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High Center Volume Does Not Mitigate Risk Associated with Using High Donor Risk Organs in Liver Transplantation

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Abstract

Background

High-risk donor allografts increase access to liver transplant, but potentially reduce patient and graft survival.

Aims

It is unclear whether the risk associated with using marginal donor livers is mitigated by increasing center experience.

Methods

The United Network for Organ Sharing registry was queried for adult first-time liver transplant recipients between 2/2002 and 12/2015. High donor risk was defined as donor risk index >1.9, and 1-year patient and graft survival were compared according to donor risk index in small and large centers. Multivariable Cox regression estimated the hazard ratio (HR) associated with using high-risk donor organs, according to a continuous measure of annual center volume.

Results

The analysis included 51,770 patients. In 67 small and 67 large centers, high donor risk index predicted increased mortality (p = 0.001). In multivariable analysis, high-donor risk index allografts predicted greater mortality hazard at centers performing 20 liver transplants per year (HR 1.35; 95% CI 1.22, 1.49; p < 0.001) and, similarly, at centers performing 70 per year (HR 1.35; 95% CI 1.26, 1.43; p < 0.001). The interaction between high donor risk index and center volume was not statistically significant (p = 0.747), confirming that the risk associated with using marginal donor livers was comparable between smaller and larger centers. Results were consistent when examining graft loss.

Conclusion

At both small and large centers, high-risk donor allografts were associated with reduced patient and graft survival after liver transplant. Specific strategies to mitigate the risk of liver transplant involving high-risk donors are needed, in addition to accumulation of center expertise.

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Abbreviations

LT:

Liver transplantation

DRI:

Donor risk index

HR:

Hazard ratio

NASH:

Nonalcoholic steatohepatitis

HCC:

Hepatocellular carcinoma

UNOS:

United Network for Organ Sharing

MELD:

Model for end-stage liver disease

References

  1. O’Leary JG, Lepe R, Davis GL. Indications for liver transplantation. Gastroenterology. 2008;134:1764–1776.

    Article  PubMed  Google Scholar 

  2. Adcock L, Macleod C, Dubay D, et al. Adult living liver donors have excellent long-term medical outcomes: the University of Toronto liver transplant experience. Am J Transpl. 2010;10:364–371.

    Article  CAS  Google Scholar 

  3. Selzner M, Goldaracena N, Echeverri J, et al. Normothermic ex vivo liver perfusion using steen solution as perfusate for human liver transplantation: first North American results. Liver Transpl. 2016;22:1501–1508.

    Article  PubMed  Google Scholar 

  4. Maluf DG, Edwards EB, Kauffman HM. Utilization of extended donor criteria liver allograft: is the elevated risk of failure independent of the model for end-stage liver disease score of the recipient? Transplantation. 2006;82:1653–1657.

    Article  PubMed  Google Scholar 

  5. Nemes B, Gámán G, Polak WG, et al. Extended-criteria donors in liver transplantation Part II: reviewing the impact of extended-criteria donors on the complications and outcomes of liver transplantation. Expert Rev Gastroenterol Hepatol. 2016;10:841–859.

    Article  CAS  PubMed  Google Scholar 

  6. Feng S, Goodrich NP, Bragg-Gresham JL, et al. Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transpl. 2006;6:783–790.

    Article  CAS  Google Scholar 

  7. Axelrod DA, Schnitzler M, Salvalaggio PR, Swindle J, Abecassis MM. The economic impact of the utilization of liver allografts with high donor risk index. Am J Transpl. 2007;7:990–997.

    Article  CAS  Google Scholar 

  8. Maluf DG, Edwards EB, Stravitz RT, Kauffman HM. Impact of the donor risk index on the outcome of hepatitis C virus-positive liver transplant recipients. Liver Transpl. 2009;15:592–599.

    Article  PubMed  Google Scholar 

  9. Bonney GK, Aldersley MA, Asthana S, et al. Donor risk index and MELD interactions in predicting long-term graft survival: a single-centre experience. Transplantation. 2009;87:1858–1863.

