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Background: We aimed to examine the association between recipient race/ethnicity and sex, donor liver quality, and liver transplant graft survival., Methods: Adult non-status 1 liver recipients transplanted between March 1, 2002, and December 31, 2008, were identified using Scientific Registry of Transplant Recipients data. The factors of interest were recipient race/ethnicity and sex. Donor risk index (DRI) was used as a donor quality measure. Logistic regression was used to assess the association between race/ethnicity and sex in relation to the transplantation of low-quality (high DRI) or high-quality (low DRI) livers. Cox regression was used to assess the association between race/ethnicity and sex and liver graft failure risk, accounting for DRI., Results: Hispanics were 21% more likely to receive low-quality grafts compared to whites (odds ratio [OR]=1.21, P=0.002). Women had greater odds of receiving a low-quality graft compared to men (OR=1.24, P<0.0001). Despite adjustment for donor quality, African American recipients still had higher graft failure rates compared to whites (hazard ratio [HR]=1.28, P<0.001). Hispanics (HR=0.89, P=0.023) had significantly lower graft failure rates compared to whites despite higher odds of receiving a higher DRI graft. Using an interaction model of DRI and race/ethnicity, we found that the impact of DRI on graft failure rates was significantly reduced for African Americans compared to whites (P=0.02)., Conclusions: This study shows that while liver graft quality differed significantly by recipient race/ethnicity and sex, donor selection practices do not seem to be the dominant factor responsible for worse liver transplant outcomes for minority recipients.

Incident ESRD after liver transplantation (LT) is associated with high post-transplant mortality. We constructed and validated a continuous renal risk index (RRI) to predict post-LT ESRD. Data for 43,514 adult recipients of deceased donor LT alone (February 28, 2002 to December 31, 2010) were linked from the Scientific Registry of Transplant Recipients and the Centers for Medicare and Medicaid Services ESRD Program. An adjusted Cox regression model of time to post-LT ESRD was fitted, and the resulting equation was used to calculate an RRI for each LT recipient. The RRI included 14 recipient factors: age, African-American race, hepatitis C, cholestatic disease, body mass index ≥ 35, pre-LT diabetes, ln creatinine for recipients not on dialysis, ln albumin, ln bilirubin, serum sodium<134 mEq/L, status-1, previous LT, transjugular intrahepatic portosystemic shunt, and acute dialysis at LT. This RRI was validated and had a C statistic of 0.76 (95% confidence interval, 0.75 to 0.78). Higher RRI associated significantly with higher 5-year cumulative incidence of ESRD and post-transplant mortality. In conclusion, the RRI constructed in this study quantifies the risk of post-LT ESRD and is applicable to all LT alone recipients. This new validated measure may serve as an important prognostic tool in ameliorating post-LT ESRD risk and improve survival by informing post-LT patient management strategies.

Background and Objectives: Candidates with AKI including hepatorenal syndrome often recover renal function after successful liver transplantation (LT). This study examined the incidence and risk factors associated with renal nonrecovery within 6 months of LT alone among those receiving acute renal replacement therapy (RRT) before LT., Design, Setting, Participants, & Measurements: Scientific Registry of Transplant Recipients data were linked with Centers for Medicare and Medicaid Services ESRD data for 2112 adult deceased-donor LT-alone recipients who received acute RRT for ≤90 days before LT (February 28, 2002 to August 31, 2010). Primary outcome was renal nonrecovery (post-LT ESRD), defined as transition to chronic dialysis or waitlisting or receipt of kidney transplant within 6 months of LT. Cumulative incidence of renal nonrecovery was calculated using competing risk analysis. Cox regression identified recipient and donor predictors of renal nonrecovery., Results: The cumulative incidence of renal nonrecovery after LT alone among those receiving the pre-LT acute RRT was 8.9%. Adjusted renal nonrecovery risk increased by 3.6% per day of pre-LT RRT (P<0.001). Age at LT per 5 years (P=0.02), previous-LT (P=0.01), and pre-LT diabetes (P<0.001) were significant risk factors of renal nonrecovery. Twenty-one percent of recipients died within 6 months of LT. Duration of pretransplant RRT did not predict 6-month post-transplant mortality., Conclusions: Among recipients on acute RRT before LT who survived after LT alone, the majority recovered their renal function within 6 months of LT. Longer pre-LT RRT duration, advanced age, diabetes, and re-LT were significantly associated with increased risk of renal nonrecovery.

