Patient decision making about organ quality in liver transplantation

Patient and family engagement interventions for enhancing patient safety in the perioperative journey: a scoping review

BACKGROUND

Surgical procedures present intricate challenges within healthcare delivery, often associated with higher risks of adverse events compared with non-surgical contexts. Patient and family engagement (PFE) throughout the perioperative journey is a possibility to enhance care quality, safety and patient-centredness. However, literature addressing PFE across the entirety of the perioperative journey remains sparse.

OBJECTIVE

The current scoping review aims to comprehensively map the existing interventions with PFE approach focused on improving patient safety across various types of surgical procedures throughout the perioperative journey. In addition, the review aims to understand the level and type of PFE approach adopted in this context.

ELIGIBILITY CRITERIA

Articles published in indexed peer-reviewed journals from 2003 to 2023, written in English, Portuguese or Spanish, that report on interventions with PFE approach targeting adult surgical patients, their families, caregivers, patient advocates and patient champions. The review includes articles reporting on both inpatient and ambulatory surgical patients.

METHODS

Following Joanna Briggs Institute guidelines and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews framework, this review systematically searched PubMed, Web of Science, SCOPUS, CINAHL, and PsycINFO for relevant articles. Eligible interventions were categorised using PFE framework regarding the level of engagement and mapped according to the WHO Global Patient Safety Action Plan 2021-2030.

RESULTS

Out of 765 records initially identified, 32 met the eligibility criteria for data extraction and analysis, of which 40% originated from the USA, followed by the UK (18%) and Canada (12%). 47% of the interventions targeted 'multiple/all types' of procedures, 19% focused on cardiothoracic surgeries and 9% on gynaecological procedures or organ transplant. The majority of the interventions (88%) focused on PFE at the direct care level, predominantly adopting a consultation-based approach. Furthermore, 81% of eligible interventions emphasised patient information and education, 16% addressed codevelopment of policy and 3% of interventions focused on patient advocacy.

CONCLUSION

The findings show a predominant focus on PFE interventions targeting patient safety at the direct care level, particularly in the provision of patient information and education. However, interventions at organisational and policy-making levels are notably scarce. Further investment is required to promote interventions engaging patients and families at broader organisational and policy-making levels.

Scoring donor lungs for graft failure risk: The Lung Donor Risk Index (LDRI)

Lung transplantation lags behind other solid organ transplants in donor lung utilization due, in part, to uncertainty regarding donor quality. We sought to develop an easy-to-use donor risk metric that, unlike existing metrics, accounts for a rich set of donor factors. Our study population consisted of n = 26 549 adult lung transplant recipients abstracted from the United Network for Organ Sharing Standard Transplant Analysis and Research file. We used Cox regression to model graft failure (GF; earliest of death or retransplant) risk based on donor and transplant factors, adjusting for recipient factors. We then derived and validated a Lung Donor Risk Index (LDRI) and developed a pertinent online application (https://shiny.pmacs.upenn.edu/LDRI_Calculator/). We found 12 donor/transplant factors that were independently predictive of GF: age, race, insulin-dependent diabetes, the difference between donor and recipient height, smoking, cocaine use, cytomegalovirus seropositivity, creatinine, human leukocyte antigen (HLA) mismatch, ischemia time, and donation after circulatory death. Validation showed the LDRI to have GF risk discrimination that was reasonable (C = 0.61) and higher than any of its predecessors. The LDRI is intended for use by transplant centers, organ procurement organizations, and regulatory agencies and to benefit patients in decision-making. Unlike its predecessors, the proposed LDRI could gain wide acceptance because of its granularity and similarity to the Kidney Donor Risk Index.

Do patient decision aids help people who are facing decisions about solid organ transplantation? A systematic review

BACKGROUND

Decisions about solid organ transplantation are complex. Patient decision aids (PDAs) enhance traditional education, by improving knowledge and supporting patients to align their values with treatments. There are increasing numbers of transplantation PDAs, however, it is unclear whether these are effective. We conducted a systematic review of studies assessing the impact of PDA use in transplantation.

