Criteria For Organ Allocation Research Articles

Myosteatosis independently predicts transplant-free survival in patients with primary sclerosing cholangitis

BackgroundPrimary Sclerosing Cholangitis (PSC) is a progressive cholestatic liver disease with liver transplantation (LT) as the only curative therapy. Some regions use body-weight-loss as standard-exception criteria for organ allocation but data on the impact of body composition on survival of patients with PSC is scarce. MethodsAbdominal MRI of PSC patients were quantitatively analyzed for intramuscular fat fraction (IMFF) as surrogate of myosteatosis. Clinical and laboratory data were retrieved from patient records. Primary outcome was transplant-free survival (TFS). Results116 PSC patients were included. Median age was 38 (18–71) years with 74 (64%) male patients. 15 (13%) patients had significant weigh loss. IMFF was significantly associated with survival. Multivariate regression analysis showed IMFF ≥ 15% as independent predictor for TFS (p = 0.032, HR 3.215 CI 1.104–9.366), but not significant weight loss (p = 0.618). ConclusionIMFF is independently associated with TFS in patients with PSC and may identify patients with more urgent need for LT. NCT03584204.

Public values and guiding principles for implementing epitope compatibility in kidney transplantation allocation criteria: results from a Canadian online public deliberation

BackgroundEpitope compatibility in deceased donor kidney allocation is an emerging area of precision medicine (PM), seeking to improve compatibility between donor kidneys to transplant candidates in the hope of avoiding kidney rejection. Though the potential benefits of using epitope compatibility are promising, the implied modification of deceased organ allocation criteria requires consideration of significant clinical and ethical trade-offs. As a matter of public policy, these trade-offs should consider public values and preferences. We invited members of the Canadian public to participate in a deliberation about epitope compatibility in deceased donor kidney transplantation; to identify what is important to them and to provide recommendations to policymakers.MethodsAn online public deliberation was conducted with members of the Canadian public, in which participants were asked to construct recommendations for policymakers regarding the introduction of epitope compatibility to kidney allocation criteria. In the present paper, a qualitative analysis was conducted to identify the values reflected in participants’ recommendations. All virtual sessions were recorded, transcribed, and analyzed using NVivo 12 software.ResultsThirty-two participants constructed nine recommendations regarding the adoption of epitope compatibility into deceased donor kidney allocation. Five values were identified that drove participants’ recommendations: Health Maximization, Protection/Mitigation of Negative Impacts, Fairness, Science/Evidence-based Healthcare, and Responsibility to Maintain Trust. Conflicts between these values were discussed in terms of operational principles that were required for epitope compatibility to be implemented in an acceptable manner: the needs for Flexibility, Accountability, Transparent Communication and a Transition Plan. All nine recommendations were informed by these four principles. Participant deliberations were often dominated by the conflict between Health Maximization and Fairness or Protection/Mitigation of Negative Impacts, which was discussed as the need for Flexibility. Two additional values (Efficient Use of Resources and Logic/Rationality) were also discussed and were reasons for some participants voting against some recommendations.ConclusionsPublic recommendations indicate support for using epitope compatibility in deceased donor kidney allocation. A flexible approach to organ allocation decision-making may allow for the balancing of Health Maximization against maintaining Fairness and Mitigating Negative Impacts. Flexibility is particularly important in the context of epitope compatibility and other PM initiatives where evidence is still emerging.

Machine Learning Models for Prediction of Posttreatment Recurrence in Early-Stage Hepatocellular Carcinoma Using Pretreatment Clinical and MRI Features: A Proof-of-Concept Study.