Under an ideal implementation of Model for End-Stage Liver Disease (MELD)-based liver allocation, the only factors that would predict deceased donor liver transplantation (DDLT) rates would be the MELD score, blood type, and donation service area (DSA). We aimed to determine whether additional factors are associated with DDLT rates in actual practice. Data from the Scientific Registry of Transplant Recipients for all adult candidates wait-listed between March 1, 2002 and December 31, 2008 (n = 57,503) were analyzed. Status 1 candidates were excluded. Cox regression was used to model covariate-adjusted DDLT rates, which were stratified by the DSA, blood type, liver-intestine policy, and allocation MELD score. Inactive time on the wait list was not modeled, so the computed DDLT hazard ratios (HRs) were interpreted as active wait-list candidates. Many factors, including the candidate's age, sex, diagnosis, hospitalization status, and height, prior DDLT, and combined listing for liver-kidney or liver-intestine transplantation, were significantly associated with DDLT rates. Factors associated with significantly lower covariate-adjusted DDLT rates were a higher serum creatinine level (HR = 0.92, P < 0.001), a higher bilirubin level (HR = 0.99, P = 0.001), and the receipt of dialysis (HR = 0.83, P < 0.001). Mild ascites (HR = 1.15, P < 0.001) and hepatic encephalopathy (grade 1 or 2, HR = 1.05, P = 0.02; grade 3 or 4, HR = 1.10, P = 0.01) were associated with significantly higher adjusted DDLT rates. In conclusion, adjusted DDLT rates for actively listed candidates are affected by many factors aside from those integral to the allocation system; these factors include the components of the MELD score itself as well as candidate factors that were considered but were deliberately omitted from the MELD score in order to keep it objective. These results raise the question whether additional candidate characteristics should be explicitly incorporated into the prioritization of wait-list candidates because such factors are already systematically affecting DDLT rates under the current allocation system., (Copyright © 2012 American Association for the Study of Liver Diseases.)

The proportion of patients undergoing liver transplantation (LT), with concomitant renal dysfunction, markedly increased after allocation by the model for end-stage liver disease (MELD) score was introduced. We examined the incidence of subsequent post-LT end-stage renal disease (ESRD) before and after the policy was implemented. Data on all adult deceased donor LT recipients between April 27, 1995 and December 31, 2008 (n = 59 242), from the Scientific Registry of Transplant Recipients, were linked with Centers for Medicare & Medicaid Services' ESRD data. Cox regression was used to (i) compare pre-MELD and MELD eras with respect to post-LT ESRD incidence, (ii) determine the risk factors for post-LT ESRD and (iii) quantify the association between ESRD incidence and mortality. Crude rates of post-LT ESRD were 12.8 and 14.5 per 1000 patient-years in the pre-MELD and MELD eras, respectively. Covariate-adjusted post-LT ESRD risk was higher in the MELD era (hazard ratio [HR]= 1.15; p = 0.0049). African American race, hepatitis C, pre-LT diabetes, higher creatinine, lower albumin, lower bilirubin and sodium >141 mmol/L at LT were also significant predictors of post-LT ESRD. Post-LT ESRD was associated with higher post-LT mortality (HR = 3.32; p < 0.0001). The risk of post-LT ESRD, a strong predictor of post-LT mortality, is 15% higher in the MELD era. This study identified potentially modifiable risk factors of post-LT ESRD. Early intervention and modification of these risk factors may reduce the burden of post-LT ESRD., (©2011 The Authors Journal compilation © 2011 The American Society of Transplantation and the American Society of Transplant Surgeons.)

We sought to characterize sex-based differences in access to deceased donor liver transplantation. Scientific Registry of Transplant Recipients data were used to analyze n = 78 998 adult candidates listed before (8/1997-2/2002) or after (2/2002-2/2007) implementation of Model for End-Stage Liver Disease (MELD)-based liver allocation. The primary outcome was deceased donor liver transplantation. Cox regression was used to estimate covariate-adjusted differences in transplant rates by sex. Females represented 38% of listed patients in the pre-MELD era and 35% in the MELD era. Females had significantly lower covariate-adjusted transplant rates in the pre-MELD era (by 9%; p < 0.0001) and in the MELD era (by 14%; p < 0.0001). In the MELD era, the disparity in transplant rate for females increased as waiting list mortality risk increased, particularly for MELD scores ≥15. Substantial geographic variation in sex-based differences in transplant rates was observed. Some areas of the United States had more than a 30% lower covariate-adjusted transplant rate for females compared to males in the MELD era. In conclusion, the disparity in liver transplant rates between females and males has increased in the MELD era. It is especially troubling that the disparity is magnified among patients with high MELD scores and in certain regions of the United States., (©2011 The Authors Journal compilation©2011 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Access to liver transplantation is reportedly inequitable for racial/ethnic minorities, but inadequate adjustments for geography and disease progression preclude any meaningful conclusions. We aimed to evaluate the association between candidate race/ethnicity and liver transplant rates after thorough adjustments for these factors and to determine how uniform racial/ethnic disparities were across Model for End-Stage Liver Disease (MELD) scores. Chronic end-stage liver disease candidates initially wait-listed between February 28, 2002 and February 27, 2007 were identified from Scientific Registry for Transplant Recipients data. The primary outcome was deceased donor liver transplantation (DDLT); the primary exposure covariate was race/ethnicity (white, African American, Hispanic, Asian, and other). Cox regression was used to estimate the covariate-adjusted DDLT rates by race/ethnicity, which were stratified by the donation service area and MELD score. With averaging across all MELD scores, African Americans, Asians, and others had similar adjusted DDLT rates in comparison with whites. However, Hispanics had an 8% lower DDLT rate versus whites [hazard ratio (HR) = 0.92, P = 0.011]. The disparity among Hispanics was concentrated among patients with MELD scores < 20, with HR = 0.84 (P = 0.021) for MELD scores of 6 to 14 and HR = 0.85 (P = 0.009) for MELD scores of 15 to 19. Asians with MELD scores < 15 had a 24% higher DDLT rate with respect to whites (HR = 1.24, P = 0.024). However, Asians with MELD scores of 30 to 40 had a 46% lower DDLT rate (HR = 0.54, P = 0.004). In conclusion, although African Americans did not have significantly different DDLT rates in comparison with similar white candidates, race/ethnicity-based disparities were prominent among subgroups of Hispanic and Asian candidates. By precluding the survival benefit of liver transplantation, this inequity may lead to excess mortality for minority candidates., ((c) 2010 AASLD.)