METHODS

We searched the Cochrane Register of Controlled Trials, CINAHL, EMBASE, MEDLINE, and PsycINFO databases from database inception to October 26, 2020. We included primary studies of solid organ transplantation PDAs defined by the International Patient Decision Aids Standards. All comparators and reported outcomes were included. Mean difference in knowledge (before vs. after) was standardized on a 100-point scale. Pooled-effect for PDAs was calculated and compared to the standard of care for randomized controlled trials (RCTs) and meta-analyzed using random effects. Analysis of all other outcomes was limited due to heterogeneity (PROSPERO registration, CRD42020215940).

RESULTS

Seven thousand four hundred and sixty-three studies were screened, 163 underwent full-text review, and 15 studies with 4278 participants were included. Nine studies were RCTs. Seven RCTs assessed knowledge; all demonstrated increased knowledge with PDA use (mean difference, 8.01;95%CI 4.69-11.34, p < .00001). There were many other outcomes, including behavior and acceptability, but these were too heterogenous and infrequently assessed for meaningful synthesis.

CONCLUSIONS

This review found that PDAs increase knowledge compared to standard education, though the effect size is small. PDAs are mostly considered acceptable; however, it is difficult to determine whether they improve other decision-making components due to the limited evidence about non-knowledge-based outcomes.

Assessment of donor quality and risk of graft failure after liver transplantation: The ID2 EAL score

Accurate assessment of donor quality at the time of organ offer for liver transplantation candidates may be inadequately captured by the donor risk index (DRI). We sought to develop and validate a novel objective and simple model to assess donor risk using donor level variables available at the time of organ offer. We utilized national data from candidates undergoing primary LT (2013-2019) and assessed the prediction of graft failure 1 year after LT. The final components were donor Insulin-dependent diabetes mellitus, Donor type (DCD or DBD), cause of Death = CVA, serum creatinine, Age, height, and weight (length). The ID² EAL score had better discrimination than DRI using bootstrap corrected concordant index over time, especially in the current era. We explored donor-recipient matching. Relative risk of graft failure ranged from 1.15 to 3.5 based on relevant donor-recipient matching by the ID² EAL score. As an example, for certain recipients, a young DCD donor offer was preferable to an older DBD with relevant comorbidities. The ID² EAL score may serve as an important tool for patient discussion about donor risk and decisions regarding offer acceptance. In addition, the score may be preferable to succinctly capture donor risk in future organ allocation that considers continuous distribution (www.iddealscore.com).

Waitlisted and Transplant Patient Perspectives on Expanding Access to Deceased-Donor Kidney Transplant: A Qualitative Study

Background:

A concerning number of kidneys (eg, expanded donor criteria, extended criteria, or marginal kidneys) are discarded yearly while patients experience significant morbidity and mortality on the transplant waitlist. Novel solutions are needed to solve the shortage of kidneys available for transplant. Patient perceptions regarding the use of these less than ideal kidneys remain unexplored.

Objective:

To explore the perspectives of patients who have previously received a less than ideal kidney in the past and patients awaiting transplant who could potentially benefit from one.

Design:

Qualitative description study.

Setting:

2 provinces in Canada participated (Saskatchewan and Manitoba).

Patients:

Patients with end-stage kidney disease who were awaiting kidney transplant and were either (a) aged 65 years and older, or (b) 55 years and older with other medical conditions (eg, diabetes).

Methods:

Criterion sampling was used to identify participants. Semi-structured, one-on-one interviews were conducted virtually, which explored perceived quality of life, perceptions of less than ideal kidneys, risk tolerance for accepting one, and educational needs to make such a choice. The interviews were transcribed verbatim and thematic analysis was used to analyze the data.

Results:

15 interviews were conducted with usable data (n = 10 pretransplant; n = 5 posttransplant). Participants were a mean of 65.5 ± 8.8 years old. Four interrelated themes became prominent including (1) patient awareness and understanding of their situation or context, (2) a desire for information, (3) a desire for freedom from dialysis, and (4) trust. Subthemes of transparency, clarity, standardization, and autonomy were deemed important for participant education. The majority of pretransplant participants (n = 8/10) indicated that between 3 and 5 years off of dialysis would make the risk of accepting a less than ideal kidney feel worthwhile.

Limitation:

The study setting was limited to 2 Canadian provinces, which limits the generalizability. Furthermore, the participants were homogenous in demographics such as ethnicity.

