Post on 29-Mar-2015
Toward a strategy to use more organs and distribute them to those in need
Jean EmondNew York
Considerations for allocation
• DSA based allocation results in vastly disparate silos of supply and demand
• Donation rates can not correct variations in the incidence of liver disease need
• Medical geography of patient care does not correlate with DSA boundaries
• The current system results in high organ wastage• Marginal organs are the ones being shipped the
farthest• Centers must be incentivized to use the organs
0 10 20 30 40 50 60 70 800
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
18000000
20000000
Population
Population
Populations of US OPO’s
N=59Mean 5.22 mMinimum: 1.28 mMaximum: 18.99 mRation of min to max15.75
Waitlist size by OPO (2009)
0 10 20 30 40 50 60 70 800
20
40
60
80
100
120
140
160PT/million
PT/million
N= 50Mean = 49.8/millionMinimum=5.25Maximum=134.2Ratio of smallest to biggest 25.5
Medical geography does not equal either political geography or DSA’s
Liver donation rate by OPO
0 10 20 30 40 50 60 70 800
5
10
15
20
25
30
35
40
45
50
liver rate
liver rate
N= 58Mean =22.2Minimum 12.8Maximum 43.05Ratio: 3.5
Liver gap by allocation unit
0 10 20 30 40 50 60
-200
0
200
400
600
800
1000
1200
1400
1600
Series1
Minimum = -99Maximum = 1395
Livers procured per donor by allocation unit
Liver discard rate not correlated with donor rate or waitlist rate
Factors in discard
• Low incentive to use (small waitlist)• Aggressive evaluation of high risk donors may
increase discard rate• Poor placement strategies/timing and cold
ischemia• Pre-donation biopsy• Lack of commitment to use by recipient center– Centers rewarded for cherry picking
Liver potential 2009
• Total donors 8022• Total liver donors 6739• Livers transplanted 6016• Livers not transplanted 723• Total net potential for better use and
innovation: 2006
12
ECD livers and living donors account for the majority of transplants since 2004 at NYP Hospital
0
10
20
30
40
50
60
70
80
90
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
LDLT
Import
Region 9
*2009 volume is through 8/31/09
Machine preservation of the human liver:Potential for selecting high risk grafts and Optimizing function: James Guarrera
Liver imports by OPO 2009
Fraction of ECD by DSA:Not all donating populations are equal
1998 Cirrhosis Discharge vs. Death Rate
y = 0.0527x + 4.1959
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0
Discharge Rate (Cases/100,000 population)P-value=0.0068 R2=0.116
Death
Rate
(C
ases/1
00
,00
0 p
op
ula
tio
n)
NY Counties
Linear (NY Counties)
Linear (NY Counties)