Hospital Resource Use with Donation after Cardiac Death Allografts in Liver Transplantation: A Matched Controlled Analysis from 2007 to 2011

A cost comparison of liver acquisition fees for donation after circulatory death versus donation after brain death donors

Donation after circulatory death (DCD) donors now represent over 30% of the deceased donor pool in the United States. Compared to donation after brain death, DCD is less likely to result in transplantation. For each potential donor whose organs cannot be utilized for transplantation (ie, dry run), fees are associated with the attempted donation, which add to the overall costs of organ acquisition. To better characterize the true costs of DCD liver acquisition, we performed a cost comparison of the fees associated with organ acquisition for DCD versus donation after brain death at a single transplant institute that comprises 2 liver transplant centers. Cost, recipient, and transportation data for all cases, including fees associated with liver acquisition from July 1, 2019, to October 31, 2021, were collected. We found that the total cost of DCD liver acquisition per liver transplant was $15,029 more than that for donation after brain death donation, with 18% of the costs of the DCD transplant attributed to dry runs. Overall, the costs associated with DCD transplantation accounted for 34.5% of the total organ acquisition costs; however, DCD transplantation accounted for 30.3% of the transplantation volume. Because the expansion of DCD is essential to increasing the availability of liver grafts for transplantation, strategies need to be implemented to decrease the costs associated with dry runs, including using local recovery, transferring donors to hospitals close to transplant centers, and performing more prerecovery organ analysis. Moreover, these strategies are needed to ensure that financial disincentives to DCD procurement and utilization do not reverse the gains made by expanding the organ donor pool using machine perfusion technologies.

Medical Assistance in Dying (MAiD) as a Source of Liver Grafts: Honouring the Ultimate Gift

OBJECTIVE

To report the clinical outcomes of liver transplants from donors after medical assistance in dying (MAiD) versus donors after cardiac death (DCD) and deceased brain death (DBD).

SUMMARY BACKGROUND DATA

In North America, the number of patients needing liver transplants exceeds the number of available donors. In 2016, MAiD was legalized in Canada.

METHODS

All patients undergoing deceased donor liver transplantation at Toronto General Hospital between 2016 and 2021 were included in the study. Recipient perioperative and postoperative variables and donor physiological variables were compared among 3 groups.

RESULTS

Eight hundred seven patients underwent deceased donor liver transplantation during the study period, including DBD (n=719; 89%), DCD (n=77; 9.5%), and MAiD (n=11; 1.4%). The overall incidence of biliary complications was 6.9% (n=56), the most common being strictures (n=55;6.8%), highest among the MAiD recipients [5.8% (DBD) vs. 14.2% (DCD) vs. 18.2% (MAiD); P =0.008]. There was no significant difference in 1 year (98.4% vs. 96.4% vs. 100%) and 3-year (89.3% vs. 88.7% vs. 100%) ( P =0.56) patient survival among the 3 groups. The 1- and 3- year graft survival rates were comparable (96.2% vs. 95.2% vs. 100% and 92.5% vs. 91% vs. 100%; P =0.37).

CONCLUSION

With expected physiological hemodynamic challenges among MAiD and DCD compared with DBD donors, a higher rate of biliary complications was observed in MAiD donors, with no significant difference noted in short-and long-term graft outcomes among the 3 groups. While ethical challenges persist, good initial results suggest that MAiD donors can be safely used in liver transplantation, with results comparable with other established forms of donation.

Frailty, mortality, and health care utilization after liver transplantation: From the Multicenter Functional Assessment in Liver Transplantation (FrAILT) Study

BACKGROUND AND AIMS

Frailty is a well-established risk factor for poor outcomes in patients with cirrhosis awaiting liver transplantation (LT), but whether it predicts outcomes among those who have undergone LT is unknown.

APPROACH AND RESULTS

Adult LT recipients from 8 US centers (2012-2019) were included. Pre-LT frailty was assessed in the ambulatory setting using the Liver Frailty Index (LFI). "Frail" was defined by an optimal cut point of LFI ≥ 4.5. We used the 75th percentile to define "prolonged" post-LT length of stay (LOS; ≥12 days), intensive care unit (ICU) days (≥4 days), and inpatient days within 90 post-LT days (≥17 days). Of 1166 LT recipients, 21% were frail pre-LT. Cumulative incidence of death at 1 and 5 years was 6% and 16% for frail and 4% and 10% for nonfrail patients (overall log-rank p = 0.02). Pre-LT frailty was associated with an unadjusted 62% increased risk of post-LT mortality (95% CI, 1.08-2.44); after adjustment for body mass index, HCC, donor age, and donation after cardiac death status, the HR was 2.13 (95% CI, 1.39-3.26). Patients who were frail versus nonfrail experienced a higher adjusted odds of prolonged LT LOS (OR, 2.00; 95% CI, 1.47-2.73), ICU stay (OR, 1.56; 95% CI, 1.12-2.14), inpatient days within 90 post-LT days (OR, 1.72; 95% CI, 1.25-2.37), and nonhome discharge (OR, 2.50; 95% CI, 1.58-3.97).