Portal vein thrombosis (PVT) complicates the liver transplant operation and potentially affects waiting list survival. The implications on calculations of survival benefit, which balance both waiting list and posttransplant survival effects of PVT, have not been determined. The objective of this study is to describe the effect of PVT on the survival benefit of liver transplantation. Using Scientific Registry of Transplant Recipients data on adult liver transplant candidates wait-listed between September 2001 and December 2007, Cox proportional hazard models were fitted to estimate the covariate-adjusted effect of PVT on transplant rate, waiting list survival, and posttransplant survival. We then used sequential stratification to estimate liver transplant survival benefit by cross-classifications defined by Model for End-Stage Liver Disease (MELD) score and PVT status. The prevalence of reported PVT among 22,291 liver transplant recipients was 4.02% (N = 897). PVT was not a predictor of waiting list mortality (hazard ratio = 0.90, P = 0.23) but was a predictor of posttransplant mortality (hazard ratio = 1.32, P = 0.02). Overall, transplant benefit was not significantly different for patients with PVT versus without PVT (P = 0.21), but there was a shift in the benefit curve. Specifically, the threshold for transplant benefit among patients without PVT was MELD score >11 compared to MELD score >13 for patients with PVT. PVT is associated with significantly higher posttransplant mortality but does not affect waiting list mortality. Among patients with low MELD score, PVT is associated with less transplant survival benefit. Clinicians should carefully consider the risks of liver transplantation in clinically stable patients who have PVT., ((c) 2010 AASLD.)

Changes in organ allocation policy in 2002 reduced the number of adult patients on the liver transplant waiting list, changed the characteristics of transplant recipients and increased the number of patients receiving simultaneous liver-kidney transplantation (SLK). The number of liver transplants peaked in 2006 and declined marginally in 2007 and 2008. During this period, there was an increase in donor age, the Donor Risk Index, the number of candidates receiving MELD exception scores and the number of recipients with hepatocellular carcinoma. In contrast, there was a decrease in retransplantation rates, and the number of patients receiving grafts from either a living donor or from donation after cardiac death. The proportion of patients with severe obesity, diabetes and renal insufficiency increased during this period. Despite increases in donor and recipient risk factors, there was a trend towards better 1-year graft and patient survival between 1998 and 2007. Of major concern, however, were considerable regional variations in waiting time and posttransplant survival. The current status of liver transplantation in the United States between 1999 and 2008 was analyzed using SRTR data. In addition to a general summary, we have included a more detailed analysis of liver transplantation for hepatitis C, retransplantation and SLK transplantation.

More candidates with creatinine levels >or= 2 mg/dL have undergone liver transplantation (LT) since the implementation of Model for End-Stage Liver Disease (MELD)-based allocation. These candidates have higher posttransplant mortality. This study examined the effect of serum creatinine on survival benefit among candidates undergoing LT. Scientific Registry of Transplant Recipients data were analyzed for adult LT candidates listed between September 2001 and December 2006 (n = 38,899). The effect of serum creatinine on survival benefit (contrast between waitlist and post-LT mortality rates) was assessed by sequential stratification, an extension of Cox regression. At the same MELD score, serum creatinine was inversely associated with survival benefit within certain defined MELD categories. The survival benefit significantly decreased as creatinine increased for candidates with MELD scores of 15 to 17 or 24 to 40 at LT (MELD scores of 15-17, P < 0.0001; MELD scores of 24-40, P = 0.04). Renal replacement therapy at LT was also associated with significantly decreased LT benefit for patients with MELD scores of 21 to 23 (P = 0.04) or 24 to 26 (P = 0.01). In conclusion, serum creatinine at LT significantly affects survival benefit for patients with MELD scores of 15 to 17 or 24 to 40. Given the same MELD score, patients with higher creatinine levels receive less benefit on average, and the relative ranking of a large number of wait-listed candidates with MELD scores of 15 to 17 or 24 to 40 would be markedly affected if these findings were incorporated into the allocation policy.

