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Alejandra Villamil - Argentina - Tuesday 29 - Organ Allocation Optimizing donor-recipient match
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Alejandra Villamil - Argentina - Tuesday 29 - Organ Allocation Optimizing donor-recipient match Presentation Transcript

  • 1. 2011 Organ Donation Congress Buenos Aires Alejandra Villamil Hospital Italiano de Buenos Aires “ Donor Risk Index in Liver Transplantation”
  • 2. Liver Transplantation “ A dance for two”
  • 3. Liver Transplantation Ideal Donor Ideal Recipient Ideal “couple” Optimal patient and graft survival
  • 4. Ideal Donor Ideal Recipient Ideal “couple” Do we always get what we want? Optimal patient and graft survival
  • 5. The Transplant Scenario Critical scarcity of cadaveric donors
    • Insufficient to satisfy recipient demand
    • Progressive increase in waiting time
    • Increased waiting list mortality
  • 6. Strategies to overcome organ scarcity Expand the donor pool Optimize the distribution of available organs
    • Living donors
    • Extended criteria donors (ECD)
    • Split liver transplants
    • Domino transplant
    • MELD Score liver allocation system
  • 7. Strategies to overcome organ scarcity Expand the donor pool Optimize the distribution of available organs
    • Extended criteria donors (ECD)
    • MELD Score liver allocation system
    The strongest answer to the organ shortage problem
  • 8. Extended Criteria Donors Donor with risk factors for early or delayed graft dysfunction Disease transmission
    • Infections
    • Malignancy
    Functional Risk
  • 9. Extended Criteria Donors Donor with risk factors for early or delayed graft dysfunction Disease transmission
    • Infections
    • Malignancy
    Functional Risk Dychotomic variable (yes / no) Continous variable Every donor has an individual functional risk
  • 10. Assesment of Organs Functional Risk Donor Risk Index Quantitative scale based on 8 donor variables that defines a relative risk of graft failure Feng S. AJT 2006 Apr; 6(4):783790
    • Age
    • Race
    • Height
    • Cause of Death
    • DCD
    • Partial / Split
    • Cold ischemia time
    • Sharing of organs
    Provides Objectivity Reproducibility Comparability *All variables knowable at the time of offering
    • Decision making
    • Historical and prospective
    • analysis
  • 11. The increase in the number of livers parallels an increase in the average DRI, corresponding to a decrease in organ quality Graft Quality in Adult Liver Transplants The historical perspective Median Donor Risk Index in successive years SRTR 2005
  • 12. What is the cost of lower quality organs? Lower quality organs “do worst” than ideal organs Feng S. AJT 2006 Apr; 6(4):783790
    • Mechanical ventilation.
    • Hemodyalisis
    • Infectious complications
    • ICU stay
    • Hospitalization days
    • Rejection episodes (?)
    • Hospital costs
    • Mortality !!
    The “more s ” of ECD Adjusted graft survival by Donor Risk Index
  • 13. What is the cost of lower quality organs? Lower quality organs “do worst” than ideal organs Feng S. AJT 2006
    • Mechanical ventilation.
    • Hemodyalisis
    • Infectious complications
    • ICU stay
    • Hospitalization days
    • Rejection episodes (?)
    • In hospital costs
    • Mortality !!
    The “mores” of ECD Adjusted graft survival by Donor Risk Index Who will carry the burden?