CONCLUSIONS

Compared with nonfrail patients, frail LT recipients had a higher risk of post-LT death and greater post-LT health care utilization, although overall post-LT survival was acceptable. These data lay the foundation to investigate whether targeting pre-LT frailty will improve post-LT outcomes and reduce resource utilization.

Donation After Circulatory Death Yields Survival Rates Similar to Donation After Brain Death Liver Transplant, Which Effectively Expands the Donor Pool

OBJECTIVES

Liver allograft shortage has necessitated greater use of donations after circulatory death. Limited data are available to compare recipients' health care utilization for donation after circulatory death versus brain death.

MATERIALS AND METHODS

Liver transplant data for our center from November 2016 until May 2019 were obtained (208 donations after brain death and 39 after circulatory death). We excluded patients <18 years old and multiorgan transplants; for cost data only, we also excluded retransplants. Primary outcome was recipients' health care utilization in donation after circulatory death versus brain death and included index admission length of stay, readmissions, and charges from transplant to 6 months. Secondary outcomes were patient and graft survival.

RESULTS

Donors from circulatory death were younger than donors from brain death (median age 32 vs 40 years; P < .01). Recipient body mass index (31.23 vs 29.38 kg/m2), Model for End-Stage Liver Disease score (17 vs 19), portal vein thrombosis (15.8% vs 18.0%), length of stay (7 vs 8 days), and 30-, 90-, and 180-day posttransplant index admissions were not significantly different. Charges for index admission were equivalent for donation after circulatory death ($370771) and brain death ($374272) (P = .01). Charges for readmissions at 30 and 180 days were not significantly different (P = .80 and P = .19, respectively). Rates for graft failure (10.3% vs 4.8%; P = .08) and recipient death (10.3% vs 3.8%; P = .17) at 6 months posttransplant were similar.

CONCLUSIONS

Donation after circulatory death versus brain death liver transplant recipients had similar lengths of stay and equivalent index admission charges. Graft and patient survival and charges from transplant to 6 months were similar. Donation after circulatory death liver allografts provide a safe, costequivalent donor pool expansion after careful donorrecipient selection.

Biliary complications after liver transplantation: current perspectives and future strategies

Importance

Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease and with acute liver failure, and it is associated with excellent outcomes and survival rates at 1 and 5 years. The incidence of biliary complications (BCs) after LT is reported to range from 5% to 20%, most of them occurring in the first three months, although they can occur also several years after transplantation.

Objective

The aim of this review is to summarize the available evidences on pathophysiology, risk factors, diagnosis and therapeutic management of BCs after LT.

Evidence Review

a literature review was performed of papers on this topic focusing on risk factors, classifications, diagnosis and treatment.

Findings

Principal risk factors include surgical techniques and donor's characteristics for biliary leakage and anastomotic biliary strictures and vascular alterations for non- anastomotic biliary strictures. MRCP is the gold standard both for intra- and extrahepatic BCs, while invasive cholangiography should be restricted for therapeutic uses or when MRCP is equivocal. About treatment, endoscopic techniques are the first line of treatment with success rates of 70-100%. The combined success rate of ERCP and PTBD overcome 90% of cases. Biliary leaks often resolve spontaneously, or with the positioning of a stent in ERCP for major bile leaks.

Conclusions and Relevance

BCs influence morbidity and mortality after LT, therefore further evidences are needed to identify novel possible risk factors, to understand if an immunological status that could lead to their development exists and to compare the effectiveness of innovative surgical and machine perfusion techniques.

The UK-DCD-Risk-Score - practical and new guidance for allocation of a specific organ to a recipient?