Unlabelled: Disease-specific analysis of liver transplant survival benefit, which encompasses both pre- and posttransplant events, has not been reported. Therefore, we evaluated the effect of alcoholic liver disease (ALD) and hepatitis C virus (HCV) infection on waiting list mortality, posttransplant mortality, and the survival benefit of deceased donor liver transplantation using United States data from the Scientific Registry of Transplant Recipients on 38,899 adults placed on the transplant waiting list between September 2001 and December 2006. Subjects were classified according to the presence/absence of HCV and ALD. Cox regression was used to estimate waiting list mortality and posttransplant mortality separately. Survival benefit was assessed using sequential stratification. Overall, the presence of HCV significantly increased waiting list mortality, with a covariate-adjusted hazard ratio (HR) for HCV-positive (HCV+) compared with HCV-negative (HCV-) HR = 1.19 (P = 0.0001). The impact of HCV+ was significantly more pronounced (P = 0.001) among ALD-positive (ALD+) patients (HR = 1.36; P < 0.0001), but was still significant among ALD-negative (ALD-) patients (HR = 1.11; P = 0.02). The contrast between ALD+ and ALD- waiting list mortality was significant only among HCV+ patients (HR = 1.14; P = 0.006). Posttransplant mortality was significantly increased among HCV+ (versus HCV-) patients (HR = 1.26; P = 0.0009), but not among ALD+ (versus ALD-) patients. Survival benefit of transplantation was significantly decreased among HCV+ compared with HCV- recipients with model for end-stage liver disease (MELD) scores 9-29, but was significantly increased at MELD >or=30. ALD did not influence the survival benefit of transplantation at any MELD score., Conclusion: Except in patients with very low or very high MELD scores, HCV status has a significant negative impact on the survival benefit of liver transplantation. In contrast, the presence of ALD does not influence liver transplant survival benefit.

Background: We propose a continuous kidney donor risk index (KDRI) for deceased donor kidneys, combining donor and transplant variables to quantify graft failure risk., Methods: By using national data from 1995 to 2005, we analyzed 69,440 first-time, kidney-only, deceased donor adult transplants. Cox regression was used to model the risk of death or graft loss, based on donor and transplant factors, adjusting for recipient factors. The proposed KDRI includes 14 donor and transplant factors, each found to be independently associated with graft failure or death: donor age, race, history of hypertension, history of diabetes, serum creatinine, cerebrovascular cause of death, height, weight, donation after cardiac death, hepatitis C virus status, human leukocyte antigen-B and DR mismatch, cold ischemia time, and double or en bloc transplant. The KDRI reflects the rate of graft failure relative to that of a healthy 40-year-old donor., Results: Transplants of kidneys in the highest KDRI quintile (>1.45) had an adjusted 5-year graft survival of 63%, compared with 82% and 79% in the two lowest KDRI quintiles (<0.79 and 0.79-<0.96, respectively). There is a considerable overlap in the KDRI distribution by expanded and nonexpanded criteria donor classification., Conclusions: The graded impact of KDRI on graft outcome makes it a useful decision-making tool at the time of the deceased donor kidney offer.

Continuous quality improvement efforts have become a central focus of leading health care organizations. The transplant community has been a pioneer in periodic review of clinical outcomes to ensure the optimal use of limited donor organs. Through data collected from the Organ Procurement and Transplantation Network (OPTN) and analyzed by the Scientific Registry of Transplant Recipients (SRTR), transplantation professionals have intermittent access to specific, accurate and clinically relevant data that provides information to improve transplantation. Statistical process control techniques, including cumulative sum charts (CUSUM), are designed to provide continuous, real-time assessment of clinical outcomes. Through the use of currently collected data, CUSUMs can be constructed that provide risk-adjusted program-specific data to inform quality improvement programs. When retrospectively compared to currently available data reporting, the CUSUM method was found to detect clinically significant changes in center performance more rapidly, which has the potential to inform center leadership and enhance quality improvement efforts.

Currently, patients awaiting deceased-donor liver transplantation are prioritized by medical urgency. Specifically, wait-listed chronic liver failure patients are sequenced in decreasing order of Model for End-stage Liver Disease (MELD) score. To maximize lifetime gained through liver transplantation, posttransplant survival should be considered in prioritizing liver waiting list candidates. We evaluate a survival benefit based system for allocating deceased-donor livers to chronic liver failure patients. Under the proposed system, at the time of offer, the transplant survival benefit score would be computed for each patient active on the waiting list. The proposed score is based on the difference in 5-year mean lifetime (with vs. without a liver transplant) and accounts for patient and donor characteristics. The rank correlation between benefit score and MELD score is 0.67. There is great overlap in the distribution of benefit scores across MELD categories, since waiting list mortality is significantly affected by several factors. Simulation results indicate that over 2000 life-years would be saved per year if benefit-based allocation was implemented. The shortage of donor livers increases the need to maximize the life-saving capacity of procured livers. Allocation of deceased-donor livers to chronic liver failure patients would be improved by prioritizing patients by transplant survival benefit.