Conclusion:

These findings indicate that patients are comfortable to accept a less than ideal kidney for transplant in situations where their autonomy is respected, they are provided clear, standardized, and transparent information, and when they trust their physician. These results will be used to inform the development of a new national registry for expanding access to deceased-donor kidney transplant.

Trial Registration:

Not registered.

An exploratory analysis of patient factors influencing acceptance of extended criteria liver grafts

INTRODUCTION AND OBJECTIVES

There is a shortage of ideal donor organs with consequential increasing waitlist times, drop-off, and mortality. Teams have thus extended the donor criteria. Little is known about patients' actual choices and what factors may influence their decisions regarding different extended criteria liver grafts.

PATIENTS AND METHODS

The documented acceptance or refusal of seven extended criteria liver graft types of patients consented for transplant in a single institution over a 2-year period was reviewed. Patient factors including sex, age, indication, aetiology, and model for end-stage liver disease (MELD) score were analysed using logistic regression.

RESULTS

Most patients were willing to accept most graft types. MELD score did not impact the acceptance or refusal of any graft type. Older patients and those with hepatocellular carcinoma (HCC) or ascites had significantly higher rates of acceptance. Hepatitis B or C disease aetiology was predictive of willingness to accept a similarly infected graft, respectively. HCC was predictive of acceptance of grafts from donors with a cancer history.

CONCLUSIONS

In general, patients embrace the available extended criteria donors. Our analysis suggests that consent should be revisited as patients deteriorate or ameliorate on the waitlist, especially if in the form of ascites or HCC but not necessarily MELD score.

Consent to organ offers from public health service “Increased Risk” donors decreases time to transplant and waitlist mortality

Background

The Public Health Service Increased Risk designation identified organ donors at increased risk of transmitting hepatitis B, hepatitis C, and human immunodeficiency virus. Despite clear data demonstrating a low absolute risk of disease transmission from these donors, patients are hesitant to consent to receiving organs from these donors. We hypothesize that patients who consent to receiving offers from these donors have decreased time to transplant and decreased waitlist mortality.

Methods

We performed a single-center retrospective review of all-comers waitlisted for liver transplant from 2013 to 2019. The three competing risk events (transplant, death, and removal from transplant list) were analyzed. 1603 patients were included, of which 1244 (77.6%) consented to offers from increased risk donors.

Results

Compared to those who did not consent, those who did had 2.3 times the rate of transplant (SHR 2.29, 95% CI 1.88–2.79, p < 0.0001), with a median time to transplant of 11 months versus 14 months (p < 0.0001), as well as a 44% decrease in the rate of death on the waitlist (SHR 0.56, 95% CI 0.42–0.74, p < 0.0001). All findings remained significant after controlling for the recipient age, race, gender, blood type, and MELD. Of those who did not consent, 63/359 (17.5%) received a transplant, all of which were from standard criteria donors, and of those who did consent, 615/1244 (49.4%) received a transplant, of which 183/615 (29.8%) were from increased risk donors.

Conclusions

The findings of decreased rates of transplantation and increased risk of death on the waiting list by patients who were unwilling to accept risks of viral transmission of 1/300–1/1000 in the worst case scenarios suggests that this consent process may be harmful especially when involving “trigger” words such as HIV. The rigor of the consent process for the use of these organs was recently changed but a broader discussion about informed consent in similar situations is important.

The 3-T Model of Informed Consent for Nonstandard Risk Donors: A Proposal for Transplant Clinical Practice

Background

The risk of disease transmission from nonstandard risk donors (NSRDs) is low, and outcomes are similar or better relative to transplants performed with standard criteria donors. However, NSRDs have posed new ethical challenges to the informed consent (IC) process. Based on the shared decision-making model, coinciding with the 3 main timings of the IC process ([1] pretransplant assessments and waiting list registration, [2] time on the waiting list, and [3] time of the organ offer), we put forward a model (3-T Model) to summarize the knowledge on IC for NSRDs and to deliver conceptual and practical support to transplant providers on this emergent issue.

Methods

We searched PubMed and analyzed data from our area to provide evidence and ethical arguments to promote standardization of the timing of patient information, degree of patient participation, and disclosure of donor risk factors throughout the 3 stages of the time continuum leading to the potential acceptance of NSRDs.