BACKGROUND. Posttreatment recurrence is an unpredictable complication after liver transplant for hepatocellular carcinoma (HCC) that is associated with poor survival. Biomarkers are needed to estimate recurrence risk before organ allocation. OBJECTIVE. This proof-of-concept study evaluated the use of machine learning (ML) to predict recurrence from pretreatment laboratory, clinical, and MRI data in patients with early-stage HCC initially eligible for liver transplant. METHODS. This retrospective study included 120 patients (88 men, 32 women; median age, 60.0 years) with early-stage HCC diagnosed who were initially eligible for liver transplant and underwent treatment by transplant, resection, or thermal ablation between June 2005 and March 2018. Patients underwent pretreatment MRI and posttreatment imaging surveillance. Imaging features were extracted from postcontrast phases of pretreatment MRI examinations using a pretrained convolutional neural network. Pretreatment clinical characteristics (including laboratory data) and extracted imaging features were integrated to develop three ML models (clinical model, imaging model, combined model) for predicting recurrence within six time frames ranging from 1 through 6 years after treatment. Kaplan-Meier analysis with time to recurrence as the endpoint was used to assess the clinical relevance of model predictions. RESULTS. Tumor recurred in 44 of 120 (36.7%) patients during follow-up. The three models predicted recurrence with AUCs across the six time frames of 0.60-0.78 (clinical model), 0.71-0.85 (imaging model), and 0.62-0.86 (combined model). The mean AUC was higher for the imaging model than the clinical model (0.76 vs 0.68, respectively; p = .03), but the mean AUC was not significantly different between the clinical and combined models or between the imaging and combined models (p > .05). Kaplan-Meier curves were significantly different between patients predicted to be at low risk and those predicted to be at high risk by all three models for the 2-, 3-, 4-, 5-, and 6-year time frames (p < .05). CONCLUSION. The findings suggest that ML-based models can predict recurrence before therapy allocation in patients with early-stage HCC initially eligible for liver transplant. Adding MRI data as model input improved predictive performance over clinical parameters alone. The combined model did not surpass the imaging model's performance. CLINICAL IMPACT. ML-based models applied to currently underutilized imaging features may help design more reliable criteria for organ allocation and liver transplant eligibility.

The current and future role of artificial intelligence in optimizing donor organ utilization and recipient outcomes in heart transplantation

Heart failure (HF) is a leading cause of morbidity and mortality in the United States. While medical management and mechanical circulatory support have undergone significant advancement in recent years, orthotopic heart transplantation (OHT) remains the most definitive therapy for refractory HF. OHT has seen steady improvement in patient survival and quality of life (QoL) since its inception, with one-year mortality now under 8%. However, a significant number of HF patients are unable to receive OHT due to scarcity of donor hearts. The United Network for Organ Sharing has recently revised its organ allocation criteria in an effort to provide more equitable access to OHT. Despite these changes, there are many potential donor hearts that are inevitably rejected. Arbitrary regulations from the centers for Medicare and Medicaid services and fear of repercussions if one-year mortality falls below established values has led to a current state of excessive risk aversion for which organs are accepted for OHT. Furthermore, non-standardized utilization of extended criteria donors and donation after circulatory death, exacerbate the organ shortage. Data-driven systems can improve donor-recipient matching, better predict patient QoL post-OHT, and decrease needless organ waste through more uniform application of acceptance criteria. Thus, we propose a data-driven future for OHT and a move to patient-centric and holistic transplantation care processes.

Poorly differentiated hepatocellular carcinoma: resection is equivalent to transplantation in patients with low liver fibrosis.

Organ allocation criteria for liver transplantation focus on tumor size and multifocality while tumor differentiation and existing liver damage are omitted. This study analyzes the impact of hepatocellular carcinoma (HCC) grade and liver fibrosis comparing resection (SX) to transplantation (LT). The National Cancer Database was queried between 2004 and 2016 for solitary HCC meeting Milan criteria undergoing SX vsLT. Two groups were created: low fibrosis (LF) vs high fibrosis (HF) and stratified by grade. Cox multivariable regression models, Kaplan-Meier survival analyses and log-rank tests were performed. 1515 patients were identified; 780 had LT and 735 had SX. Median overall survival (mOS) was 39.7 months; LT mOS was 47.9 months vs SX mOS of 34.9 months (P<.001). Multivariate analysis revealed SX, no chemotherapy, longer hospital stays, and age to be associated with worse survival. However, while transplantation conferred survival benefit for well-moderately differentiated tumors, SX vsLT did not impact survival for poorly differentiated HCC in LF patients, independent of tumor size. HCC differentiation and liver fibrosis, but not size, synergistically determine efficacy of SX vsLT. Therefore, current HCC transplantation criteria should incorporate tumor grade or liver fibrosis for optimal organ allocation.

