Improve Organ Utilization Research Articles

The OPTN Expeditious Task Force: Improved Organ Utilization and Efficiency to Drive Transformational Growth in Solid Organ Transplant in the United States

The Organ Procurment and Transplant Network (OPTN) Expeditious Task Force (ETF) was conceived and initiated in response to a need to move quickly to greatly expand successful deceased-donor transplant across the U.S. The ETF, using data from the top 20% of transplant programs ranked by ability to manage successful growth in transplant volume, came up with a bold aim of facilitating 60,000 successful transplants by 2026 to save more lives. In order to achieve this transformational growth, the ETF will use a data-driven approach, partnering with key stakeholders across the transplant system to secure commitments, reduce barriers, obtain data, align metrics, evaluate new technologies, and run short trials that will better inform future policy developments. To achieve this growth, the two primary aims of the ETF are increasing system efficiency and improving organ and donor utilization. The initial ETF workstreams will focus on 6 areas that include assessments of organ non-utilization (where donors are consented but organs not recovered) and non-use (where organs are recovered but not transplanted), facilitating community events to address challenges in utilization and efficiency; hosting transplant growth collaboratives focused on securing resources needed for transformational growth; creating tools for patient empowerment; evaluating OPTN policies to remove barriers; and designing short trials of rescue pathways for organs at risk for non-use.

Minimizing risk while maximizing opportunity: The infectious disease organ offer process survey.

The purpose of this study was to understand how transplant infectious disease (TID) physicians assess a potential donor with known or suspected infection and describe posttransplant management. We designed a survey of 10 organ offer scenarios and asked questions pertaining to organ acceptability for transplantation and management posttransplant. The survey was distributed to TID clinicians via transplant society listservs and email. Responses were recorded in REDCap, and descriptive statistics were employed. One hundred thirteen infectious disease physicians responded to the survey, of whom 85 completed all cases. Respondents were generally in agreement regarding organ acceptability, although some divergence was seen when evaluating lungs from donors with influenza, tuberculosis, or multidrug-resistant Acinetobacter infection. Posttransplant management showed more variation. Areas of optimization were identified: (1) Further understanding of where risk-mitigation strategies within the donor offer process may improve donor acceptability and therefore organ utilization; (2) importance of recipient considerations in assessing degree of infectious risk; and (3) gaps in evidenced-based data regarding optimal posttransplant management of recipients. Evaluation of donor offers by TID clinicians is a complex process. Although the survey does not itself serve to make recommendations regarding best practices, it highlights areas where generation of data to inform acceptance and management practices may allow for improved organ utilization and recipient management.

The Public Health Service "Increased Risk" 2020 Policy Change Has not Improved Organ Utilization in the United States: A Nationwide Cohort Study.

To assess the effects of the 2020 United States Public Health Service (PHS) "Increased Risk" Guidelines update. Donors labeled as "Increased Risk" for transmission of infectious diseases have been found to have decreased organ utilization rates despite no significant impact on recipient survival. Recently, the PHS provided an updated guideline focused on "Increased Risk" organ donors, which included the removal of the "Increased Risk" label and the elimination of the separate informed consent form, although the actual increased risk status of donors is still ultimately transmitted to transplant physicians. We sought to analyze the effect of this update on organ utilization rates. This was a retrospective analysis of the Organ Procurement and Transplantation Network database which compared donor organ utilization in the 2 years before the June 2020 PHS Guideline update for increased-risk donor organs (June 2018-May 2020) versus the 2 years after the update (August 2020-July 2022). The organ utilization rate for each donor was determined by dividing the number of organs transplanted by the total number of organs available for procurement. Student t test and multivariable logistic regression models were used for analysis. There were 17,272 donors in the preupdate cohort and 17,922 donors in the postupdate cohort; of these, 4,977 (28.8%) and 3,893 (21.7%) donors were considered "Increased Risk", respectively. There was a 2% decrease in overall organ utilization rates after the update, driven by a 3% decrease in liver utilization rates and a 2% decrease in lung utilization rates. After multivariable adjustment, donors in the postupdate cohort had 10% decreased odds of having all organs transplanted. The 2020 PHS "Increased Risk" Donor Guideline update was not associated with an increase in organ utilization rates in the first 2 years after its implementation, despite a decrease in the proportion of donors considered to be at higher risk. Further efforts to educate the community on the safe usage of high-risk organs are needed and may increase organ utilization.

