (DCD, 34%; DBD, 1%; P < .01) were significantly higher in the DCD group. Research conducted by Chan and associates 28 indicated no incidence of PNF from DCD allografts.…”

Section: Complications Of Livers From Donation After Cardiac Death Domentioning

confidence: 99%

Untitled

2015

Exp Clin Transplant

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There are increasing numbers of patients on liver transplant waiting lists, and there is a continuing organ shortage crisis. Therefore, more centers and organ procurement organizations are developing protocols for donation after cardiac death. However, the effect of donation after cardiac death allografts on overall patient survival remains controversial, with some centers reporting equivalent patient posttransplant survival but many others indicating increased rates of complications, retransplant, utilization of resources, and death. Several potential risk factors that predict graft loss and recipient complications have been identified. To improve patient outcomes and reduce dropouts, experimental strategies that target both donors and recipients at various phases of the transplant process have focused on attenuating ischemia-reperfusion injury and have achieved encouraging results. In the present article, our goal is to provide an overview of the current status of, and recent advances in, liver transplant from donation after cardiac death, to better understand the risks and potential benefits of donation after cardiac death liver transplant.

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The Increased Costs of Donation After Cardiac Death Liver Transplantation

Abstract: Higher rates of graft failure and biliary complications translate into markedly increased direct medical care costs for DCD recipients. These important financial implications should be considered in decisions regarding the use of DCD livers.

Cited by 95 publications

References 16 publications

Liver transplant outcomes using ideal donation after circulatory death livers are superior to using older donation after brain death donor livers

Liver transplant outcomes using ideal donation after circulatory death livers are superior to using older donation after brain death donor livers

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