Results

Each of the 3 timings carries special ethical significance and entails well-defined duties for transplant providers relative to patient involvement and information of the benefits and risks associated with NSRDs. Based on our framework, experience, and interpretation of the literature, we put forward a list of recommendations to combine standardization (ie, timing, content, and degree of patient participation) and individualization of IC.

Conclusions

The 3-T Model may enable the prevention of physicians' arbitrariness and the promotion of patient-centered care. Future studies will assess the effectiveness of the 3-T Model in transplant clinical practice.

Determinants of kidney transplant candidates' decision to accept organ donor intervention transplants and participate in post-transplant research: A conjoint analysis

Deceased organ donor intervention research aims to increase organ quality and quantity for transplantation. We assessed the proportion of kidney transplant candidates who would accept "intervention organs," participate in organ intervention research, and factors influencing acceptance. Kidney transplant candidates were presented 12 hypothetical scenarios, which varied three attributes, donor age, predicted waiting time to receive another organ offer, and research risk to the organ. Candidates were also randomly assigned to one of two conditions varying recipient risk. For each scenario, candidates agreed to accept the intervention organ or remain waitlisted. We fit a multivariable logit model to determine the association between scenario attributes and the acceptance decision. Of 249 participants, most (96%) accepted intervention organs under some or all conditions. Factors independently associated with candidates' greater likelihood of accepting an intervention organ included: low risk to the kidney from the intervention (OR 20.53 [95% Confidence Interval (CI), 13.91-30.29]); younger donor age (OR 3.72 [95% CI, 2.83-4.89]), longer time until the next organ offer (OR 3.48 [95% CI, 2.65-4.57]), and greater trust in their transplant physician (OR 1.03 [95% CI, 1.00-1.06]). Candidates with a lower likelihood of acceptance had been waitlisted longer (OR 0.97 per month [95% CI, 0.96-0.99]) and were Black (OR 0.21 [95% CI, 0.08-0.55]). Most candidates would accept an intervention organ, which should encourage transplant leaders to conduct deceased donor organ intervention trials.

Designing a Liver Transplant Patient and Family Decision Support Tool for Organ Offer Decisions

BACKGROUND

For liver transplant candidates on the waiting list, deciding to accept a donor organ with known or potential risk factors can be stressful and can lead to declined offers. Current education for patients and family often takes place during transplant evaluations and can be overwhelming and result in low retention and poor understanding of donor quality.

METHODS

In the first phase, we sought to understand provider experiences when counseling patients about donor risks and donor offers. We conducted interviews and focus groups with liver transplant providers at 1 local center and at a national clinician conference. Twenty providers participated: 15 hepatologists and 5 surgeons. The provider feedback was used to create an initial outline of content that is consistent with decision support frameworks. In a second phase, graphic design collaborators created mockups of a patient-friendly tool. We reviewed mockups with 4 transplant coordinators and 9 liver transplant candidates for feedback on clarity and utility to prepare for an organ offer. Patient responses allowed a comparison of perceived readiness to receive an offer call before and after viewing mockups.

RESULTS

We identified themes relating to the offer process, repetition and timing of education, and standardization and tailoring of content. The results indicated a gap in available education after the evaluation session, and information specific to offer decisions is needed. Patient feedback emphasized the need to review the offer process before a real offer.

CONCLUSIONS

Patients and providers responded favorably to a patient tool addressing existing gaps in education while waiting for a donor offer. Additional patient, family, and provider feedback will guide the development of an interactive tool to prepare patients and families for an offer decision.

Organ utilization - the next hurdle in transplantation?

Nonutilization of organs from consented deceased donors remains a significant factor in limiting patient access to transplantation. Critical to reducing waste is a clear understanding of why organs are not used: accurate metrics are essential to identify the extent and causes of waste but use of these measures as targets or comparators between units/jurisdictions must be done with caution as focus on any one measure may result in unintended adverse consequences. Comparison between centres or countries may be misleading because of variation in definitions, patient or graft characteristics. Two of the most challenging areas to improve appropriate deceased donor organ utilization are appetite for risk and lack of validated tools to help identify an organ that will function appropriately. Currently, the implanting surgeon is widely considered to be accountable for the use of a donated organ so guidelines must be clear to allow and support sensible decisions and recognition that graft failure or inadvertent disease transmission are not necessarily attributable to poor decision-making. Accepting an organ involves balancing risk and benefit for the potential recipient. Novel technologies such as machine perfusion may allow for more robust guidance as to the functioning of the organ.