Introduction: Multiple factors contribute to the overall outcome in donation after circulatory death liver transplantation. The majority is however inconsistently reported with various acceptance criteria and thresholds, when to decline a specific graft. Recent improvement in outcome was based on an increased awareness of the cumulative risk, combining donor and recipient parameters, which encouraged the community to accept livers with an overall higher risk. Areas covered: This review pictures the large number of risk factors in this field with a special focus on parameters, which contribute to available prediction models. Next, features of the recently developed UK-DCD-Risk-Score, which led to a significantly impaired graft survival, above a suggested threshold of >10 score points, are discussed. The clinical impact of this new model on the background of other prediction tools with their subsequent limitations is highlighted in a next chapter. Finally, we provide suggestions, how to further improve outcomes in this challenging field of transplantation. Expert opinion: Despite the recent development of new prediction models, including the UK-DCD-Risk-Score, which provides a sufficient prediction of graft loss after DCD liver transplantation, the consideration of other confounders is essential to better understand the overall risk and metabolic liver status to improve the comparability of clinical studies. More uniform definitions and thresholds of individual risk factors are required.

Vascular and Biliary Complications Following Deceased Donor Liver Transplantation: A Meta-analysis

OBJECTIVE

To assess biliary and vascular complications after liver transplantations (LTs) sourced from deceased donors.

METHODS

This study reviewed potentially relevant English-language articles gathered from PubMed and Medline published from 2012 to 2017. One additional study was carried out using our institution's database for articles published from 2013 to 2017. Biliary and vascular complications from adult patients receiving their first deceased-donor LT were included. This meta-analysis was performed using Review Manager version 5.2 (Cochrane Collaboration, Copenhagen, Denmark) and the study quality was evaluated using the Newcastle-Ottawa Scale.

RESULTS

Ten studies met our inclusion criteria. Heterogeneity in donation after cardiac death (DCD) and donation after brain death (DBD) recipients was observed and minimized after pooling a subgroup analysis. This latter analysis focused on biliary stricture, biliary leaks and stones, and vascular thrombosis and stenosis. Meta-analyses showed that patients receiving DCD organs have a greatly increased risk of biliary complications compared to those receiving DBD organs, particularly the following: biliary leaks and stones (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.22-2.34); and biliary stricture (OR = 1.58, 95% CI 1.21-2.06). DCD grafts tended to be but were not significantly associated with DBD regarding vascular thrombosis (OR = 1.62, 95% CI 1.05-2.50), and the risk of vascular stenosis in DCD grafts was not statistically significant (OR = 1.25, 95% CI, .70-2.25).

CONCLUSION

DCD was associated with an increased risk of biliary complications after LT, tended to indicate an increased risk of vascular thrombosis versus, and was not associated with an increased risk of vascular stenosis compared to DBD. There was no significant difference between the grafts.

Strategies That Reduce 90-Day Readmissions and Inpatient Costs After Liver Transplantation

Liver transplantation (LT) is hospital-resource intensive and associated with high rates of readmission. We have previously shown a reduction in 30-day readmission rates by implementing a specifically designed protocol to increase access to outpatient care. The aim of this work is to determine if the strategies that reduce 30-day readmission after LT were effective in also reducing 90-day readmission rates and costs. A protocol was developed to reduce inpatient readmissions after LT that expanded outpatient services and provided alternatives to readmission. The 90-day readmission rates and costs were compared before and after implementing strategies outlined in the protocol. Multivariable analysis was used to control for potential confounding factors. Over the study period, 304 adult primary LTs were performed on patients with a median biological Model for End-Stage Liver Disease of 22. There were 112 (37%) patients who were readmitted within 90 days of transplant. The readmission rates before and after implementation of the protocol were 53% and 26%, respectively (P < 0.001). The most common reason for readmission was elevated liver tests/rejection (24%). In multivariable analysis, the protocol remained associated with avoiding readmission (odds ratio, 0.33; 95% confidence interval, 0.20-0.55; P < 0.001). The median length of stay after transplant before and after protocol implementation was 8 days and 7 days, respectively. A greater proportion of patients were discharged to hospital lodging after protocol implementation (10% versus 19%; P = 0.03). The 90-day readmission costs were reduced by 55%, but the total 90-day costs were reduced by only 2.7% because of higher outpatient costs and index admission costs. In conclusion, 90-day readmission rates and readmission costs can be reduced by improving access to outpatient services and hospital-local lodging. Total 90-day costs were similar between the 2 groups because of higher outpatient costs after the protocol was introduced.

Outcomes of Controlled Donation After Cardiac Death Compared With Donation After Brain Death in Liver Transplantation: A Systematic Review and Meta-analysis

BACKGROUND

Controlled donation after cardiac death (CDCD) is increasingly common for liver transplantation due to donor shortage. However, the outcomes, in terms of grafts and recipients, remain unclear. The current study is a systematic review and meta-analysis that compared CDCD with donation after brain death (DBD).

