Scientific Registry Of Transplant Recipients Database Research Articles

The impact of donor consent mechanism on organ procurement organization performance in the United States

Lack of donor organ availability represents a major limitation to the success of solid organ transplantation. The Scientific Registry of Transplant Recipients (SRTR) publishes performance reports of organ procurement organizations (OPO) in the United States, but does not stratify by the mechanism of donor consent, namely first-person authorization (organ donor registry) and next-of-kin authorization. This study aimed to report the trends in deceased organ donation in the United States and assess the regional differences in OPO performance after accounting for the different mechanisms of donor consent. The SRTR database was queried for all eligible deaths (2008-2019) which were then stratified based on the mechanism of donor authorization. Multivariable logistic regression was performed to assess the probability of organ donation across OPOs based on specific donor consent mechanisms. Eligible deaths were divided into 3 cohorts based on the probability to donate. Consent rates at the OPO level were calculated for each cohort. Organ donor registration among adult eligible deaths in the U.S. increased over time (2008: 10% vs 2019: 39%, p < 0.001), coincident with a decline in next-of-kin authorization rates (2008: 70% vs 2019: 64%, p < 0.001). At the OPO level, the increased organ donor registration was associated with lower next-of-kin authorization rates. Among eligible deaths with medium- and low-probability of donation, recruitment was highly variable across OPO's, ranging from 36% to 75% in the medium-probability group (median 54%, IQR 50%-59%) and 8% and 73% in the low-probability group (median 30%, IQR 17%-38%). Significant variability exists across OPOs in the consent of potentially persuadable donors after adjusting for population demographic differences and the mechanism of consent. Current metrics may not truly reflect OPO performance as they do not account for consent mechanism. There is further opportunity for improvement in deceased organ donation through targeted initiatives across OPOs, modeled after regions with the best performance.

Donor-Recipient Body Mass Index Matching in Lung Transplantation

Purpose Donor-recipient size matching, in terms of height, total lung capacity and chest x-ray measurements, has been studied and is known to affect outcomes. Less is known about the impact of BMI matching which could have equally important implications on outcomes. We analyzed the Scientific Registry of Transplant Recipients (SRTR) database to determine the effects of BMI-matching on patient survival and graft function after lung transplant. Methods We evaluated a national cohort of patients from the SRTR database who underwent single or double lung Tx between 2006-17. Donor and recipient BMI were categorized using the World Health Organization classification: underweight (BMI 14.0-18.49); normal, (18.5-24.99); overweight (25.00-29.99); obese (≥30.00). In addition, donor and recipient BMI categories were used to stratify patients based on donor-recipient BMI matching: same category; donor BMI in a higher category than the recipient; recipient BMI in a higher category than the donor. The association between donor BMI, recipient BMI, as well as donor-recipient BMI similarity and overall risk of death or risk of graft loss were separately evaluated using multivariable Cox regression. Results Among 20,404 patients, median donor BMI was 25.1 [IQR 22.3-28.7] and median recipient BMI was 25.4 [IQR 21.6-28.7]. For donors, 3.5% were underweight, 44.6% were normal weight, 32.7% were overweight, and 19.2% were obese. For recipients, these were 8.5%, 38.8%, 37.2%, and 15.6%, respectively. Donor BMI was not associated with overall risk of death or risk of graft loss. By comparison, relative to normal weight recipients, underweight recipients had a 42% higher risk of death (Hazard Ratio 1.42 [95% CI 1.02-2.00]). Relative to patients receiving organs from a donor in a similar BMI category, donor-recipient differences in BMI category were neither associated with risk of death nor graft loss. Conclusion Consistent with prior reports, recipient BMI was an important factor in lung transplant outcomes, but donor-recipient BMI matching, or lack of, did not have an effect. Neither donor BMI nor donor-recipient size matching based on BMI are associated with improved Tx outcomes.