Understanding Delayed Graft Function to Improve Organ Utilization and Patient Outcomes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation

Delayed graft function (DGF) is a common complication after kidney transplant. Despite extensive literature on the topic, the extant definition of DGF has not been conducive to advancing the scientific understanding of the influences and mechanisms contributing to its onset, duration, resolution, or long-term prognostic implications. In 2022, the National Kidney Foundation sponsored a multidisciplinary scientific workshop to comprehensively review the current state of knowledge about the diagnosis, therapy, and management of DGF and conducted a survey of relevant stakeholders on topics of clinical and regulatory interest. In this Special Report, we propose and defend a novel taxonomy for the clinical and research definitions of DGF, address key regulatory and clinical practice issues surrounding DGF, review the current state of therapies to reduce and/or attenuate DGF, offer considerations for clinical practice related to the outpatient management of DGF, and outline a prospective research and policy agenda.

Early patient and liver allograft outcomes from donation after circulatory death donors using thoracoabdominal normothermic regional: a multi-center observational experience.

Donation after circulatory death (DCD) liver allografts are associated with higher rates of primary non-function (PNF) and ischemic cholangiopathy (IC). Advanced recovery techniques, including thoracoabdominal normothermic regional perfusion (TA-NRP), may improve organ utilization and patient and allograft outcomes. Given the increasing US experience with TA-NRP DCD recovery, we evaluated outcomes of DCD liver allografts transplanted after TA-NRP. Liver allografts transplanted from DCD donors after TA-NRP were identified from 5/1/2021 to 1/31/2022 across 8 centers. Donor data included demographics, functional warm ischemic time (fWIT), total warm ischemia time (tWIT) and total time on TA-NRP. Recipient data included demographics, model of end stage liver disease (MELD) score, etiology of liver disease, PNF, cold ischemic time (CIT), liver function tests, intensive care unit (ICU) and hospital length of stay (LOS), post-operative transplant related complications. The donors' median age was 32 years old and median BMI was 27.4. Median fWIT was 20.5 min; fWIT exceeded 30 min in two donors. Median time to initiation of TA-NRP was 4 min and median time on bypass was 66 min. The median recipient listed MELD and MELD at transplant were 22 and 21, respectively. Median allograft CIT was 292 min. The median length of follow up was 257 days. Median ICU and hospital LOS were 2 and 7 days, respectively. Three recipients required management of anastomotic biliary strictures. No patients demonstrated IC, PNF or required re-transplantation. Liver allografts from TA-NRP DCD donors demonstrated good early allograft and recipient outcomes.

Evaluation of Functional Warm Ischemia Time during Controlled Donation after Circulatory Determination of Death using Normothermic Regional Perfusion (ECMO-TT): a prospective multicenter cohort study.

Controlled donation after circulatory determination of death (cDCD) seems an effective way to mitigate the critical shortage of available organs for transplant worldwide. As a recently developed procedure for organ retrieval, some questions remain unsolved such as the uncertainty regarding the effect of functional warm ischemia time (FWIT) on organs´ viability. We developed a multicenter prospective cohort study collecting all data from evaluated organs during cDCD from 2017 to 2020. All the procedures related to cDCD were performed with normothermic regional perfusion. The analysis included organ retrieval as endpoint and FWIT as exposure of interest. The effect of FWIT on the likelihood for organ retrieval was evaluated with Relative distribution analysis. A total amount of 507 organs´ related information was analyzed from 95 organ donors. Median donor age was 62 years, and 63% of donors were male. Stroke was the most common diagnosis before withdrawal life sustaining therapy (61 %), followed by anoxic encephalopathy (21 %). This analysis showed that length of FWIT was inversely associated with organ retrieval rates for liver, kidneys, and pancreas. No statistically significant association was found for lungs. Results showed an inverse association between functional warm ischemia time (FWIT) and retrieval rate. We also have postulated optimal FWIT's thresholds for organ retrieval. FWIT for liver retrieval remained between 6 and less than 11 min and in case of kidneys and pancreas, the optimal FWIT for retrieval was 6 to 12 min. These results could be valuable to improve organ utilization and for future analysis.