Graft survival rates from deceased donors aged 35 years or less among all primary pediatric kidney transplant recipients in the United States between 1996 and 2004 were retrospectively examined to determine the effect of HLA-DR mismatches on graft survival. Zero HLA-DR-mismatched kidneys had statistically comparable 5-year graft survival (71%), to 1-DR-mismatched kidneys (69%) and 2-DR-mismatched kidneys (71%). When compared to donors less than 35 years of age, the relative rate of allograft failure was 1.32 (p = 0.0326) for donor age greater than or equal to age 35. There was no statistical increase in the odds of developing a panel-reactive antibody (PRA) greater than 30% at the time of second waitlisting, based upon the degree of HLA-A, -B or -DR mismatch of the first transplant, nor was there a 'dose effect' when more HLA antigens were mismatched between the donor and recipient. Therefore, pediatric transplant programs should utilize the recently implemented Organ Procurement and Transplantation Network's (OPTN)allocation policy, which prioritizes pediatric recipients to receive kidneys from deceased donors less than 35 years of age, and should not turn down such kidney offers to wait for a better HLA-DR-matched kidney.

Liver transplantation in 2006 generally resembled previous years, with fewer candidates waiting for deceased donor liver transplants (DDLT), continuing a trend initiated with the implementation of the model for end-stage liver disease (MELD). Candidate age distribution continued to skew toward older ages with fewer children listed in 2006 than in any prior year. Total transplants increased due to more DDLT with slightly fewer living donor liver transplants (LDLT). Waiting list deaths and time to transplant continued to improve. In 2006, there also were fewer DDLT for patients with MELD <15, fewer pediatric Status 1A/B transplants and more transplants from donation after cardiac death (DCD) donors. Adjusted patient and graft survival rates were similar for LDLT and DDLT. This article also contains in-depth analyses of transplantation for hepatocellular carcinoma (HCC). Recipients with HCC had lower adjusted 3-year posttransplant survival than recipients without HCC. HCC recipients who received pretransplant ablative treatments had superior adjusted 3-year posttransplant survival compared to HCC recipients who did not. Intestinal transplantation continued to slowly increase with the largest number of candidates on the waiting list since 1997. Survival rates have increased over time. Small children waiting for intestine grafts continue to have the highest waiting list mortality.

Context: Disparities in access to organ transplantation exist for racial minorities, women, and patients with lower socioeconomic status or inadequate insurance. Rural residents represent another group that may have impaired access to transplant services., Objective: To assess the association of rural residence with waiting list registration for heart, liver, and kidney transplant and rates of transplantation among wait-listed candidates., Design, Setting, and Patients: Five-year US cohort of 174,630 patients who were wait-listed and who underwent heart, liver, or kidney transplantation between 1999 and 2004., Main Outcome Measures: Rates of new waiting list registrations and transplants per million population for residents of 3 residential classifications (rural/small town population, <10,000; micropolitan, 10,000-50,000; and metropolitan >50,000 or suburb of major city)., Results: Compared with urban residents, waiting list registration rates for rural/small town residents were significantly lower for heart (covariate-adjusted rate ratio [RR] = 0.91; 95% confidence interval [CI], 0.86-0.96; P<.002), liver (RR = 0.86; 95% CI, 0.83-0.89; P<.001), and kidney transplants (RR = 0.92; 95% CI, 0.90-0.95; P<.001). Compared with residents in urban areas, rural/small town residents had lower relative transplant rates for heart (RR = 0.88; 95% CI, 0.81-0.94; P = .004), liver (RR = 0.80; 95% CI, 0.77-0.84; P<.001), and kidney transplantation (covariate-adjusted RR = 0.90; 95% CI, 0.88-0.93; P<.001). These disparities were consistent across national organ allocation regions. Significantly longer waiting times among rural patients wait-listed for heart transplantation were observed but not for liver and kidney transplantation. There were no significant differences in posttransplantation outcomes between groups., Conclusions: Patients living in rural areas had a lower rate of wait-lisiting and transplant of solid organs, but did not experience significantly different outcomes following transplant. Differences in rates of wait-listing and transplant may be due to variations in the burden of disease between different patient groups or barriers to evaluation and waiting list entry for rural residents with organ failure.

Background: A national policy to allocate kidneys from expanded criteria donors (ECD) took effect October 31, 2002., Methods: To assess its impact, we analyzed data from the Scientific Registry of Transplant Recipients for ECD kidney candidates and recipients between November 1999 and October 2005., Results: The likelihood of being listed for ECD transplant, of receiving any transplant, and of receiving an ECD transplant were assessed using logistic regression models. As of October 31, 2005, 42.6% of candidates were listed with an ECD designation (range by donation service area [DSA], 1.9% to 94.9%). ECD-listed candidates were likely to be older, diabetic, and sensitized. By October 31, 2005, candidates listed for ECD as of November 1, 2002 were 41% more likely to receive any kidney transplant than those not ECD-listed. Among ECD-listed recipients, 30.1% received an ECD transplant and 69.9% a non-ECD transplant. Recipients more likely to receive an ECD transplant were significantly older and in DSAs where a high percentage of ECD transplants were performed and/or a low percentage of candidates were ECD-listed., Conclusions: A large, regionally variable fraction of candidates are opting to receive ECD offers. Listing with an ECD designation increases the likelihood of transplantation in selected populations. Selective listing of ECD candidates is associated with a higher likelihood of receiving an ECD transplant.