Lung Transplant Outcomes Based on Immunosuppressive Regimen at Discharge: Data from the US Scientific Registry of Transplant Recipients (SRTR)

<h3>Purpose</h3> There is currently no FDA approved immunosuppressive regimen for lung transplant (Tx) recipients; however, patients routinely receive a CNI-based regimen. The SRTR database was analyzed to provide real-world evidence of the efficacy and safety of tacrolimus-based immunosuppressive regimens post lung Tx. <h3>Methods</h3> Adult and pediatric recipients of a primary deceased donor lung Tx between January 1, 1999 and December 31, 2017 were followed for 3 years post-transplant based on immunosuppressive regimen at discharge: immediate-release tacrolimus (TAC IR)+mycophenolate mofetil (MMF), TAC IR+azathioprine (AZA), cyclosporine (CYA)+MMF, or CYA+AZA. The primary outcome was the composite endpoint of graft failure or death (all cause) at 1 year post-transplant. Cox proportional hazard models were used to test for baseline characteristics associated with a greater risk of graft failure or death in adults. <h3>Results</h3> Data were available for 26,080 lung Tx recipients (25,355 adults and 725 pediatric patients). The most common discharge immunosuppressive regimen was TAC IR+MMF in both groups. Post-transplant outcomes are shown in Tables 1 (adults) and 2 (pediatrics). Factors associated with a greater risk of graft failure or death in adults on TAC IR+MMF included: recipient age ≥65 years, single lung transplant, hospital stay >24 days, BMI <18.5 kg/m², serum creatinine ≥1.0 mg/dL, donor age ≥55 years, and donor race (Black). The risk of graft failure or death was significantly greater in adults receiving CYA+MMF or CYA+AZA compared to TAC IR+MMF. <h3>Conclusion</h3> Discharge immunosuppressive regimens in lung Tx recipients changed over the period from 1999-2017, with a substantial increase in the use of TAC IR+MMF. Adult and pediatric lung Tx recipients receiving TAC IR+MMF had a cumulative incidence of graft failure or death at 1 year post transplant less than 9% (graft survival >91%) and had the lowest rejection rates without increased risks of infection or malignancy.

Liver transplantation for alcoholic hepatitis in the United States: Excellent outcomes with profound temporal and geographic variation in frequency.

Medical-refractory severe alcoholic hepatitis (AH) has a high mortality. The national frequency, longer term outcomes and regional practices of AH liver transplantation (LT) in the United States are not well described, despite the increasing mortality from alcohol-associated liver disease. We analyzed the trends in frequency and outcomes of UNOS data on 39455 adult patients who underwent LT from 2014 to 2019, including AH LT recipients. LTs for AH increased 5-fold, from 28 in 2014 to 138 in 2019, varying 8-fold between UNOS regions. Three transplant centers accounted for 50%-90% of AH LTs within each region. The number of transplant centers performing AH LTs increased from 14 in 2014 to 47 in 2019. AH patients were younger (mean=39.4years), had higher MELD scores (mean=36.8), and were more often on dialysis (46.0%) and in ICU (38.4%), compared to other indications (all P<.05). One- and 5-year graft survivals for AH LT recipients were 91.7% and 81.9%, respectively. The frequency of AH LT is increasing rapidly, with excellent medium-term outcomes. An impact of AH recurrence on patient or graft survival is not apparent in this national analysis. There are marked geographic variations in practices, highlighting the lack of selection criteria standardization.

Outcomes of Multi-Organ Transplant in Adult Patients With Congenital Heart Disease.