    Article  PubMed  Google Scholar 

  10. Alhamad T, Malone AF, Brennan DC, Stratta RJ, Chang SH, Wellen JR, et al. Transplant center volume and the risk of pancreas allograft failure. Transplantation. 2017. doi:10.1097/TP.0000000000001628.

    Google Scholar 

  11. Kopp W, van Meel M, Putter H, Samuel U, Arbogast H, Schareck W, et al. Center Volume is associated with outcome after pancreas transplantation within the Eurotransplant region. Transplantation. 2017;101(6):1247–1253.

    Article  PubMed  Google Scholar 

  12. Axelrod DA, Guidinger MK, McCullough KP, Leichtman AB, Punch JD, Merion RM. Association of center volume with outcome after liver and kidney transplantation. Am J Transpl. 2004;4:920–927.

    Article  Google Scholar 

  13. Kilic A, George TJ, Beaty CA, Merlo CA, Conte JV, Shah AS. The effect of center volume on the incidence of postoperative complications and their impact on survival after lung transplantation. J Thorac Cardiovasc Surg. 2012;144:1502–1508. (discussion 8–9).

    Article  PubMed  Google Scholar 

  14. Arnaoutakis GJ, George TJ, Allen JG, Russell SD, Shah AS, Conte JV, et al. Institutional volume and the effect of recipient risk on short-term mortality after orthotopic heart transplant. J Thorac Cardiovasc Surg. 2012;143:157–167, 67.e1.

  15. Thabut G, Christie JD, Kremers WK, Fournier M, Halpern SD. Survival differences following lung transplantation among US transplant centers. JAMA. 2010;304:53–60.

    Article  CAS  PubMed  Google Scholar 

  16. Weiss ES, Allen JG, Meguid RA, et al. The impact of center volume on survival in lung transplantation: an analysis of more than 10,000 cases. Ann Thorac Surg. 2009;88:1062–1070.

    Article  PubMed  Google Scholar 

  17. Reames BN, Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and operative mortality in the modern era. Ann Surg. 2014;260:244–251.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med. 1979;301:1364–1369.

    Article  CAS  PubMed  Google Scholar 

  19. Abecassis M, Bridges ND, Clancy CJ, et al. Solid-organ transplantation in older adults: current status and future research. Am J Transpl. 2012;12:2608–2622.

    Article  CAS  Google Scholar 

  20. UNOS. United Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research Database. Available from: http://optn.transplant.hrsa.gov/data/about/OPTNDatabase.asp.

  21. Recipients SRoT. Survival Following Transplant 2017. Available from: https://www.srtr.org/about-the-data/guide-to-key-transplant-program-metrics/txguidearticles/survival-following-transplant/.

  22. Hayes D, Hartwig MG, Tobias JD, Tumin D. Lung transplant center volume ameliorates adverse influence of prolonged ischemic time on mortality. Am J Transpl. 2017;17:218–226.

    Article  Google Scholar 

  23. Ozhathil DK, Li Y, Smith JK, et al. Effect of centre volume and high donor risk index on liver allograft survival. HPB (Oxford). 2011;13:447–453.

    Article  Google Scholar 

  24. Ozhathil DK, Li YF, Smith JK, et al. Impact of center volume on outcomes of increased-risk liver transplants. Liver Transpl. 2011;17:1191–1199.

    Article  PubMed  Google Scholar 

  25. Attia M, Silva MA, Mirza DF. The marginal liver donor–an update. Transpl Int. 2008;21:713–724.

    Article  PubMed  Google Scholar 

  26. Sahni NR, Dalton M, Cutler DM, Birkmeyer JD, Chandra A. Surgeon specialization and operative mortality in United States: retrospective analysis. BMJ. 2016;354:i3571.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Hayes D, Sweet SC, Benden C, Kopp BT, Goldfarb SB, Visner GA, et al. Transplant center volume and outcomes in lung transplantation for cystic fibrosis. Transpl Int. 2017;30(4):371–377.