Background: To ensure the continued success of whole organ pancreas and islet transplantation, deceased donor pancreas allocation policy must continue to evolve., Methods: To assess the existing system, the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing Kidney and Pancreas Transplant Committee retrospectively analyzed the disposition and outcomes of deceased donor pancreata in the United States between January 1, 2000 and December 31, 2003., Results: During the time period studied, consent was obtained but the pancreas was not recovered in 48% (11,820) of organ donors. The most common reasons given for nonrecovery were poor quality of the pancreas and difficulty in placement. Of whole organ pancreata that were transplanted, 90% were from donors with a body mass index (BMI) 50 years (P=0.04), and there were trends toward lower graft survival with donor BMI >30 (P=0.06) and increasing cold-ischemia time., Conclusions: Based on these data, the OPTN adopted a new allocation algorithm in which pancreata from donors >30 kg/m or >50 years of age are, unless accepted for a local whole organ pancreas transplant candidate, preferentially allocated for islet transplantation. These data also suggest that many good quality pancreata are not procured, emphasizing the need for improved communication and cooperation between organ procurement organizations and pancreas and islet transplant programs.

Kidney and pancreas transplantation in 2005 improved in quantity and outcome quality, despite the increasing average age of kidney graft recipients, with 56% aged 50 or older. Geography and ABO blood type contribute to the discrepancy in waiting time among the deceased donor (DD) candidates. Allocation policy changes are decreasing the median times to transplant for pediatric recipients. Overall, 6% more DD kidney transplants were performed in 2005 with slight increases in standard criteria donors (SCD) and expanded criteria donors (ECD). The largest increase (39%) was in donation after cardiac death (DCD) from non-ECD donors. These DCD, non-ECD kidneys had equivalent outcomes to SCD kidneys. 1-, 3- and 5-year unadjusted graft survival was 91%, 80% and 70% for non-ECD-DD transplants, 82%, 68% and 53% for ECD-DD grafts, and 95%, 88% and 80% for living donor kidney transplants. In 2005, 27% of patients were discharged without steroids compared to 3% in 1999. Acute rejection decreased to 11% in 2004. There was a slight increase in the number of simultaneous pancreas-kidney transplants (895), with fewer pancreas after kidney transplants (343 from 419 in 2004), and a stable number of pancreas alone transplants (129). Pancreas underutilization appears to be an ongoing issue.

The optimal use of kidneys from small pediatric deceased donors remains undetermined. Using data from the Scientific Registry of Transplant Recipients, 2886 small (< 21 kg) pediatric donors between 1993 and 2002 were identified. Donor factors predictive of kidney recovery and transplantation (1343 en bloc; 1600 single) were identified by logistic regression. Multivariable Cox regression was used to assess the risk of graft loss. The rate of kidney recovery from small pediatric donors was significantly higher with increasing age, weight and height. The odds of transplant of recovered small donor kidneys were significantly higher with increasing age, weight, height and en bloc recovery (adjusted odds ratio = 65.8 vs. single; p < 0.0001), and significantly lower with increasing creatinine. Compared to en bloc, solitary transplants had a 78% higher risk of graft loss (p < 0.0001). En bloc transplants had a similar graft survival to ideal donors (p = 0.45) while solitary transplants had an increased risk of graft loss (p < 0.0001). En bloc recovery of kidneys from small pediatric donors may result in the highest probability of transplantation. Although limited by the retrospective nature of the study, kidneys transplanted en bloc had a similar graft survival to ideal donors but may not maximize the number of successfully transplanted recipients.

Access to timely, risk-adjusted measures of transplant center outcomes is crucial for program quality improvement. The cumulative summation technique (CUSUM) has been proposed as a sensitive tool to detect persistent, clinically relevant changes in transplant center performance over time. Scientific Registry of Transplant Recipients data for adult kidney and liver transplants (1/97 to 12/01) were examined using logistic regression models to predict risk of graft failure (kidney) and death (liver) at 1 year. Risk-adjusted CUSUM charts were constructed for each center and compared with results from the semi-annual method of the Organ Procurement and Transplantation Network (OPTN). Transplant centers (N = 258) performed 59 650 kidney transplants, with a 9.2% 1-year graft failure rate. The CUSUM method identified centers with a period of significantly improving (N = 92) or declining (N = 52) performance. Transplant centers (N = 114) performed 18 277 liver transplants, with a 13.9% 1-year mortality rate. The CUSUM method demonstrated improving performance at 48 centers and declining performance at 24 centers. The CUSUM technique also identified the majority of centers flagged by the current OPTN method (20/22 kidney and 8/11 liver). CUSUM monitoring may be a useful technique for quality improvement, allowing center directors to identify clinically important, risk-adjusted changes in transplant center outcome.

