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Delayed graft function (DGF) in kidney transplant significantly increases inpatient and outpatient cost. Targeted, mild hypothermia in organ donors after neurologic determination of death significantly reduced the rate of DGF in a recent randomized controlled clinical trial. To assess the potential economic benefit of national implementation of donor hypothermia, rates of reduction DGF were combined with estimates of the impact of DGF on hospital cost and total health expenditure for standard and extended criteria donor organs (SCD and ECD). DGF increases the cost of the transplant episode by $9487 for ECD transplant and $10 342 for SCD transplant. Medicare recipients with DGF incur an additional $18 513 spending for ECD and $14 948 in SCD transplants over the first year. An absolute reduction in DGF rate after kidney transplantation consistent with trial results (ECD 25%, SCD 7%) has the potential to lower annual hospital cost for kidney transplant by $13 178 746 and annual Medicare spending by $20 970 706 compared to standard donor management practice using static cold storage. Targeted mild hypothermia improves care of renal transplant patients by safely reducing DGF rates in both ECD and SCD transplant. Broader application of this safe, effective, and low-cost intervention could reduce healthcare expenditures for providers and insurers., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

While the costs to Medicare of solid organ transplants are varied and considerable, the total Medicare expenditure of $4.4 billion for solid organ transplant recipients in 2014 remained less than 1% of all Medicare expenditures. For patients covered by Medicare, the ratio of pre- to posttransplant cost of care varied widely by organ and within some organ categories by patient characteristics. This chapter reports pretransplant costs for all solid organ candidates covered by Medicare to allow investigators to further explore the relative cost of transplant compared with alternative management., (.)

Organ and tissue donation are options at the end of a patient's life. Physicians and surgeons should have no direct role to play in the solicitation of organ donation and consent for organ recovery from the family of either a brain dead patient or a neurologically devastated patient. Certainly organ and tissue donation, and transplant procedures are life-saving and life-changing for many patients with organ failure and life-altering conditions. Due in part to the disparity between supply and demand for these resources, the potential exists for ethical tensions between the caring physician and surgeon team's advocacy for their patient, and the family at the end of the patient's life, and the process of organ donation. In this article, we will discuss the evolution of the legislative landscape for organ donation in the past decade, the concept of first person consent and its implications, the process of recovery and finally concerns regarding issues of conflict of interest regarding the handling and processing of the donor gift.

Background: Limited data are available on outcome implications of clopidogrel use before kidney transplantation., Methods: A novel dataset linking national transplant registry data with records from a large pharmacy claims clearinghouse (2005 to 2010) was examined to estimate risks of post-transplant death and graft failure associated with clopidogrel fills within 90 or more than 90 days before transplant., Results: Clopidogrel fills within 90 days of transplant were associated with 61% of increased relative mortality risk and 23% of increased graft failure risk. Risks were higher in those whose last clopidogrel fill was more than 90 days before transplantation (111% for death, 59% for graft loss). Adverse prognostic associations persisted among recipients of live and deceased donor allografts, older recipients, and those with diabetes or reported cardiovascular disease., Conclusions: Clopidogrel use before kidney transplantation portends increased risks of post-transplant death and graft loss. Pharmacy claims may identify novel prognostic markers not currently captured in the transplant registry., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Severe geographic disparities exist in liver transplantation; for patients with comparable disease severity, 90-day transplant rates range from 18% to 86% and death rates range from 14% to 82% across donation service areas (DSAs). Broader sharing has been proposed to resolve geographic inequity; however, we hypothesized that the efficacy of broader sharing depends on the geographic partitions used. To determine the potential impact of redistricting on geographic disparity in disease severity at transplantation, we combined existing DSAs into novel regions using mathematical redistricting optimization. Optimized maps and current maps were evaluated using the Liver Simulated Allocation Model. Primary analysis was based on 6700 deceased donors, 28 063 liver transplant candidates, and 242 727 Model of End-Stage Liver Disease (MELD) changes in 2010. Fully regional sharing within the current regional map would paradoxically worsen geographic disparity (variance in MELD at transplantation increases from 11.2 to 13.5, p = 0.021), although it would decrease waitlist deaths (from 1368 to 1329, p = 0.002). In contrast, regional sharing within an optimized map would significantly reduce geographic disparity (to 7.0, p = 0.002) while achieving a larger decrease in waitlist deaths (to 1307, p = 0.002). Redistricting optimization, but not broader sharing alone, would reduce geographic disparity in allocation of livers for transplant across the United States., (© Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons.)