Poorly Differentiated Hepatocellular Carcinoma: Resection is Equivalent to Transplantation in Patients with Low Liver Fibrosis

Introduction: Organ allocation criteria for liver transplantation (e.g. Milan) focus on tumor size and multifocality while tumor differentiation and existing liver damage are omitted. This study analyzes the impact of hepatocellular carcinoma (HCC) grade and liver fibrosis comparing resection (SX) to transplantation (LT). Methods: The National Cancer Database was queried between 2004-2016 for solitary HCC meeting Milan criteria undergoing SX vs. LT. Two groups were created: low fibrosis (LF) vs high fibrosis (HF) and stratified by grade. Cox multivariable regression models, Kaplan-Meier survival analyses and log-rank tests were performed. Results: 1515 patients were identified; 780 had LT and 735 had SX. Median overall survival (mOS) was 39.7 months; LT mOS was 47.9 months vs SX mOS of 34.9 months (P<.001). Multivariate analysis revealed SX, no chemotherapy, longer hospital stay, and age to be associated with worse survival. However, while transplantation conferred survival benefit for well-moderately differentiated tumors, SX vs. LT did not impact survival for poorly differentiated HCC in LF patients, independent of tumor size. Discussion: HCC differentiation and liver fibrosis, but not size, synergistically determine efficacy of SX vs. LT. Therefore, current HCC transplantation criteria should incorporate tumor grade or liver fibrosis for optimal organ allocation.

Poorly differentiated hepatocellular carcinoma: resection is equivalent to transplantation in patients with low liver fibrosis

Presenter: Omid Salehi MD | Saint Elizabeth's Medical Center Background: Organ allocation criteria for liver transplantation (e.g. Milan) focus on tumor size and multifocality to determine candidacy, while tumor differentiation and degree of liver damage are omitted. This study investigates a synergistic effect of hepatocellular carcinoma (HCC) differentiation grade with degree of liver fibrosis on survival when comparatively analyzing resection (SX) vs transplantation (LT) and whether these parameters should be included in organ allocation algorithms. Methods: The National Cancer Database was queried between 2004-2016 for patients with solitary HCC meeting Milan criteria undergoing SX vs. LT. Two groups were created based on liver damage (low fibrosis (LF) vs high fibrosis (HF)) and stratified by grade. Cox multivariable regression models, Kaplan-Meier survival analyses and log-rank tests were performed. Results: 1515 patients met inclusion criteria; 780 had LT and 735 had SX. Median overall survival (mOS) was 39.7 months and 5-year survival (5YS) was 58.2%; LT mOS was 47.9 months vs SX mOS of 34.9 months (P < .001), LT 5YS was 68.7% vs SX 5YS of 44.2% (P < .001). Multivariate analysis revealed SX, no chemotherapy, longer hospital length of stay, and age to be factors associated with worse survival. However, while transplantation conferred survival benefit for well-moderately differentiated tumors, type of surgery did not impact survival for poorly differentiated HCC in LF patients. This pattern was independent of tumor size. Conclusion: HCC differentiation and liver fibrosis, but not size, synergistically determine efficacy of SX vs. LT. Therefore, to optimally allocate organs for HCC transplantation, current criteria should give more weight to tumor grade or liver fibrosis compared to tumor size.