Nanoparticle-Based Interventions for Liver Transplantation.

Liver transplantation is the only treatment for hepatic insufficiency as a result of acute and chronic liver injuries/pathologies that fail to recover. Unfortunately, there remains an enormous and growing gap between organ supply and demand. Although recipients on the liver transplantation waitlist have significantly higher mortality, livers are often not allocated because they are (i) classified as extended criteria or marginal livers and (ii) subjected to longer cold preservation time (>6 h) with a direct correlation of poor outcomes with longer cold ischemia. Downregulating the recipient's innate immune response to successfully tolerate a graft having longer cold ischemia times or ischemia-reperfusion injury through induction of immune tolerance in the graft and the host would significantly improve organ utilization and post-transplant outcomes. Broadly, technologies proposed for development aim to extend the life of the transplanted liver through post-transplant or recipient conditioning. In this review, we focus on the potential benefits of nanotechnology to provide unique pre-transplant grafting and recipient conditioning of extended criteria donor livers using immune tolerance induction and hyperthermic pre-conditioning.

Donor Liver Blood Tests and Liver Transplant Outcomes: UK Registry Cohort Study.

Safely increasing organ utilization is a global priority. Donor serum transaminase levels are often used to decline livers, despite minimal evidence to support such decisions. This study aimed to investigate the impact of donor "liver blood tests" on transplant outcomes. This retrospective cohort study used the National Health Service registry on adult liver transplantation (2016-2019); adjusted regressions models were used to assess the effect of donor "liver blood tests" on outcomes. A total of 3299 adult liver transplant recipients were included (2530 following brain stem death, 769 following circulatory death). Peak alanine transaminase (ALT) ranged from 6 to 5927 U/L (median = 45). Donor cause of death significantly predicted donor ALT; 4.2-fold increase in peak ALT with hypoxic brain injury versus intracranial hemorrhage (adjusted P < 0.001). On multivariable analysis, adjusting for a wide range of factors, transaminase level (ALT or aspartate aminotransferase) failed to predict graft survival, primary nonfunction, 90-d graft loss, or mortality. This held true in all examined subgroups, that is, steatotic grafts, donation following circulatory death, hypoxic brain injury donors, and donors, in which ALT was still rising at the time of retrieval. Even grafts from donors with extremely deranged ALT (>1000 U/L) displayed excellent posttransplant outcomes. In contrast, donor peak alkaline phosphatase was a significant predictor of graft loss (adjusted hazard ratio = 1.808; 1.016-3.216; P = 0.044). Donor transaminases do not predict posttransplant outcomes. When other factors are favorable, livers from donors with raised transaminases can be accepted and transplanted with confidence. Such knowledge should improve organ utilization decision-making and prevent future unnecessary organ discard. This provides a safe, simple, and immediate option to expand the donor pool.

Beyond donation to organ utilization in the UK.

Optimizing deceased donor organ utilization is gaining recognition as a topical and important issue, both in the United Kingdom (UK) and globally. This review discusses pertinent issues in the field of organ utilization, with specific reference to UK data and recent developments within the UK. A multifaceted approach is likely required in order to improve organ utilization. Having a solid evidence-base upon which transplant clinicians and patients on national waiting lists can base decisions regarding organ utilization is imperative in order to bridge gaps in knowledge regarding the optimal use of each donated organ. A better understanding of the risks and benefits of the uses of higher risk organs, along with innovations such as novel machine perfusion technologies, can help clinician decision-making and may ultimately reduce the unnecessary discard of precious deceased donor organs. The issues facing the UK with regards to organ utilization are likely to be similar to those in many other developed countries. Discussions around these issues within organ donation and transplantation communities may help facilitate shared learning, lead to improvements in the usage of scarce deceased donor organs, and enable better outcomes for patients waiting for transplants.