This article reviews trends in pediatric solid organ transplantation over the last decade, as reflected in OPTN/SRTR data. In 2004, children younger than 18 years made up nearly 3% of the 86,378 candidates for organ transplantation and nearly 7% of the 27,031 organ transplant recipients. Children accounted for nearly 14% of the 7152 deceased organ donors. The transplant community recognizes important differences between pediatric and adult organ transplant recipients, including different etiologies of organ failure, surgical procedures that are more complex or technically challenging, effects of development on the pharmacokinetic properties of common immunosuppressants, unique immunological aspects of transplant in the developing immune system and increased susceptibility to posttransplant complications, particularly infectious diseases. For these reasons, and because of the impact of end-stage organ failure on growth and development, the transplant community has generally provided pediatric candidates with special consideration in the allocation of deceased donor organs. Outcomes following kidney, liver and heart transplantation in children often rank among the best. This article emphasizes that the prospects for solid organ transplantation in children, especially those aged 1-10 years are excellent. It also identifies themes warranting further consideration, including organ availability, adolescent survival and challenges facing pediatric transplant clinical research.

Continued progress in organ donation will help enable transplantation to alleviate the increasing incidence of end-stage organ disease. This article discusses the implementation and effect of the federally initiated Organ Donation Breakthrough Collaborative; it then reviews organ donation data, living and deceased, from 1995 to 2004. It is the first annual report of the Scientific Registry of Transplant Recipients to include national data following initiation of the collaborative in 2003. Prior to that, annual growth in deceased donation was 2%-4%; in 2004, after initiation of the collaborative, deceased donation increased 11%. Identification and dissemination of best practices for organ donation have emphasized new strategies for improved consent, including revised approaches to minority participation, timing of requests and team design. The number of organs recovered from donation after cardiac death (DCD) grew from 64 in 1995 to 391 in 2004. While efforts are ongoing to develop methodologies for identifying expanded criteria donors (ECD) for organs other than kidney, it is clear DCD and ECD raise questions regarding cost and recovery. The number of living donor organs increased from 3493 in 1995 to 7002 in 2004; data show trends toward more living unrelated donors and those providing non-directed donations.

Background: The U.S. Organ Procurement and Transplantation Network recently implemented a policy allocating expanded criteria donor (ECD) kidneys by waiting time alone. ECD kidneys were defined as having a risk of graft failure > or = 1.7 times that of ideal donors. ECDs include any donor > or = 60 years old and donors 50 to 59 years old with at least two of the following: terminal creatinine >1.5 mg/dL, history of hypertension, or death by cerebrovascular accident. The impact of this policy on use of ECD kidneys is assessed., Methods: The authors compared use of ECD kidneys recovered in the 18 months immediately before and after policy implementation. Differences were tested using t test and chi2 analyses., Results: There was an 18.3% increase in ECD kidney recoveries and a 15.0% increase in ECD kidney transplants in the first 18 months after policy implementation. ECD kidneys made up 22.1% of all recovered kidneys and 16.8% of all transplants, compared with 18.8% (P<0.001) and 14.5% (P<0.001), respectively, in the prior period. The discard rate was unchanged. The median relative risk (RR) for graft failure for transplanted ECD kidneys was 2.07 versus 1.99 in the prepolicy period (P=not significant); the median RR for procured ECD kidneys was unchanged at 2.16. The percentage of transplanted ECD kidneys with cold ischemia times (CIT) <12 hr increased significantly; the corresponding percentage for CIT > or = 24 hr decreased significantly., Conclusions: The recent increase in ECD kidney recoveries and transplants appears to be related to implementation of the ECD allocation system.

This article uses OPTN/SRTR data to review trends in pediatric transplantation over the last decade. In 2003, children younger than 18 made up 3% of the 82,885 candidates for organ transplantation and 7% of the 25,469 organ transplant recipients. Children accounted for 14% of the 6,455 deceased organ donors. Pediatric organ transplant recipients differ from their adult counterparts in several important aspects, including the underlying etiology of organ failure, the complexity of the surgical procedures, the pharmacokinetic properties of common immunosuppressants, the immune response following transplantation, the number and degree of comorbid conditions, and the susceptibility to post-transplant complications, especially infectious diseases. Specialized pediatric organ transplant programs have been developed to address these special problems. The transplant community has responded to the particular needs of children and has provided them special consideration in the allocation of deceased donor organs. As a result of these programs and protocols, children are now frequently the most successful recipients of organ transplantation; their outcomes following kidney, liver, and heart transplantation rank among the best. This article demonstrates that substantial improvement is needed in several areas: adolescent outcomes, outcomes following intestine transplants, and waiting list mortality among pediatric heart and lung candidates.