    Article  PubMed  Google Scholar 

  28. Whitson BA, Black SM. Organ assessment and repair centers: the future of transplantation is near. World J Transpl. 2014;4:40–42.

    Google Scholar 

  29. Hayanga JA, Lira A, Vlahu T, et al. Procedural volume and survival after lung transplantation in the United States: the need to look beyond volume in the establishment of quality metrics. Am J Surg. 2016;211:671–676.

    Article  PubMed  Google Scholar 

  30. Braat AE, Blok JJ, Putter H, et al. The Eurotransplant donor risk index in liver transplantation: ET-DRI. Am J Transpl. 2012;12:2789–2796.

    Article  CAS  Google Scholar 

  31. Blok JJ, Braat AE, Adam R, et al. Validation of the donor risk index in orthotopic liver transplantation within the Eurotransplant region. Liver Transpl. 2012;18:112–119.

    Article  PubMed  Google Scholar 

  32. Collett D, Friend PJ, Watson CJ. Factors associated with short and long term liver graft survival in the United Kingdom: development of a UK donor liver index. Transplantation. 2017;101(4):786–792.

    Article  PubMed  Google Scholar 

  33. Jesudian A, Desale S, Julia J, et al. Donor factors including donor risk index predict fibrosis progression, allograft loss, and patient survival following liver transplantation for hepatitis c virus. J Clin Exp Hepatol. 2016;6:109–114.

    Article  PubMed  Google Scholar 

  34. Aranzana EM, Coppini AZ, Ribeiro MA, Massarollo PC, Szutan LA, Ferreira FG. Model for end-stage liver disease, model for liver transplantation survival and donor risk index as predictive models of survival after liver transplantation in 1,006 patients. Clinics (Sao Paulo). 2015;70:413–418. doi:10.6061/clinics/2015(06)05. Epub Jun 1 2015.

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Transplantation, Department of General Surgery, Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210-1240, USA

    Eliza W. Beal, Sylvester M. Black, Ashraf EL-Hinnawi & Kenneth Washburn

  2. Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA

    Khalid Mumtaz

  3. Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA

    Don Hayes Jr.

  4. Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, 43205, USA

    Dmitry Tumin

Authors
  1. Eliza W. Beal
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  2. Sylvester M. Black
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  3. Khalid Mumtaz
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  4. Don Hayes Jr.
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  5. Ashraf EL-Hinnawi
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  6. Kenneth Washburn
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  7. Dmitry Tumin
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Contributions

EWB, SMB, KM, DH, AE, KW and DT designed the study. EWB and DT analyzed the data. EWB, SMB, KM, DH, AE, KW and DT interpreted the data. EWB prepared the manuscript. EWB, SMB, KM, DH, AE, KW and DT provided critical review and final approval of the manuscript.

Corresponding author

Correspondence to Eliza W. Beal.

Ethics declarations

Conflict of interest

The data reported here were provided by the United Network for Organ Sharing (UNOS)/Organ Procurement and Transplantation Network (OPTN). The interpretation and reporting of these data are the responsibility of the authors and are not official policy or interpretation of UNOS/OPTN.

Electronic supplementary material

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Figure S1

Kaplan-Meier curves of graft survival after liver transplantation, comparing low and high donor risk index (DRI) allografts, according to dichotomized annual transplant center volume (large ≥ 40 LT/year, small < 40 LT/year) (TIFF 689 kb)

Figure S2

Hazard ratio of graft loss after liver transplantation, comparing high-risk and low-risk donor allografts, according to continuous annual transplant center volume (TIFF 689 kb)

Supplementary material 3 (DOCX 27 kb)

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Beal, E.W., Black, S.M., Mumtaz, K. et al. High Center Volume Does Not Mitigate Risk Associated with Using High Donor Risk Organs in Liver Transplantation. Dig Dis Sci 62, 2578–2585 (2017). https://doi.org/10.1007/s10620-017-4639-2

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  • DOI: https://doi.org/10.1007/s10620-017-4639-2

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