METHODS

We conducted an electronic search of MEDLINE, EMBASE, and the Cochrane Database (from January 2007 to May 2017). Studies reporting Maastricht category III or IV CDCD liver transplantation were screened for inclusion. We appraised studies using the Newcastle-Ottawa scale and meta-analyzed using a fixed or random effects model.

RESULTS

A total of 21 studies, with 12,035 patients, were included in data analysis. CDCD did not differ from DBD in patient survival (hazard ration: 1.20; 95% confidence interval [CI]: 0.98 to 1.47; P = .07), graft survival (hazard ratio: 1.24; 95% CI: 0.99 to 1.56; P = .06), primary nonfunction (odds ratio [OR]: 1.74; 95% CI: 1.00 to 3.03; P = .05), hepatic artery thrombosis (OR: 1.17; 95% CI: 0.78 to 1.74; P = .45). However, CDCD was associated with biliary complications (OR: 2.48; 95% CI: 2.05 to 3.00), retransplantation (OR: 2.54; 95% CI: 1.99 to 3.26), and peak alanine aminotransferase (weighted mean difference: 330.88; 95% CI: 259.88 to 401.87). A subgroup analysis that included only hepatitis C virus (HCV)-positive recipients showed no significant difference between CDCD and DBD in biliary complications (P = .16), retransplantion (P = .15), HCV recurrence (P = .20), and peak alanine aminotransferase (P = .06).

CONCLUSIONS

CDCD transplantation is the most viable alternative to DBD transplantation in the current critical shortage of liver organs. HCV infection may not be the inferior factor of postoperative outcomes and survival.

Expanding the donor pool: Donation after circulatory death and living liver donation do not compromise the results of liver transplantation

Because of the shortfall between the number of patients listed for liver transplantation (LT) and the available grafts, strategies to expand the donor pool have been developed. Donation after circulatory death (DCD) and living donor (LD) grafts are not universally used because of the concerns of graft failure, biliary complications, and donor risks. In order to overcome the barriers for the implementation of using all 3 types of grafts, we compared outcomes after LT of DCD, LD, and donation after brain death (DBD) grafts. Patients who received a LD, DCD, or DBD liver graft at the University of Toronto were included. Between January 2009 through April 2017, 1054 patients received a LT at our center. Of these, 77 patients received a DCD graft (DCD group); 271 received a LD graft (LD group); and 706 received a DBD graft (DBD group). Overall biliary complications were higher in the LD group (11.8%) compared with the DCD group (5.2%) and the DBD group (4.8%; P < 0.001). The 1-, 3-, and 5-year graft survival rates were similar between the groups with 88.3%, 83.2%, and 69.2% in the DCD group versus 92.6%, 85.4%, and 84.7% in the LD group versus 90.2%, 84.2%, and 79.9% in the DBD group (P = 0.24). Furthermore, the 1-, 3-, and 5-year patient survival was comparable, with 92.2%, 85.4%, and 71.6% in the DCD group versus 95.2%, 88.8%, and 88.8% in the LD group versus 93.1%, 87.5%, and 83% in the DBD group (P = 0.14). Multivariate Cox regression analysis revealed that the type of graft did not impact graft survival. In conclusion, DCD, LD, and DBD grafts have similar longterm graft survival rates. Increasing the use of LD and DCD grafts may improve access to LT without affecting graft survival rates. Liver Transplantation 24 779-789 2018 AASLD.

Hypothermic machine perfusion in liver transplantation

A finite supply of donor organs has led many transplant centers to accept marginal liver allografts with increasing frequency. These allografts may be at higher risk of primary nonfunction, early allograft dysfunction, and other recipient complications following liver transplantation. Machine perfusion preservation is an emerging technology that limits ischemia/reperfusion injury associated with preservation and may lead to improved outcomes following transplantation. Increased used of machine perfusion in liver preservation may permit an expansion of the donor pool. In this review, we examine the major clinical experience of hypothermic machine perfusion in human liver transplantation.Liver Transplantation 24 276-281 2018 AASLD.