Beyond donation to organ utilization in the USA.

The deceased donor organ pool has broadened beyond young, otherwise healthy head trauma victims. But an abundance of donated organs only benefits patients if they are accepted, expeditiously transported and actually transplanted. This review focuses on postdonation challenges and opportunities to increase the number of transplants through improved organ utilization. We build upon recently proposed changes in terminology for measuring organ utilization. Among organs recovered for transplant, the nonuse rate (NUR REC ) has risen above 25% for kidneys and pancreata. Among donors, the nonuse rate (NUR DON ) has risen to 40% for livers and exceeds 70% for thoracic organs. Programme-level variation in offer acceptance rates vastly exceeds variation in the traditional, 1-year survival benchmark. Key opportunities to boost utilization include donation after circulatory death and hepatitis C virus (HCV)+ organs; acute kidney injury and suboptimal biopsy kidneys; older and steatotic livers. Underutilization of less-than-ideal, yet transplant-worthy organs remains an obstacle to maximizing the impact of the U.S. transplant system. The increased risk of inferior posttransplant outcomes must always be weighed against the risks of remaining on the waitlist. Advanced perfusion technologies; tuning allocation systems for placement efficiency; and data-driven clinical decision support have the potential to increase utilization of medically complex organs.

Temporal changes in the utilization of kidneys from hepatitis C virus–infected donors in the United States

Despite data demonstrating increased utilization of kidneys from hepatitis C virus (HCV)-infected donors, it is unknown whether this is due to an increase in the donor pool or improved organ utilization and whether data from early pilot trials were temporally associated with changes in organ utilization. We used data from the Organ Procurement and Transplantation Network on all kidney donors and recipients of kidney transplants from January 1, 2015, to March 31, 2022 to evaluate temporal changes using joinpoint regression. Our primary analyses compared donors on the basis of their HCV viremic status (HCV-infected vs HCV-negative). Kidney utilization changes were assessed by evaluating the kidney discard rate and kidneys transplanted per donor. A total of 81 833 kidney donors were included in the analysis. There was a statistically significant decrease in the discard rates of HCV-infected kidney donors from 40% to just over 20% over a 1-year period, with a concurrent increase in kidneys transplanted per donor. This increased utilization occurred in tandem with the publication of pilot trials involving HCV-infected kidney donors in HCV-negative recipients rather than an increase in the donor pool. Ongoing clinical trials may strengthen existing data, which could result in this practice becoming the accepted standard of care.

Determining the impact of ex-vivo lung perfusion on hospital costs for lung transplantation: A retrospective cohort study.

Ex-vivo lung perfusion (EVLP) has improved organ utilization for lung transplantation, but it is not yet known whether the benefits of this technology offset its additional costs. We compared the institutional costs of lung transplantation before vs after EVLP was available to identify predictors of costs and determine the health-economic impact of EVLP. We performed a retrospective, before-after, propensity-score weighted cohort study of patients wait-listed for lung transplant at University Health Network (UHN) in Ontario, Canada, between January 2005 and December 2019 using institutional administrative data. We compared costs, in 2019 Canadian Dollars ($), between patients referred for transplant before EVLP was available (Pre-EVLP) to after (Modern EVLP). Cumulative costs were estimated using a novel application of multistate survival models. Predictors of costs were identified using weighted log-gamma generalized linear regression. A total of 1,199 patients met inclusion criteria (352 Pre-EVLP; 847 Modern EVLP). Mean total costs for the transplant hospitalization were $111,878 ($94,123-$130,767) in the Pre-EVLP era and $110,969 ($87,714-$136,000) in the Modern EVLP era. Cumulative five-year costs since referral were $278,777 ($82,575-$298,135) in the Pre-EVLP era and $293,680 ($252,832-$317,599) in the Modern EVLP era. We observed faster progression to transplantation when EVLP was available. EVLP availability was not a predictor of waitlist (cost ratio [CR] 1.04 [0.81-1.37]; p=0.354) or transplant costs (CR 1.02 [0.80-1.29]; p=0.425) but was associated with lower costs during posttransplant years 1&2 (CR 0.75 [0.58-1.06]; p=0.05) and posttransplant years 3+ (CR 0.43 [0.26-0.74]; p=0.001). At our center, EVLP availability was associated with faster progression to transplantation at no significant marginal cost.

