Changes to liver transplant allocation and the changing patterns in utilization of donor liver biopsy
Leah Aakjar1, Jennifer M. Brewer1, David O'Sullivan2, Wasim Dar3, Michael Einstein3, Glyn Morgan3, Bishoy Emmanuel3, Eva Urtasun Sotil3, Colin Swales3, Elizabeth Richardson3, william Sardella3, Oscar Serrano3
1Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, United States, 2Research, Hartford Hospital, Hartford, Connecticut, United States, 3Transplant & Comprehensive Liver Center, Hartford Hospital, Hartford, Connecticut, United States
Objective: In February 2020, the liver transplantation (LT) allocation policy changed, likely affecting institutional behavior changes for the acceptance of donated organs. Histological evaluation of a potential donor liver can provide useful information prior to LT and may reduce discard rates. However, utilization of liver biopsy (LB) is not standardized across Organ Procurement Organizations. We sought to review LB utilization patterns before and after the liver allocation modification (LAM) to determine if LB rates were associated with allograft discard rates, patient and graft survival. Design: Data from the Organ Procurement Transplant Network (OPTN) were analyzed on the utilization of LB before and after the implementation of LAM. Era 1 was defined as January 1, 2018 to February 3, 2020; Era 2 was defined as February 4, 2020 to June 1, 2021. Statistical comparisons between eras were performed. Univariable and multivariable models were constructed to determine donor characteristics that were correlated with obtaining a LB during the eras. Kaplan-Meier survival analysis was performed to determine the impact of LB on patient and graft survival. Setting: United States Patients: All LT recipients and deceased donors registered with OPTN between January 1, 2018 and June 1, 2021 Main Outcome Measures: rates of LB and allograft discard, patient and graft survival. Results: Of the 29,905 LB performed from January 1, 2018 to June 1, 2021, 17,949 (60%) were performed in Era 1 and 11,956 (40%) were performed in Era 2. During the study time period, there were 11,043 LB performed; 6,488 (58.8%) in Era 1 and 4,555 (41.2%) in Era 2 (p<0.001). Era 1 demonstrated a LB rate of 36.1% while Era 2 demonstrated a LB rate of 38.1% (p<0.001). Donor characteristics associated with obtaining a LB were BMI, race, age, history of DM, and era. The discard rate between Era 1 (15.8%) and Era 2 (15.0%) did not differ (p=0.097). In Era 1, the 1- and 3-year patient survival for LT recipients was 93.3% and 83.5%, respectively, while the 1- and 3-year graft survival was 96.7% and 94.4%, respectively. In Era 2, the 1-year patient and graft survival for LT recipients was 89.9% and 96.1%, respectively. Conclusion: The LAM led to changes in LT acceptance patterns. Changes in liver allocation led to a statistically significant increase in the utilization of LB, which may be due to wider catchment areas for potential recipients and the lower rates of transplant teams traveling for a potential donor organ. These changes appear to have had no effect on the rates of allograft discard, patient, or graft survival.
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