BackgroundThe prevalence of adult congenital heart disease (ACHD) is increasing in the United States because of improved survival into adulthood. The unique physiology of ACHD commonly leads to multiorgan dysfunction, prompting interest in outcomes after multiorgan (heart+X) transplantation.Methods and ResultsWe queried the SRTR (Scientific Registry of Transplant Recipients) database to examine 5‐year outcomes in ACHD patients (aged ≥18 years) who underwent dual organ (heart+kidney/liver/lung) transplantation between 2000 and 2016. Cox proportional hazards models were constructed to look at survival of dual organ transplant recipients versus heart‐only recipients in the ACHD population and heart+lung recipients versus heart‐only recipients in the ACHD populations and versus non‐ACHD recipients of heart+lung transplant. We then constructed a multivariable model to investigate independent risk factors for 5‐year mortality after multiorgan transplant. Overall, 5‐year mortality was greater for multiorgan (heart+kidney/liver/lung) transplant compared with heart‐only transplant. On further analysis, only heart+lung transplant was associated with increased mortality. Outcomes after heart+lung transplant were no different between the ACHD and non‐ACHD population. Risk factors for increased risk of 5‐year mortality in ACHD patients after multiorgan transplant included heart+lung transplant, previous cardiac surgery, and severe functional limitation.ConclusionsThe mortality risk associated with multiorgan heart transplant in ACHD patients is attributable primarily to heart+lung transplants. Multiorgan transplant in ACHD does not convey increased risk compared with the non‐ACHD population. Need for multiorgan transplant should not be an impediment to listing ACHD patients needing a heart transplant.

Liver Transplantation Trends and Outcomes for Hereditary Hemorrhagic Telangiectasia in the United States.

Liver arteriovenous malformations (AVM) in hereditary hemorrhagic telangiectasia (HHT) can necessitate liver transplantation. There is limited data on HHT patients undergoing liver transplantation (LT) in the United States. Two sources of data were used: (1) Scientific Registry of Transplant Recipients (SRTR) database (1998-2016) (2) Single center liver transplant database (Mayo Clinic Rochester, MN). The aims of this study were (1) to determine trends in LT for HHT-related liver involvement in the United States using the SRTR database; (2) to identify clinical characteristics, indications, and outcomes for LT in HHT. Thirty-nine HHT patients were listed for LT in the SRTR database from 1998-2016 to 1998-2001 (n = 1); 2002-2005 (n = 4); 2006-2010 (n = 10), and 2011-2016 (n = 24). Twenty-four underwent LT at a median age of 47.5 years (interquartile range, 37.0-58.5 years). Median calculated MELD score at time of LT was 8.0 (interquartile range, 7.0-9.5), and 75% received an exception MELD score. Two status-1 patients died during transplant surgery. Nineteen (86%) patients were alive after a median post-LT follow-up of 48 months, whereas 2 patients were lost to follow-up. Five of the aforementioned HHT patients underwent LT at Mayo Clinic, 4 with high output cardiac failure, and 1 with biliary ischemia. All 5 were alive at the time of last follow-up with good graft function and resolution of heart failure. Outcomes after LT for HHT patients are excellent with 86% survival after a median follow-up of 48 months and resolution of heart failure. LT listing for HHT has increased in substantially in more recent eras.

Impact of Protease Inhibitor-Based Anti-Retroviral Therapy on Outcomes for HIV+ Kidney Transplant Recipients.

Excellent outcomes have been demonstrated among select HIV-positive kidney transplant (KT) recipients with well-controlled infection, but to date, no national study has explored outcomes among HIV+ KT recipients by antiretroviral therapy (ART) regimen. Intercontinental Marketing Services (IMS) pharmacy fills (1/1/01-10/1/12) were linked with Scientific Registry of Transplant Recipients (SRTR) data. A total of 332 recipients with pre- and posttransplantation fills were characterized by ART at the time of transplantation as protease inhibitor (PI) or non-PI-based ART (88 PI vs. 244 non-PI). Cox proportional hazards models were adjusted for recipient and donor characteristics. Comparing recipients by ART regimen, there were no significant differences in age, race, or HCV status. Recipients on PI-based regimens were significantly more likely to have an Estimated Post Transplant Survival (EPTS) score of >20% (70.9% vs. 56.3%, p=0.02) than those on non-PI regimens. On adjusted analyses, PI-based regimens were associated with a 1.8-fold increased risk of allograft loss (adjusted hazard ratio [aHR] 1.84, 95% confidence interval [CI] 1.22-2.77, p=0.003), with the greatest risk observed in the first posttransplantation year (aHR 4.48, 95% CI 1.75-11.48, p=0.002), and a 1.9-fold increased risk of death as compared to non-PI regimens (aHR 1.91, 95% CI 1.02-3.59, p=0.05). These results suggest that whenever possible, recipients should be converted to a non-PI regimen prior to kidney transplantation.