  • 14. Impact of donor quality on transplant outcomes “ Best organs for the sickest patients” Unable to survive the additional challenge of a poor quality organ SRTR Median Donor Risk Index (DRI)by MELD at Transplant Liver utilization practices
  • 15. Is it fair to expose the healthiest candidates, who benefit the least from transplantation, to bear the additional burden of high risk grafts? Impact of donor quality on transplant outcomes “ Worst organs for the healthiest patients”
  • 16. What is the impact of ECD across MELD Scores? Analysis of the outcome of transplantation with EDC (DRI >1.7) stratified by MELD Score The higher risk of graft failure for low quality organs remained stable across MELD categories The impact of suboptimal graft quality is not magnified by increased recipient severity Maluf, D.G. Transplantation 2006
  • 17. Combined impact of graft quality and disease severity Schaubel D, ATC 2006 Survival benefit for MELD >18 with high DRI organs Survival benefit for MELD >15 -17 with medium DRI organs Survival benefit for MELD >12 -14 with low DRI organs MELD <12 negative survival benefit from transplantation Intention to Treat analysis: What is the risk of doing the transplant with this graft versus the risk of not doing the transplant for a given recipient. Elective Risk of Death in first year Transplantation of the sickest candidates with lower quality livers may be justifiable and appropriate
  • 18. Combined impact of graft quality and disease severity Schaubel D, ATC 2006 Survival benefit for MELD >18 with high DRI organs Survival benefit for MELD >15 -17 with medium DRI organs Survival benefit for MELD >12 -14 with low DRI organs MELD <12 negative survival benefit from transplantation Intention to Treat analysis: What is the risk of doing the transplant with this graft versus the risk of not doing the transplant for a given recipient. Elective Risk of Death in first year Low MELD candidates transplantation with poor quality organs might be deleterious !
  • 19. Economic impact of ECDs on Transplantation High MELD score is the strongest predictor of liver transplant costs. Washburn W.K , Am J Transplant 2006. Axelrod, D.A. Am J Transplant 2007 DRI has been reported to increase hospital costs independently of the recipient status Average hospital charges by donor quality Sickest candidates High MELD score Poor quality organ High DRI + Higher costs Can we pay the price?
  • 20. Lucas McCormack, HPB World Congress 2010 Other alternatives for “ livers that nobody wants” Analysis of the experience in Hospital Aleman de Buenos Aires Are the two groups comparable? ECD could be an alternative for patients “underserved” by MELD Score distribution (ie HCC over Milan criteria, refractory ascites, HIV + patients) LNW (n=26) Control (n=25) p value Time in our LT Program (days) 53 (1-696) 42 (1-788) 0.72 Position on the WL 71 (31-432) 18 (2-29) <0.001 MELD score 13 (6-21) 18 (6-34) 0.02 MELD corrected 13 (6-21) 22 (7-34) <0.001 Donor risk factors (≤2 vs. 3-4 factors) 11/ 15 19/6 0.03
  • 21. Should donor and recipient be matched in liver transplantation?
  • 22. Ethics of ECD Which principles should guide allocation of ECDs? Maximize utility Maximize survival benefit Higher post Tx survival Considering in-list mortality and post Tx survival ECDs for low MELD scores ECDs for high MELD scores ALERT ! Deterioration of transplant outcomes among candidates with MELD < 20 has been attributed to the use of high DRI organs Volk, ECDs for other patients
  • 23. Which principles should guide allocation of ECDs? Decision making Recipient disease severity (MELD score) Donor quality (Donor Risk Index) Logistics Estimated ischemia time Opprtunity for another offer Consider time! Each decission should be taken in a case by case basis
  • 24. Disciplina de Transplante de Fígado - FMUSP n = 204 Prof. Dr. Luiz Augusto Carneiro D’Albuquerque ECDs: What proportion of the donor pool? The proportion of ECDs is expected to keep growing The Brazil example
  • 25. Meses % sobrevida USA SSESP American Transplant Registry ( Estado de São Paulo) Significant increase in ECDs is expected to impact transplant results Are doctors and patients ready to pay the prize? Prof. Dr. Luiz Augusto Carneiro D’Albuquerque The Brazil example ECDs: What proportion of the donor pool?
  • 26. In conclusion
    • High risk grafts perform more poorly than low risk grafts.
    • This negative impact is not magnified by recipient’s severity.
    • Candidates with high MELD scores obtain substantial survival
    • benefit from undergoing Tx, even with high DRI grafts.
    • Candidates with low MELD scores can be harmed from poor
    • quality grafts.
    • Candidates whose severity is misrepresented by MELD score
    • might benefit from the allocation of these organs.
  • 27. The introduction of ECDs is today a most important strategy to fight organ shortage