Survey of Clinician Opinions on Kidney Transplantation from Hepatitis C Virus Positive Donors: Identifying and Overcoming Barriers

Background

Transplant practices related to use of organs from Hepatitis C virus infected donors (DHCV+) is evolving rapidly.

Methods

We surveyed U.S. kidney transplant programs by email and professional society listserv postings between 7/19-1/20 to assess attitudes, management strategies, and barriers related to use of viremic (nucleic acid testing (NAT)+) donor organs in HCV uninfected recipients.

Results

Staff at 112 unique programs responded, representing 54% of U.S. adult kidney transplant programs and 69% of adult deceased donor kidney transplant volume in 2019. Most survey respondents were transplant nephrologists (46%) or surgeons (43%). Among responding programs, 67% currently transplant DHCV antibody+/NAT- organs under a clinical protocol or as standard of care. By comparison, only 58% offer DHCV NAT+ kidney transplant to HCV- recipients, including 35% under clinical protocols, 14% as standard of care, and 9% under research protocols. Following transplant of DHCV NAT+ organs to uninfected recipients, 53% start direct acting antiviral agent (DAA) therapy after discharge and documented viremia. Viral monitoring protocols after DHCV NAT+ to HCV uninfected recipient kidney transplantation varied substantially. 56% of programs performing these transplants report having an institutional plan to provide DAA treatment if declined by the recipient's insurance. Respondents felt a mean decrease in waiting time of ≥18 months (range 0-60) justifies the practice. Program concerns related to use of DHCV NAT+ kidneys include insurance coverage concerns (72%), cost (60%), and perceived risk of transmitting resistant infection (44%).

Conclusions

Addressing knowledge about safety and logistical/financial barriers related to use of DHCV NAT+ kidney transplantation for HCV uninfected recipients may help reduced discards and expand the organ supply.

Patients and their family members prioritize post-transplant survival over waitlist survival when considering donor hearts for transplantation

Heart transplant providers often focus on post-transplant outcomes when making donor decisions, potentially at the expense of higher waitlist mortality. This study aimed to assess public opinion regarding the selection of donor hearts and the balance between pre- and post-transplant risk. The authors generated a survey to investigate public opinion regarding donor acceptance. The survey was shared freely online across social media platforms in April-May 2019. A total of 718 individuals responded to the survey, with an equal distribution between patients and family members. Respondents consistently favored post-transplant outcomes over waitlist outcomes. About 83.9% of respondents favored a hospital with longer waitlist times, worse waitlist outcomes, but excellent post-transplant survival over a hospital with short waitlist times, a high waitlist survival, and inferior post-transplant survival. This preference was no different between pediatric and adult populations (P = .7), patient and family members (P = .935), or those with a pre- vs post-transplant perspective (P = .985). Patients and their family members consistently favor improved post-transplant survival over waitlist survival when considering the risks of accepting a donor organ. These findings suggest that current practice patterns of donor selection align with the opinions of patients and family members with heart failure or who have undergone heart transplantation.

Development and preliminary evaluation of ilearnKAS: An animated video about kidney allocation to support transplant decision-making

BACKGROUND

We aimed to develop and feasibility test an educational video culturally targeted to African American (AA) patients regarding kidney allocation.

METHODS

We iteratively refined an animated video for AAs with multiple stakeholder input and conducted a one-group, pre-post study with 50 kidney transplant candidates to assess video feasibility and acceptability. A mixed population was chosen to obtain race-specific acceptability data and efficacy estimates for a larger study.