Increasing the Use of Kidneys From Unconventional and High-Risk Deceased Donors.

In this paper, we have reviewed the literature and report on kidney donors that are currently used at relatively low rates. Kidneys from donors with acute kidney injury (AKI) seem to have outcomes equivalent to those from donors without AKI, provided one can rule out significant cortical necrosis. Kidneys from donors with preexisting diabetes or hypertension may have marginally lower aggregate survival but still provide patients with a significant benefit over remaining on the wait list. The Kidney Donor Profile Index derives only an aggregate association with survival with a very modest C statistic; therefore, the data indicated that this index should not be the sole reason to discard a kidney, except perhaps in patients with extremely low estimated posttransplant survival scores. It is important to note that the Scientific Registry of Transplant Recipients models of risk adjustment should allay concerns regarding regulatory issues for observed outcomes falling below expectations. The successful utilization of kidneys from donation after cardiac death over the past decade shows how expanding our thinking can translate into more patients benefiting from transplantation. Given the growing number of patients on the wait list, broadening our approach to kidney acceptance could have an important impact on the population with end-stage renal disease. Many lives could be prolonged by carefully considering use of kidneys that are often discarded.

Identifying candidates with favorable prognosis following liver transplantation for hepatocellular carcinoma: Data mining analysis.

The optimal cutoff of each value in configuring selection criteria for pre-transplant assessment of hepatocellular carcinoma (HCC) remains uncertain. To build a predictive model for recurrent HCC, we performed data mining analysis on patients who underwent LT for HCC at University Health Network (n = 246). The model was externally validated using a cohort from the Scientific Registry of Transplant Recipients (SRTR) database (n = 9,769). Among 246 patients, 14.6% (n = 36) experienced recurrent HCC within 2.5 years post-LT. The risk prediction model for recurrent HCC identified two subgroups with low-risk (total tumor diameter [TTD] <4 cm and serum alpha-fetoprotein [AFP] <73 ng/ml, n = 135) and with high-risk (TTD >4 cm and/or AFP >73 ng/ml, n = 111). The reproducibility of the model was validated through the SRTR database; overall patient survival rate was significantly better in low-risk group than high-risk group (P < 0.0001). Using Cox regression model, this yardstick, not Milan criteria, was revealed to efficiently predict post-transplant survival independent of underlying characteristics (P < 0.0001). Grouping LT candidates with pre-LT HCC by the cutoffs of TTD 4 cm and AFP 73 ng/ml which were unearthed by data mining analysis efficiently classify patients according by the post-transplant prognosis.

MP9-19 DO HOSPITAL RANKINGS CORRELATE WITH ACTUAL OUTCOMES?