We propose a Medicare Demonstration Project to develop a standard acquisition charge for kidney paired donation. A new payment strategy is required because Medicare and commercial insurance companies may not directly pay living donor costs intended to lead to transplantation of a beneficiary of a different insurance provider. Until the 1970s, when organ procurement organizations were empowered to serve as financial intermediaries to pay the upfront recovery expenses for deceased donor kidneys before knowing the identity of the recipient, there existed similar limitations in the recovery and placement of deceased donor organs. Analogous to the recovery of deceased donor kidneys, kidney paired donation requires the evaluation of living donors before identifying their recipient. Tissue typing, crossmatching and transportation of living donors or their kidneys represent additional financial barriers. Finally, the administrative expenses of the organizations that identify and coordinate kidney paired donation transplantation require reimbursement akin to that necessary for organ procurement organizations. To expand access to kidney paired donation for more patients, we propose a model to reimburse paired donation expenses analogous to the proven strategy used for over 30 years to pay for deceased donor solid organ transplantation in America., (© Copyright 2012 The American Society of Transplantation and the American Society of Transplant Surgeons.)

We examined the UNOS database from 7/15/00-7/17/05 for Regional deceased donor liver utilization. For each region, we performed logistic regression and derived odds ratios (OR) for donor characteristics associated with livers being transplanted outside of the region or not transplanted at all. Regions with smallest and least significant OR were considered aggressive users of suboptimal organs. We estimated how many untransplanted livers from less aggressive regions might be used by more aggressive regions. Only Region 9 was significantly more aggressive than others (median OR: 6 vs. 16; p < 0.01; median OR size: 1.4 vs. 3.6; p < 0.01). Region 9 transplanted at higher median Model for End-stage Liver Disease (MELD) score (20.4 [6-73] vs. 18.3 [6-70], p < 0.01), but had the lowest one- and five-yr graft survival (p < 0.01). Of 30,474 livers, 5056 were not transplanted, of which 3690 were procured outside Region 9 but met Region 9 use criteria. Of these, 1488 and 1807 livers had donor risk indices ≤ 2, for hypothetical 12 and 8 h cold ischemia time (CIT), respectively. Regional differences in liver utilization are profound. Region 9 is significantly more aggressive. At the most, 297-361 organs per year may have been used under Region 9's use criteria but overall graft survival may have declined., (© 2010 John Wiley & Sons A/S.)

Delayed graft function (DGF) impacts short- and long-term outcomes. We present a model for predicting DGF after renal transplantation. A multivariable logistic regression analysis of 24,337 deceased donor renal transplant recipients (2003-2006) was performed. We developed a nomogram, depicting relative contribution of risk factors, and a novel web-based calculator (http://www.transplantcalculator.com/DGF) as an easily accessible tool for predicting DGF. Risk factors in the modern era were compared with their relative impact in an earlier era (1995-1998). Although the impact of many risk factors remained similar over time, weight of immunological factors attenuated, while impact of donor renal function increased by 2-fold. This may reflect advances in immunosuppression and increased utilization of kidneys from expanded criteria donors (ECDs) in the modern era. The most significant factors associated with DGF were cold ischemia time, donor creatinine, body mass index, donation after cardiac death and donor age. In addition to predicting DGF, the model predicted graft failure. A 25-50% probability of DGF was associated with a 50% increased risk of graft failure relative to a DGF risk < 25%, whereas a > 50% DGF risk was associated with a 2-fold increased risk of graft failure. This tool is useful for predicting DGF and long-term outcomes at the time of transplant., (©2010 The Authors Journal compilation©2010 The American Society of Transplantation and the American Society of Transplant Surgeons.)