Improved Organ Utilization and Better Transplant Outcomes With In Situ Normothermic Regional Perfusion in Controlled Donation After Circulatory Death.

. We evaluated whether the use of normothermic regional perfusion (NRP) was associated with increased organ recovery and improved transplant outcomes from controlled donation after circulatory death (cDCD). . This is a retrospective analysis of UK adult cDCD donors' where at least 1 abdominal organ was accepted for transplantation between January 1, 2011, and December 31, 2019. . A mean of 3.3 organs was transplanted when NRP was used compared with 2.6 organs per donor when NRP was not used. When adjusting for organ-specific donor risk profiles, the use of NRP increased the odds of all abdominal organs being transplanted by 3-fold for liver ( P < 0.0001; 95% confidence interval [CI], 2.20-4.29), 1.5-fold for kidney ( P = 0.12; 95% CI, 0.87-2.58), and 1.6-fold for pancreas ( P = 0.0611; 95% CI, 0.98-2.64). Twelve-mo liver transplant survival was superior for recipients of a cDCD NRP graft with a 51% lower risk-adjusted hazard of transplant failure (HR = 0.494). In risk-adjusted analyses, NRP kidneys had a 35% lower chance of developing delayed graft function than non-NRP kidneys (odds ratio, 0.65; 95% CI, 0.465-0.901)' and the expected 12-mo estimated glomerular filtration rate was 6.3 mL/min/1.73 m 2 better if abdominal NRP was used ( P < 0.0001). . The use of NRP during DCD organ recovery leads to increased organ utilization and improved transplant outcomes compared with conventional organ recovery.

A Novel Digital Algorithm for Identifying Liver Steatosis Using Smartphone-Captured Images.

Background.Access to lifesaving liver transplantation is limited by a severe organ shortage. One factor contributing to the shortage is the high rate of discard in livers with histologic steatosis. Livers with <30% macrosteatosis are generally considered safe for transplant. However, histologic assessment of steatosis by a pathologist remains subjective and is often limited by image quality. Here, we address this bottleneck by creating an automated digital algorithm for calculating histologic steatosis using only images of liver biopsy histology obtained with a smartphone.Methods.Multiple images of frozen section liver histology slides were captured using a smartphone camera via the optical lens of a simple light microscope. Biopsy samples from 80 patients undergoing liver transplantation were included. An automated digital algorithm was designed to capture and count steatotic droplets in liver tissue while discounting areas of vascular lumen, white space, and processing artifacts. Pathologists of varying experience provided steatosis scores, and results were compared with the algorithm’s assessment. Interobserver agreement between pathologists was also assessed.Results.Interobserver agreement between all pathologists was very low but increased with specialist training in liver pathology. A significant linear relationship was found between steatosis estimates of the algorithm compared with expert liver pathologists, though the latter had consistently higher estimates.Conclusions.This study demonstrates proof of the concept that smartphone-captured images can be used in conjunction with a digital algorithm to measure steatosis. Integration of this technology into the transplant workflow may significantly improve organ utilization rates.

Transplantation of the Horseshoe Kidneys: A Model for Dual Adult Kidney Transplantation