Abstract 13468: Effect of Listing Criteria on Transplant Rate and Early Outcomes in Adults With Congenital Heart Disease

Introduction: Heart failure (HF) is the leading cause of death in adults with congenital heart disease (ACHD). Heart transplant (HT) is one of the few options for the treatment of advanced HF in this growing population. In October 2018, the United Network for Organ Sharing (UNOS) implemented a change in organ allocation criteria. The effect of this change on outcomes in ACHD patients (pts) after listing and transplant has not been evaluated. Hypothesis: Change in organ allocation criteria negatively impacts outcomes in ACHD patients. Methods: Data from the Scientific Registry of Transplant Recipients in pts age &gt; 18 years old listed for HT between Oct. 2016 and 0ct. 2019 and followed through March 2020 were analyzed. Pts were grouped by diagnosis (ACHD and non-ACHD) and by the time of listing (pre- and post-change in allocation criteria). Differences in comorbidities, outcomes while listed, and 1-year Kaplan Meier survival post-HT were compared among groups. For comparison, post-change criteria (status 1-6) were equated to pre-change criteria (status 1A, 1B, 2). Results: Over 3 years, 11,931 patients were listed for HT; 459 had a primary diagnosis of ACHD. ACHD was present in 279/7942 pts listed in the 2 years pre-change and 180/3989 pts in the year post-change. ACHD pts listed post-change were less likely to have a history of cardiac surgery (88% vs. 79%, p=0.01) and more likely to have an abnormal BMI (p=0.015) than ACHD pts pre-change. Post-change, ACHD pts were listed at a higher priority status compared to pre-change ACHD. (Figure). The proportion of pts transplanted with ACHD increased slightly pre- and post-change (3.7% vs. 4.1%). There was no difference in 1-year survival in ACHD pts transplanted pre- and post-change (Figure). Conclusions: Recent changes to the UNOS organ allocation policy increased the proportion of ACHD patients transplanted with no change in early post-HT survival.

Role of Locoregional Therapies in Patients With Hepatocellular Cancer Awaiting Liver Transplantation.

Hepatocellular cancer (HCC) is the fifth most common cancer in the world and the third most common cause of cancer-related deaths. The United Network for Organ Sharing has its own staging criteria for organ allocation, which is a modification of tumor-node-metastasis staging of American Joint Committee on Cancer. For the purpose of clarity, United Network for Organ Sharing staging will be described as uT1, uT2 (Milan criteria), and uT3 (eligible for downstaging) in this review. For those with unresectable HCC or those with advanced liver disease and HCC but within the Milan criteria, liver transplantation is the treatment of choice. Because of prolonged waiting period on the liver transplant list in many parts of the world for deceased donor liver transplantation, there is a serious risk of dropout from the liver transplant list because of tumor progression. For those patients, locoregional therapies might need to be considered, and moreover, there is circumstantial evidence to suggest that tumor progression after locoregional therapies might be a surrogate marker of unfavorable tumor biology. There is no consensus on the role or type of locoregional therapies in the management of patients with uT1 and uT2 eligible for liver transplant and of those with lesions larger than uT2 but eligible for downstaging protocol (uT3 lesions). In this review, we examine the role of locoregional therapies in these patients stratified by staging and propose treatment options based on the current evidence of tumor progression rates while awaiting liver transplantation and tumor recurrence rates after liver transplantation.

Attitudes, knowledge, and preferences of the Israeli public regarding the allocation of donor organs for transplantation

BackgroundThere is a stark disparity between the number of patients awaiting deceased-donor organ transplants and the rate at which organs become available. Though organs for transplantation are assumed to be a community resource, and the organ supply depends on public willingness to donate, current allocation schemes do not explicitly incorporate public priorities and preferences. This paper seeks to provide insights regarding the Israeli public’s preferences regarding criteria for organ (specifically, kidney) allocation, and to determine whether these preferences are in line with current allocation policies.MethodsA market research company administered a telephone survey to 604 adult participants representing the Jewish-Israeli public (age range: 18–95; 50% male). The questionnaire comprised 39 questions addressing participants’ knowledge, attitudes, and preferences regarding organ donation and criteria for organ allocation, including willingness to donate.ResultsThe criteria that respondents marked as most important in prioritizing waitlist candidates were maximum medical benefit (51.3% of respondents) and waiting time (21%). Donor status (i.e., whether the candidate is registered as an organ donor) was ranked by 43% as the least significant criterion. Most participants expressed willingness to donate the organs of a deceased relative; notably, they indicated that they would be significantly more willing to donate if organ allocation policies took their preferences regarding allocation criteria into account. Unlike individuals in other countries (e.g., the UK, the US, and Australia) who responded to similar surveys, Israeli survey respondents did not assign high importance to the candidate’s age (24% ranked it as the least important factor). Interestingly, in some cases, participants’ declared preferences regarding the importance of various allocation criteria diverged from their actual choices in hypothetical organ allocation scenarios.ConclusionsThe findings of this survey indicate that Israel’s citizens are willing to take part in decisions about organ allocation. Respondents did not seem to have a strict definition or concept of what they deem to be just; yet, in general, their preferences are compatible with current policy. Importantly, participants noted that they would be more willing to donate organs if their preferences were integrated into the allocation policy. Accordingly, we propose that allocation systems must strive to respect community values and perceptions while maintaining continued clinical effectiveness.