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes II1 Apr 2015MP9-19 DO HOSPITAL RANKINGS CORRELATE WITH ACTUAL OUTCOMES? Joel Durinka, Afshin Parsikia, Ryan Flynn, and Jorge Ortiz Joel DurinkaJoel Durinka More articles by this author , Afshin ParsikiaAfshin Parsikia More articles by this author , Ryan FlynnRyan Flynn More articles by this author , and Jorge OrtizJorge Ortiz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.379AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Rankings of hospital performances are increasingly prevalent. However, rankings in the lay literature such as US News and World Report may not correlate with actual outcomes after renal transplant. METHODS The Scientific Registry of Transplant Recipients (SRTR) Database was queried to identify renal transplant outcomes for both patient and graft survival in 2011 at 231 hospitals with active renal transplant programs. In addition, the list of US News & World Report Hospital rankings was used to compare a hospital ranking to the hospitals renal transplant outcomes quantified by SRTR. Outcomes included: 1 Month, 1 Year and 3 year patient and graft survival, Overall Score, Patient Survival Score, Volume, in-house ICU intensivist, technology and “would a specialist recommend their institution”. US News and World Report Rankings were compared with the SRTR database to compare a hospitals transplant outcomes to the hospitals national rank. A statistical analysis using student T-Tests and Logistic regression was used to compare the SRTR with the US News and World Report data and examine whether or not a high national ranking hospital was associated with having a strong renal transplant program. RESULTS More than half of the hospitals not ranked in the US New and World Report Top 50 have a higher than expected patient and graft survival rate. Among hospitals ranked in US News and World Report Top 50 US News ranking, 20(40%) had transplant programs with lower than expected patient and graft survival rate. A logistic regression analysis indicates that the variable of “would a specialist recommend their institution” is statistical significant (p< 0.05) for a good 1 year graft survival (p< 0.05, and odds ratio is 2.075). Additionally, having an in-house ICU intensivist, and modern technology are statistically significant for a strong 3 year graft survival rate (p< 0.05, odds ratio are 0.241 and 1.756). CONCLUSIONS The plethora of publicly available hospital ratings systems does not correlate with actual outcomes. A hospital's national ranking is a flawed indicator of transplant outcomes. Further systematic investigation into which measures predict quality outcomes in renal transplant will benefit both patients and providers. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e109 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joel Durinka More articles by this author Afshin Parsikia More articles by this author Ryan Flynn More articles by this author Jorge Ortiz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Using livers from donation after cardiac death donors—A proposal to protect the true Achilles heel

As the waiting list for organ transplant continues to increase (over 90,000 candidates as of May 30, 2007), the pressure to increase the number of donor organs is the impetus to expand the use of organs from donation after cardiac death (DCD) donors. The focus on DCD, previously referred to as non–heart-beating donor (NHBD), has led to significant increases in its utilization (Table 1), although the contribution to the donor pool remains only 7% in the United States and is disproportionately reflected in increased kidney transplants (Table 2). Prior to the acceptance of brain death, donors were required to have cessation of heart function in order to procure organs for transplantation. In some areas where brain death legislation has not been widely adopted, such as Asia, DCD represents a significant source of organs for transplantation. Although the Maastricht Conference on DCD in 1994 identified 4 categories of DCD [Category I: dead on arrival; Category II: unsuccessful resuscitation; Category III: waiting cardiac death; and Category IV: cardiac death in a braindead donor], it is easier to envision DCD based on two distinct populations, one following uncontrolled cardiopulmonary arrest (Categories I and II) and the other under conditions of controlled removal from life support, without the criteria for brain death being fulfilled. In 1995, the University of Pittsburgh provided one of the earliest comparisons between controlled and uncontrolled DCD. There were 24 DCD livers, 14 in the uncontrolled group (Group 1) and 10 in the group in which controlled termination of life support was performed in the operating room (Group 2). Of the liver grafts that were used, the immediate graft function rate was 50% (3/6) in Group 1 and 100% (6/6) in Group 2; however, the overall 2-year patient and graft survival was only 58% and 33%, respectively. In order to improve outcomes with DCD donors, the decision was made to avoid using uncontrolled DCD livers and, with further experience, to more carefully control risk factors [e.g., avoidance of old ( 60 year old) DCD donors, avoidance of donors with long ( 60 minutes) warm ischemic times during procurement, avoidance of confounding factors in the DCD donors, and minimization of cold ischemic times]. While patient survival and graft survival have improved in more recent eras, the impact of DCD on liver transplantation, as assessed from the Scientific Registry of Transplant Recipients (SRTR) database, shows that DCD graft survival was significantly lower than that of donation after brain death (DBD) grafts, with 1and 3-year graft survival of 70.2% and 63.3% for DCD recipients versus 80.4% and 72.1% for recipients of livers from conventional DBD donors. Recipients of a DCD graft had a greater incidence of primary nonfunction (11.8 versus 6.4%) and retransplantation (13.9% versus 8.3%) compared with DBD recipients. Similar findings have also been reported at single centers 12,13 The mandated period of warm ischemia imposed during the process of certifying death in controlled DCD leads to stagnation of blood in the microcirculation.