Background: The shortage of organs has called for the use of two marginal adult kidneys (MAKs) with a low nephron mass as dual adult kidneys transplanted to a single recipient. The operative techniques of the transplantation of these kidneys are still debated. Since the horseshoe kidneys have been transplanted as early as 1975, it is theorized that the technique of the en bloc transplantation of the horseshoe kidney may be applied to the MAKs. Material and Methods: The world literature search during the period 1975–2021 on the use of deceased-donor horseshoe kidneys was reviewed. The selection of the donors, the anatomy of the kidneys, the principles of organ recovery, the transplantation procedure, and the results were discussed. Finally, this technique of en bloc transplantation was applied successfully to seven pairs of MAKs and is described herein. The dual adult kidneys were simultaneously vascularized by the donor aorta and vena cava, which were anastomosed, respectively, to the recipient iliac artery and vein. Results: A total of 131 case reports of deceased horseshoe kidney donors were reviewed, of which 53 en bloc kidneys were transplanted successfully to a single recipient, and the remaining 78 were divided and transplanted as single units to 131 recipients. Twenty-five single kidneys were discarded. At the time of publication, all horseshoe kidneys had a good renal function. In the series of seven pairs of MAKs transplanted en bloc, the operative time was 3 h. There were no primary nonfunctions, no vascular thromboses, no urinary leakages, and no wound infections. Only two patients required temporary dialysis despite an average of 28.4 h of cold ischemia time. No hydronephrosis and lymphocele was experienced. Both patient and graft survival were 100%. At the time of follow-up at 36 months, serum creatinine levels averaged 1.8 mg/dL (range 1.4–1.9). Conclusions: This technique of en bloc renal transplantation using the donor aorta and vena cava for revascularization can be applied to both the horseshoe kidneys and the MAK, and improve organ utilization.

Deceased donor kidneys allocated out of sequence by organ procurement organizations

Deceased donor kidney allocation follows a ranked match-run of potential recipients. Organ procurement organizations (OPOs) are permitted to deviate from the mandated match-run in exceptional circumstances. Using match-run data for all deceased donor kidney transplants (Ktx) in the US between 2015 and 2019, we identified 1544kidneys transplanted from 933 donors with an OPO-initiated allocation exception. Most OPOs (55/58) used this process at least once, but 3 OPOs performed 64% of the exceptions and just 2 transplant centers received 25% of allocation exception Ktx. At 2 of 3 outlier OPOs these transplants increased 136% and 141% between 2015 and 2019 compared to only a 35% increase in all Ktx. Allocation exception donors had less favorable characteristics (median KDPI 70, 41% with history of hypertension), but only 29% had KDPI≥85% and the majority did not meet the traditional threshold for marginal kidneys. Allocation exception kidneys went to larger centers with higher offer acceptance ratios and to recipients with 2 fewer priority points-equivalent to 2less years of waiting time. OPO-initiated exceptions for kidney allocation are growing increasingly frequent and more concentrated at a few outlier centers. Increasing pressure to improve organ utilization risks increasing out-of-sequence allocations, potentially exacerbating disparities in access to transplantation.

The Inclusion of Biomarker Scoring During Ex-Vivo Lung Perfusion Can Improve Organ Utilization and Patient Outcomes - A Retrospective, Single Center Study

<h3>Purpose</h3> Biomarker-based scoring algorithms have been reported throughout the EVLP literature; however, the role that prediction models play in influencing surgical decision-making is not known. Herein, we sought to assess the impact of biomarker scoring on EVLP-decisions in a retrospective, single center study. <h3>Methods</h3> A total of n=20 clinical EVLP cases were used in this study. Each case was independently assessed by n=15 study participants that included surgeons, surgical fellows, organ perfusion specialists, and EVLP assistants. Each EVLP case was de-identified and presented alongside an intended recipient. Participants were asked to determine the suitability of the lung for transplant (yes/no) based on standard EVLP assessments alone and their impression of the organ on a scale from 0-10. Biomarker scores were then revealed and participants were then asked to re-answer the transplant and lung suitability questions. <h3>Results</h3> There were a total of n=300 transplant decisions in this study with and without biomarker scoring. The use of biomarker scoring greatly increased the recommendation to transplant lungs predicted to result in post-transplant extubation <72h [OR=13; 95%CI:4-45] and significantly increased a participant's lung suitability score [+1.0; 95%CI:0.4-1.5]. For lungs predicted to have excellent recipient outcomes and the historical decision was to transplant the organ, there was a 6.7% increase in transplant recommendation. Importantly, there was a net 13.3% increase in transplant recommendation when the historical decision was to decline an organ likely to result in a good outcome. Conversely, there was a 13.3% decrease in the recommendation to transplant lungs likely to produce poor outcomes (i.e., prolonged ventilation or PGD 3) using biomarker scores (OR=0.4; 95%CI:0.16-0.98). <h3>Conclusion</h3> This study demonstrates that the inclusion of biomarker scoring during EVLP can lead to an increase in organ acceptance following EVLP. Furthermore, we demonstrate that organs that were associated with poor patient outcomes are less likely to be transplanted as a result of biomarker scoring being included in EVLP assessments. Taken together, this study provides strong rationale for the adoption of biomarker scoring algorithms during EVLP.