New organ allocation criteria in liver transplantation.

The organ allocation modality in the liver transplant represents a fundamental step for the correct success of the transplantation procedure. The practical effects deriving from the adoption of the organ allocation models do not imply only clinical repercussions but also concern important ethical aspects. Alongside the general principles of fairness, justice and transparency, the organ allocation models should be aimed at providing for each patient who waits for an organ, the possibility of accessing it, preserving and maximizing the outcome of the transplant in terms of survival and quality of life. Balancing successfully the clinical and ethical aspects in an allocation model is particularly difficult and probably not completely feasible. In this brief review, the general principles governing the different models of organ allocation in liver transplantation are addressed. A particular description of the decision-making process that led to the sharing in Italy of a new allocation model based on the concept of the transplant benefit is illustrated. In this model we have tried to combine the two fundamental principles that for many years have guided the choice of allocation models, respectively based on the criteria of urgency and utility.

Determination of HLA-A, -B and -DRB1 polymorphism in brain dead organ donors representative of the Colombian general population, 2007-2014

Genes encoding for human leukocyte antigens (HLA) are highly polymorphic and of great importance in organ transplantation procedures, as determining allelic frequencies in defined populations is taken into account among the scientific criteria for organ allocation. The objective of this study was to establish the antigen HLA-A, -B, and -DRB1 haplotype frequencies in organ donors representative of the Colombian population after brain death. We conducted a descriptive retrospective study involving 2,506 cadaveric organ donors including an allelic and haplotype analysis of HLA-A, -B and -DRB1; we also determined the Hardy-Weinberg equilibrium. We identified 21, 43 and 15 allelic loci for groups A*, B* and DRB1*, respectively. We detected 1,268 HLA-A, -B and -DR, 409 HLA-A-B, 383 HLA-DR-B, and 218 HLA-A-DR haplotypes. The three loci were found to be in Hardy-Weinberg equilibrium between the number of heterozygotes observed and the expected number, with p values of ;0.05. This study provides information on the allelic distribution of HLA class I and II in organ donors from the six regions in which Colombia is structurally divided to provide transplant services.

Lung Transplantation From Donors After Previous Cardiac Surgery: Ideal Graft in Marginal Donor?

Lung transplantation is a limited by donor pool shortage. Despite the efforts to extend the graft acceptability with recurrent donor criteria reformulations, previous cardiothoracic surgery is still considered a contraindication. A donor who underwent cardiac surgery could potentially provide an ideal lung but high intraoperative risks and intrinsic technical challenges are expected during the graft harvesting. The purpose of this study is to present our dedicated protocol and four clinical cases of successful lung procurements from donors who had a previous major cardiac surgery. One donor had ascending aortic root (AAR) substitution, another had mitral valve substitution, and two had coronary artery bypass surgery. The others' eligibility criteria for organ allocation, such as ABO compatibility, PaO2/FiO2 ratio, absence of aspiration, or sepsis were respected. In one of the cases with previous coronary bypass grafting, the donor had a veno-arterial extracorporeal membrane oxygenation support. Consequently, the grafts required an ex vivo lung perfusion evaluation. We report the technical details of procurement and postoperative courses of recipients. All procurements were uneventful, without lung damage or waste of abdominal organs related to catastrophic intraoperative events. All recipients had a successful clinical outcome. We believe that successful transplantation is achievable even in a complicated setting, such as cases involving donors with previous cardiac surgery frequently are. Facing lung donor shortage, we strongly support any effort to avoid the loss of possible acceptable lungs. In particular, previous major cardiac surgery does not strictly imply a poor quality of lungs as well as unsustainable graft procurement.