We investigated graft and patient survival implications of simultaneous pancreas kidney (SPK) transplant from old donors. Data describing patients with type 1 diabetes mellitus listed for an SPK transplant from 1994 to 2005 were drawn from Organ Procurement and Transplant Network registries. Allograft survival, patient survival and long-term survival expectations among SPK recipients from young (age <45 years) and old (age >/=45 years) donors were modeled by multivariate regression. We also examined predictors of reduced early access to young donor transplants. Of 16 496 eligible SPK candidates, 8850 patients (53.6%) received an SPK transplant and 776 (8.8%) of these transplants were from old donors. Reasonable 5-year, death-censored kidney (77.8 %) and pancreas (71.3%) survivals were achieved with old donors. SPK transplantation from both young and old donors predicted lower mortality compared to continued waiting. An additional expected wait of 1.5 years for a young donor equalized long-term survival expectations to that achieved with use of old donors. Early allocation of young donor transplants declined in the more recent era and varied by region, candidate age, blood type and sensitization. We conclude that old SPK donors should be considered for patients with decreased access to young donor transplants. Prospective evaluation of this practice is needed.

The disparity between the organ supply and the demand for liver transplantation (LT) has resulted in the growing utilization of 'marginal donor' organs. While economic outcomes for subsets of 'marginal' organs have been described for renal transplantation, similar analyses have not been performed for LT. Using UNOS data for 17 710 LTs performed between 2002 and 2005, we assessed the relationship between recipient model for end-stage liver disease (MELD) score, organ quality as defined by donor risk index (DRI, Feng et al. 2005) and hospital length of stay (LOS). Single-center cost-accounting data for 338 liver transplants were then analyzed with a multivariate linear regression model to determine the estimated cost associated with a day of LOS. Overall, 8.4% of donor organs were classified as high risk (DRI > 2-2.5) and 1.9% as very high risk (DRI > 2.5). In the lowest MELD group (0-10), the LOS difference between 'ideal' donors (DRI < 1.0) and very high risk (DRI > 2.5) was 10.6 days which was associated with an estimated incremental cost of $47 986. For patients with MELD >35, the average LOS increased from 23.2 to 41.8 days when very high DRI donors were used, resulting in an estimated increase in cost of nearly $84 000. We conclude that the use of marginal liver grafts results in increased hospital costs independent of recipient risk factors.

Deceased donor factors associated with poor graft outcome are well known, but how often these factors lead to livers left untransplanted is poorly defined. A nested, case-control study was conducted using the United Network for Organ Sharing (UNOS) database from 1987 to 2005. Only those donating >/=1 solid organ were included. Primary outcome was livers not transplanted (LNT, cases) versus transplanted (LT, controls). Primary variables for multivariate analysis were donor age and obesity. Covariates included donation after cardiac death (DCD), cerebral vascular accident death, viral serologies, cancer, ALT and bilirubin. There were 23 373 (26%) LNT's from 91 362 donors who donated at least one organ. Percent LNT fell over time (1987-1990: 48%; 1991-1995: 29%; 1996-2000: 21%; 2000-2005: 16%; p < 0.01). Increased age (odds ratio: 4.2, 95% confidence interval 3.6-4.9, p < 0.01) and obesity (2.1, 1.9-2.3, p < 0.01) were significantly associated with LNT across all time periods. Other significant factors included DCD and elevated ALT. For 2001-2005, population attributable risk indicate that age >40, abnormal ALT and obesity account for 32.6%, 25.3% and 9.2% of untransplanted livers, respectively. Use of expanded criteria livers has pushed LNT lower in spite of an aging and heavier donor population. Nevertheless, age and obesity still account for a significant portion of untransplanted livers.