Machine Learning Prediction of Liver Allograft Utilization From Deceased Organ Donors Using the National Donor Management Goals Registry.

Several machine learning classifiers were trained to predict transplantation of a liver graft. We utilized 127 variables available in the DMG dataset. We included data from potential deceased organ donors between April 2012 and January 2019. The outcome was defined as liver recovery for transplantation in the operating room. The prediction was made based on data available 12-18 h after the time of authorization for transplantation. The data were randomly separated into training (60%), validation (20%), and test sets (20%). We compared the performance of our models to the Liver Discard Risk Index. Of 13 629 donors in the dataset, 9255 (68%) livers were recovered and transplanted, 1519 recovered but used for research or discarded, 2855 were not recovered. The optimized gradient boosting machine classifier achieved an area under the curve of the receiver operator characteristic of 0.84 on the test set, outperforming all other classifiers. This model predicts successful liver recovery for transplantation in the operating room, using data available early during donor management. It performs favorably when compared to existing models. It may provide real-time decision support during organ donor management and transplant logistics.

Impact of Extending Eligibility for Reinstatement of Waiting Time After Early Allograft Failure: A Decision Analysis

The shortage of deceased donor kidneys identified for potential transplantation in the United States is exacerbated by a high proportion of deceased donor kidneys being discarded after procurement. We estimated the impact of a policy proposal aiming to increase organ utilization by extending eligibility for waiting time reinstatement for recipients experiencing early allograft failure after transplantation. Decision analysis informed by clinical registry data. We used Organ Procurement and Transplantation Network data to identify 76,044 deceased-donor kidneys procured in the United States from 2013 to 2017, 80% of which were transplanted and 20% discarded. Extend waiting time reinstatement for recipients experiencing allograft failure from the current 90 days to 1 year after transplantation. Net impact to the waitlist, defined as the estimated number of additional transplants minus estimated increase in waiting list reinstatements. We estimated (1) the number of additional deceased donor kidneys that would be transplanted if there was a 5%-25% relative reduction in discards, and (2) the number of recipients who would regain waiting time under a 6-, 12-, 18-, and 24-month reinstatement policy. Reinstating a waiting time for recipients experiencing allograft failure up to 1 year after transplantation yielded more additional transplants than growth in additions to the waiting list for all model assumptions except the combination of a very low relative reduction in discards (5%) and a very high failure rate of transplanted kidneys that would previously have been discarded (≥5 times the rate of currently transplanted kidneys). Lack of empirical evidence supporting the proposed impact of such a policy change. A policy change reinstating waiting time for deceased donor kidneys recipients with allograft failure up to 1 year after transplantation should explored as a decision science-based intervention to improve organ utilization.

Role of deceased donor kidney procurement biopsies in organ allocation.

There has been an increased emphasis by the transplant community and the federal government to increase the utilization of deceased donor kidneys. Procurement biopsies during allocation are the most common reason for kidney discards. This manuscript reviews the evidence of procurement biopsies practices and utility. Procurement biopsies are performed in over half of all the kidneys recovered in the United States and account for more than one third of the kidney discards. However, there is a significant heterogeneity across the organ procurement organizations regarding the indications for biopsy, biopsy techniques and their reporting. Procurement biopsy findings are not reproducible and poorly correlate to postimplantation histology, although reasons for these limitations are not clear. Procurement biopsy findings are not associated with posttransplant outcomes after accounting for readily available donor clinical characteristics. Procurement biopsies contribute to deceased donor kidney discards but do not predict posttransplant outcomes. Research to establish the best practices for procurement biopsies is needed to improve organ utilization.