The Pluralistic Theory of Organ Allocation (in Polish)

Biomedical sciences cannot answer the question who should be saved from death if not everyone can be. This is an ethical issue. However, we face exactly this question when deliberating on the criteria for organ allocation. The main aim of this article is to formulate a pluralistic theory of just distribution of organs, which incorporates the tenets of utilitarianism, egalitarianism and sufficientarianism. Each constituent theory adopts a different value as a criterion for organ allocation. For utilitarianism it is a health benefit for the patient, for egalitarianism it is the ratio of deserts and health-related wellbeing, for suficientarianism what is important is that the candidate for a transplant be situated below the sufficientarian threshold. The article presents a proposal to reconcile these three competing theories.

New Organ Allocation System for Combined Liver-Kidney Transplants and the Availability of Kidneys for Transplant to Patients with Stage 4-5 CKD.

A new proposal has been created for establishing medical criteria for organ allocation in recipients receiving simultaneous liver-kidney transplants. In this article, we describe the new policy, elaborate on the points of greatest controversy, and offer a perspective on the policy going forward. Although we applaud the fact that simultaneous liver-kidney transplant activity will now be monitored and appreciate the creation of medical criteria for allocation in simultaneous liver-kidney transplants, we argue that some of the criteria proposed, especially those for allocating a kidney to a liver recipient with AKI, are too liberal. We call on the nephrology community to follow the consequences of this new policy and push for a re-examination of the longstanding policy of allocating kidneys to multiorgan transplant recipients before all other candidates. The charge to protect our system of equitable organ allocation is very challenging, but it is a challenge that we must embrace.

Liver transplantation in Australia and New Zealand.

Liver transplantation (LT) in Australia and New Zealand began in 1985. Over this time until December 2014, LT took place in 3700 adults and 800 children. LT is regulated with 1 unit, supported by the government, per state or region. Currently approximately 270 transplants take place per year. Organ donation rates are moderate in Australia (17 per 1 million of population) but very low in New Zealand (11 per 1 million of population). All the units share organ donors for fulminant hepatic failure cases (status 1). Recipient listing criteria and organ allocation criteria are commonly agreed to via National and Trans-Tasman agreements, which are published online. Current survival rates indicate approximately 94% 1-year survival with median survival in adults of approximately 20 years, whereas 75% of children are alive at 20 years. All units collaborate in research projects via the Australia and New Zealand Liver Transplant Registry and have published highly cited articles particularly on the prevention of hepatitis B virus recurrence. Outcomes for indigenous populations have also been analyzed. In conclusion, LT in Australia and New Zealand is well developed with transparent processes related to criteria for listing and organ allocation together with publication of outcomes. Liver Transplantation 22 830-838 2016 AASLD.

Organ transplantation in Germany: Critical examination in times of scarce resources

Organ transplantation over the last 40 years has developed into a standardized successful procedure for the replacement of heart, kidney liver, lung, and pancreas. During this time, treatment strategies have greatly improved and novel procedures such as living related organ donation have been introduced. Despite these improvements, the number of organ transplants has stalled in recent years. In the face of increasing numbers of patients on the waiting list for organ transplantation, this situation is unacceptable and ways to improve the situation of organ transplantation have to be found.The reasons for the stagnant situation in organ transplantation are manifold and include lack of awareness in the general population, insufficient organ procurement in hospitals as well as problems in organ allocation. The criteria for organ allocation have been unfairly reported to EUROTRANSPLANT by some of the presently 44 centers in order of more rapidly receive an organ for their patients on the waiting list. The evolving discussions around this so-called transplantation scandal has further eroded support for organ transplantation in Germany. A critical assessment and a well-defined plan are necessary to improve the situation, increase the number of transplanted organs, and reduce the unacceptably long waiting time for patients in Germany.