RESULTS

Median participant age was 56 years, and 50% were AA. Comparing pre-post video scores, large knowledge effect sizes were found for the cohort (r = 0.7) and in the context of AA race (r = 0.8), low health literacy (r = 0.6), low educational achievement (r = 0.7), age >55 years (r = 0.6), dialysis vintage ≥1 year (r = 0.8), low income (r = 0.7) and low technology access (r = 0.8). Over 87% of participants provided positive ratings on each of the seven acceptability items. The frequency of positive responses increased pre-post video for kidney allocation understanding (78% vs 94%, P = 0.008), decisional self-efficacy (64% vs 88%, P < 0.001) and belief in fairness (76% vs 90%, P = 0.02).

CONCLUSIONS

In collaboration with key stakeholders, a culturally targeted educational video was developed that was well received. Results are promising to impact kidney allocation knowledge among AA and non-AA kidney transplant candidates.

Attitudes of Liver Transplant Candidates Toward Organs From Increased-Risk Donors

Increased-risk donor (IRD) organs make up a significant proportion of the deceased organ donor pool but may be declined by patients on the waiting list for various reasons. We conducted a survey of patients awaiting a liver transplant to determine the factors leading to the acceptance of an IRD organ as well as what strategies could increase the rate of acceptance. Adult liver transplant candidates who were outpatients completed a survey of 51 questions on a 5-point Likert scale with categories related to demographics, knowledge of IRDs, and likelihood of acceptance. A total of 150 transplant candidates completed the survey (age 19-80 years). Male patients constituted 67.3%. Many patients (58.7%) had postsecondary education. Only 23.3% of patients had a potential living donor, and 58/144 (40.3%) were not optimistic about receiving an organ in the next 3 months. The overall IRD organ acceptance rate was 41.1%, whereas 26.2% said they would decline an IRD organ. Women were more likely to accept an IRD organ (54.3% versus 34.7%; P = 0.02). Those who had a college education or higher tended to have lower IRD organ acceptability (28.3% versus 47.4%; P = 0.07). Acceptability also increased as the specified transmission risk of human immunodeficiency virus or hepatitis C virus decreased (P < 0.001). Patients were also more likely to accept an IRD organ if they were educated on the benefits of IRD organs (eg, knowledge that an IRD organ was of better quality increased overall acceptance from 41.1% to 63.3%; P < 0.001). Our survey provides insight into liver transplant candidates who would benefit from greater education on IRD organs. Strategies targeting specific educational points are likely to increase acceptability.

Disclosure of infectious risk to heart transplant candidates: Shared decision-making is here to stay

The Public Health Service has defined 12 criteria of increased-risk (PHS-IR) for transmissible viral infections in potential organ donors where clinicians are required to document informed consent. Over the last decade, there has been a near tripling of PHS-IR donor organs in the United States. In light of the paucity in guidelines and consensus statements to guide clinicians on how to provide informed consent to potential recipients, using a typical case, we provide an overview including: how to effectively communicate infectious risk, whether clinicians should decline PHS-IR organs, the need to standardize disclosure practice across centers and finally how much information about the donor should be communicated to the transplant candidate. Many patients can be empowered by involving them in shared decision making to understand the minimal risk associated with the use of PHS-IR organs; an important step in improving donor utilization.

The donor risk index: A decade of experience

In 2006, derivation of the donor risk index (DRI) highlighted the importance of donor factors for successful liver transplantation. Over the last decade, the DRI has served as a useful metric of donor quality and has enhanced our understanding of donor factors and their impact upon recipients with hepatitis C virus, those with low Model for End-Stage Liver Disease (MELD) score, and individuals undergoing retransplantation. DRI has provided the transplant community with a common language for describing donor organ characteristics and has served as the foundation for several tools for organ risk assessment. It is a useful tool in assessing the interactions of donor factors with recipient factors and their impact on posttransplant outcomes. However, limitations of statistical modeling, choice of donor factors, exclusion of unaccounted donor and geographic factors, and the changing face of the liver transplant recipient have tempered its widespread use. In addition, the DRI was derived from data before the MELD era but is currently being applied to expand the donor pool while concurrently meeting the demands of a dynamic allocation system. A decade after its introduction, DRI remains relevant but may benefit from being updated to provide guidance in the use of extended criteria donors by accounting for the impact of geography and unmeasured donor characteristics. DRI could be better adapted for recipients with nonalcoholic fatty liver disease by examining and including recipient factors unique to this population. Liver Transplantation 23 1216-1225 2017 AASLD.