The worsening shortage of donor kidneys for transplant and the aging of both the donor and candidate populations have contributed to the increasing importance of ECD kidney transplantation. While ECD transplants have an increased risk of graft failure, for most candidates patient survival is still improved over remaining on dialysis. Because of this risk, however, ECD kidneys have a high likelihood of discard; significant geographic variation in discard and transplant rates impedes maximum utilization of these kidneys. The ECD allocation system was implemented to help facilitate expeditious placement of ECD kidneys to pre-consented candidates by a simplified allocation algorithm. Under this system, recovery and transplantation of ECD kidneys have increased at rates not seen with non-ECD kidneys and not predicted by preexisting trends. More disappointing has been the lack of effect on the percentage of discards and DGF, despite significant reductions in CIT. The disadvantage in graft survival for ECD kidneys extends equally across the spectrum of recipient characteristics, such that no one group of candidates has a proportionately smaller increase in risk. However, benefit analyses comparing the risk of accepting an ECD kidney versus waiting for a non-ECD kidney demonstrate a significant ECD benefit for older and diabetic candidates in regions with prolonged waiting times. The potential value of an ECD kidney to an individual candidate hinges upon the ability to receive it substantially earlier than a non-ECD kidney. Thus, future allocation efforts may focus on ensuring that is the case. In allocation driven by net benefit, ECD kidneys may become an alternative for those who might not otherwise receive a kidney transplant.

Outcomes for certain surgical procedures have been linked with volume: hospitals performing a high number of procedures demonstrate better outcomes than do low-volume centers. This study examines the effect of volume on hepatic and renal transplant outcomes. Data from the Scientific Registry of Transplant Recipients were analyzed for transplants performed from 1996-2000. Transplant centers were assigned to volume quartiles (kidney) or terciles (liver). Logistic regression models, adjusted for clinical characteristics and transplant center clustering, demonstrate the effect of transplant center volume quantile on 1-year post-transplant patient mortality (liver) and graft loss (kidney). The unadjusted rate of renal graft loss within 1 year was significantly lower at high volume centers (8.6%) compared with very low (9.6%), low (9.9%) and medium (9.7%) volume centers (p = 0.0014). After adjustment, kidney transplant at very low [adjusted odds ratio (AOR) 1.22; p = 0.043) and low volume (AOR 1.22 p = 0.041) centers was associated with a higher incidence of graft loss when compared with high volume centers. Unadjusted 1-year mortality rates for liver transplant were significantly different at high (15.9%) vs. low (16.9%) or medium (14.7%) volume centers. After adjustment, low volume centers were associated with a significantly higher risk of death (AOR 1.30; p = 0.0036). There is considerable variability in the range of failure between quantiles after kidney and liver transplant. Transplant outcomes are better at high volume centers; however, there is no clear minimal threshold volume.

Transplant candidates are permitted to register on multiple waiting lists. We examined multiple-listing practices and outcomes, using data on 81 481 kidney and 26 260 liver candidates registered between 7/1/95 and 6/30/00. Regression models identified factors associated with multiple-listing and its effect on relative rates of transplantation, waiting list mortality, kidney graft failure, and liver transplant mortality. Overall, 5.8% (kidney) and 3.3% (liver) of candidates multiple-listed. Non-white race, older age, non-private insurance, and lower educational level were associated with significantly lower odds of multiple-listing. While multiple-listed, transplantation rates were significantly higher for nearly all kidney and liver candidate subgroups (relative rate [RR]= 1.42-2.29 and 1.82-7.41, respectively). Waiting list mortality rates were significantly lower while multiple-listed for 11 kidney subgroups (RR = 0.22-0.72) but significantly higher for 7 liver subgroups (RR = 1.44-5.93), suggesting multiple-listing by healthier kidney candidates and sicker liver candidates. Graft failure was 10% less likely among multiple-listed kidney recipients. Multiple- and single-listed liver recipients had similar post-transplant mortality rates. Although specific factors characterize those transplant candidates likely to multiple-list, transplant access is significantly enhanced for almost all multiple-listed kidney and liver candidates.

The processes leading to donor identification, consent, organ procurement, and allocation continue to dominate debates and efforts in the field of transplantation. A considerable shortage of donors remains while the number of patients needing organ transplantation increases. This article reviews the main trends in organ donation practices and procurement patterns from both deceased and living sources in the USA. Although there have been increases in living donation in recent years, 2002 witnessed a much more modest growth of 1%. Absolute declines in living liver and lung donation were also noted in 2002. In 2002, the number of deceased donors increased by only 1.6% (101 donors). Increased donation from deceased donors provides more organs for transplantation than a comparable increase in living donation, because on average 3.6 organs are recovered from each deceased donor. The total number of organs recovered from deceased donors increased by 2.1% (462 organs). Poor organ quality continued to be the major reason given for nonrecovery of consented organs from deceased donors. The kidney is the organ most likely to be discarded after recovery. Over the past decade the discard rate of recovered kidneys has increased from 6% to 11%. Many of these are expanded criteria donor kidneys.