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

Multiple reports have demonstrated that liver transplantation following donation after circulatory death (DCD) is associated with poorer outcomes when compared with liver transplantation from donation after brain death (DBD) donors. We hypothesized that carefully selected, underutilized DCD livers recovered from younger donors have excellent outcomes. We performed a retrospective study of the United Network for Organ Sharing database to determine graft survivals for patients who received liver transplants from DBD donors of age ≥ 60 years, DBD donors < 60 years, and DCD donors < 50 years of age. Between January 2002 and December 2014, 52,271 liver transplants were performed in the United States. Of these, 41,181 (78.8%) underwent transplantation with livers from DBD donors of age < 60 years, 8905 (17.0%) from DBD donors ≥ 60 years old, and 2195 (4.2%) livers from DCD donors < 50 years of age. DCD livers of age < 50 years with < 6 hours of cold ischemia time (CIT) had superior graft survival when compared with DBD livers ≥ age 60 years (P < 0.001). In 2014, there were 133 discarded DCD livers; of these, 111 (83.4%) were from donors < age 50 years old. Young DCD donor livers (age < 50 years old) with short CITs yield results better than that seen with DBD livers > 60 years old. Careful donor organ and recipient selection can lead to excellent results, despite previous reports suggesting otherwise. Increased acceptance of these DCD livers would lead to shorter wait list times and increased national liver transplant rates. Liver Transplantation 22 1197-1204 2016 AASLD.

Longterm results of liver transplantation from donation after circulatory death

Donation after circulatory death (DCD) liver transplantation (LT) may imply a risk for decreased graft survival, caused by posttransplantation complications such as primary nonfunction or ischemic-type biliary lesions. However, similar survival rates for DCD and donation after brain death (DBD) LT have been reported. The objective of this study is to determine the longterm outcome of DCD LT in the Eurotransplant region corrected for the Eurotransplant donor risk index (ET-DRI). Transplants performed in Belgium and the Netherlands (January 1, 2003 to December 31, 2007) in adult recipients were included. Graft failure was defined as either the date of recipient death or retransplantation whichever occurred first (death-uncensored graft survival). Mean follow-up was 7.2 years. In total, 126 DCD and 1264 DBD LTs were performed. Kaplan-Meier survival analyses showed different graft survival for DBD and DCD at 1 year (77.7% versus 74.8%, respectively; P = 0.71), 5 years (65.6% versus 54.4%, respectively; P = 0.02), and 10 years (47.3% versus 44.2%, respectively; P = 0.55; log-rank P = 0.038). Although there was an overall significant difference, the survival curves almost reach each other after 10 years, which is most likely caused by other risk factors being less in DCD livers. Patient survival was not significantly different (P = 0.59). Multivariate Cox regression analysis showed a hazard ratio of 1.7 (P < 0.001) for DCD (corrected for ET-DRI and recipient factors). First warm ischemia time (WIT), which is the time from the end of circulation until aortic cold perfusion, over 25 minutes was associated with a lower graft survival in univariate analysis of all DCD transplants (P = 0.002). In conclusion, DCD LT has an increased risk for diminished graft survival compared to DBD. There was no significant difference in patient survival. DCD allografts with a first WIT > 25 minutes have an increased risk for a decrease in graft survival. Liver Transplantation 22 1107-1114 2016 AASLD.

A prospective study of a protocol that reduces readmission after liver transplantation

Health care has shifted to placing priority on quality and value instead of volume. Liver transplantation uses substantial resources and is associated with high readmission rates. Our goal was to determine if a protocol designed to reduce readmission after liver transplant was effective. We conducted a prospective study of a protocol designed to reduce readmission rates after liver transplantation by expanding outpatient services and alternatives to readmission. The 30-day readmission rate 1 year after implementing the protocol was compared to the 30-day rate for 2 years prior to implementation. Multivariate analysis was used to control for potential confounding factors. Over the study period, 167 adult primary liver transplants were performed with a mean biological Model for End-Stage Liver Disease score of 21 ± 8. Fifty-seven (34%) patients were readmitted. The most common reason for readmission was biliary complications (n = 13). The 30-day readmission rate decreased from 40% before implementing the protocol to 20% after implementation (P = 0.02). In multivariate analysis, the protocol remained associated with readmission (odds ratio, 0.39; 95% confidence interval, 0.16-0.92; P = 0.03). The mean length of stay after transplant was 13 ± 12 days preprotocol and 9 ± 5 days postprotocol (P = 0.09). Alternatives to readmission, including hospital lodging and observation status, were main factors in reducing readmission rates. If the most recent definitions of inpatient admission and observation status were applied over the entire study period, then the readmission rates preprotocol and postprotocol were 31% and 20% indicating that the revised definition of observation status accounted for 45% of the reduction in the readmission rate. Readmission after liver transplantation can be reduced without increasing length of stay by implementing a specifically designed protocol that expands outpatient services and alternatives to inpatient admission. Liver Transplantation 22 765-772 2016 AASLD.