Clinical outcomes and quality of life in recipients of livers donated after cardiac death

Donation after cardiac death (DCD) has expanded in the last decade in the US; however, DCD liver utilization has flattened in recent years due to poor outcomes. We examined clinical and quality of life (QOL) outcomes of DCD recipients by conducting a retrospective and cross-sectional review of patients from 2003 to 2010. We compared clinical outcomes of DCD recipients (n = 60) to those of donation after brain death (DBD) liver recipients (n = 669) during the same time period. DCD recipients had significantly lower rates of 5-year graft survival (P < 0.001) and a trend toward lower rates of 5-year patient survival (P = 0.064) when compared to the DBD cohort. In order to examine QOL outcomes in our cohorts, we administered the Short Form Liver Disease Quality of Life questionnaire to 30 DCD and 60 DBD recipients. The DCD recipients reported lower generic and liver-specific QOL. We further stratified the DCD cohort by the presence of ischemic cholangiopathy (IC). Patients with IC reported lower QOL when compared to DBD recipients and those DCD recipients without IC (P < 0.05). While the results are consistent with clinical experience, this is the first report of QOL in DCD recipients using standardized measures. These data can be used to guide future comparative effectiveness studies.

Pilot test of a patient decision aid about liver transplant organ quality

Prior studies have shown that patients are reluctant to accept donor-specific risks, and transplant professionals lack an effective and time-efficient means of obtaining informed consent. We designed and pilot-tested a Web-based patient decision aid (DA) on organ quality. The DA was administered to 53 liver transplant candidates (median Model for End-Stage Liver Disease score = 14, range = 7-26), and they took a mean of 15 minutes to complete it. Questions about knowledge and attitudes were asked before and after the DA. Subjects' knowledge improved, with 53% and 60% correctly answering questions about hepatitis B virus and human immunodeficiency virus transmission before the DA and 94% and 100%, respectively, correctly answering them afterward (P < 0.001). The accuracy of mortality prediction also improved from a mean 3-month mortality estimate of 22% before the DA to 12% afterward (P < 0.001). After the DA, subjects felt that it was more likely that they might be offered a less-than-perfect liver (P = 0.001), and they were more likely to consider accepting such a liver (P < 0.001). In conclusion, implementing a Web-based patient DA is feasible and improves knowledge among liver transplant candidates. The use of this tool may decrease candidates' reluctance to accept extended criteria organs.

[Diagnosis of and therapy for hepatocellular carcinoma]

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence-and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

An examination of liver offers to candidates on the liver transplant wait-list

BACKGROUND & AIMS

We aimed to characterize offers of organs to candidates awaiting liver transplantation (LT).

METHODS

We analyzed data from the United Network for Organ Sharing registry on all US LT candidates with nonfulminant disease who were offered livers from February 1, 2005, to January 31, 2010, and ultimately received transplants. We excluded candidates with a final Model for End-stage Liver Disease score of less than 15. Livers were classified as high quality if they were from donors 18-50 years of age who were ≥ 170 cm tall, of non-black race, suffered brain death secondary to trauma, hepatitis C antibody-negative, not categorized as high risk by the Centers for Disease Control, and locally or regionally located.

RESULTS

Of 33,389 candidates for LT, 20% died or were removed from the list and 64% received LT; the median (interquartile range) number of liver offers for all candidates was 5 (range, 2-12). Of those who died or were removed from the list, 84% received 1 or more liver offers. Overall, 55% of those who died or were removed from the list, and 57% of those who received LT, received 1 or more offers of a high-quality liver when they had Model for End-stage Liver Disease scores of 15 or greater (P = .005). However, the proportion of last liver offers of high quality to patients who underwent LT was twice that of patients who died or were removed from the list (28% vs 14%; P < .001). Most liver offers (68%) were refused for reasons related to donor quality.

CONCLUSIONS

Most candidates for LT who died or were removed from the list received 1 or more offers of a liver beforehand, and 55% received 1 or more offers of a high-quality liver. These findings indicate that a substantial proportion of wait-list mortality results in part from declined livers, rather than lack of opportunity, for transplantation. Understanding the real-time factors involved in the complex decision to accept a liver offer is vital to reducing wait-list mortality for LT candidates.