Urgency or Outcome as Guiding Principle for the Allocation of Deceased Donor Livers: A Questionnaire Survey Among Outpatients of a University Medical Department in Germany

IntroductionThe sickest-first principle has been pursued in the allocation of donor livers for transplantation with the introduction of algorithms based on the model of end-stage liver disease (MELD) score. In Germany outcomes of liver transplantation appear to be negatively influenced by the transplantation of patients with very high MELD scores and the use of donor organs with lower quality. Therefore, some have claimed, allocation should be based more on outcome-oriented criteria. MethodsA survey with binary questions (yes/no) regarding the appreciation of values concerning the allocation of donor livers was performed among general medical outpatients of a university hospital. End-stage liver disease patients were excluded. Two hundred four returned forms were analyzed. Percentages of valid answers are given. ResultsIn this study, 88%, 73%, and 41% of subjects answered they would be willing to undergo transplantation with an estimated outcome of 20%, 50%, and 80% 1-year mortality rate, respectively, for themselves. Choosing a possible recipient between 2 case examples, 68% of valid answers voted for the case with higher age and urgency and lower long-term survival. Seventy percent said urgency was more important than long-term outcome as a criterion for organ allocation. Under the assumption that urgency-based allocation would decrease average long-term survival of liver transplantation, 58% refused to deny even the sickest patients transplantation. Seventy-eight percent said that patients likely to achieve 50% long-term survival should not be denied liver transplantation. ConclusionIn our study a majority of subjects prioritize urgency and granting a chance to avert imminent death over long-term survival per procedure. Equitable distribution of chances for survival may be estimated more than outcome maximization in terms of aggregate life-years gained.

Donor organ distribution according to urgency of need or outcome maximization in liver transplantation. A questionnaire survey among patients and medical staff

Low donor rates in Germany cause a trade-off between equity in the distribution of chances for survival and efficiency in dead-donor liver transplantation. Public attitudes concerning the principles that should govern organ allocation are of interest. We performed a questionnaire-based study among patients and medical staff. 1826 of 2200 questionnaires were returned. 79.2%, 67.1%, and 24.4% patients wanted to accept liver transplantation for themselves if expected 1-year survival was 80%, 50%, and 20%, respectively. 57.7% affirmed 'averting immediate risk of death (urgency) is a more important criterion for organ allocation than expected long-term success' (P=0.002 against indifference). The majority of medical staff took the opposite decision. 20.7%, 8.8%, and 21.2% of patients chose 50%, 33%, and 10% as lowest acceptable 5-year survival, respectively. 49.3% accepted a survival of <10%. Variables associated with preferring urgency over efficiency as criterion for allocation were age (OR 1.009; 95% CI: 1.000-1.017; female gender (OR 1.331; 95%CI 0.992-1.784); higher education (OR 0.881; 95%CI 0.801-0.969); and refusal of transplantation for oneself (OR 1.719; 95%CI 1.272-2.324). Most patients supported urgency-based liver allocation. Patients and medical staff would accept lower survival rates than the transplant community.

Challenges for paediatric transplantation in Africa.

Transplantation is the accepted mode of treatment for patients with end-stage organ disease affecting the heart, lungs, kidney, pancreas, liver and intestine. Long-term outcomes have significantly improved and the aim of management is no longer only long-term survival, but also focuses on quality of life especially in children. Transplantation in Africa faces a number of challenges including wide socioeconomic disparity, lack of legislation around brain death and organ donation in many countries, shortage of skilled medical personnel and facilities, infectious disease burden and insecure access to and monitoring of immunosuppression. Whilst there is a need for transplantation, the establishment and sustainability of transplant programmes require careful planning with national government and institutional support. Legislation regarding brain death diagnosis and organ retrieval/donation; appropriate training of the transplant team; and transparent and equitable criteria for organ allocation are important to establish before embarking on a transplant programme. Establishing sustainable, self-sufficient transplant programmes in Africa with equal access to all citizens is an important step towards curtailing transplant tourism and organ trafficking and has a further beneficial effect in raising the level of medical and surgical care in these countries.