American Journal of Transplantation 2014; 14: 991–993 Wiley Periodicals Inc.
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Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12701
Editorial
Access to Retransplantation After Failed Donation After Circulatory Death Liver Transplantation: Eo Ire Itum A. I. Skaro1,*, L. Zhao2, L. B. VanWagner3 and M. M. Abecassis1 1
Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL 2 Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 3 Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL Corresponding author: Anton I. Skaro, [email protected]
Received and revised 14 January 2014 and accepted for publication 28 January 2014
Donation after circulatory death (DCD) has emerged as an important strategy to address the ongoing challenge of insufficient organ supply to meet waitlist demand. Federal mandates by the Health Resources and Services Administration and the Centers for Medicare and Medicaid Services (CMS) have resulted in a dramatic increase in the rate of transplants with DCD organs during the preceding decade (1). However, concerns over worse outcomes of DCD compared to donation after brain death (DBD) liver transplant have more recently led to a plateau in DCD liver utilization (2). This disturbing trend has initiated a dialogue within the transplant community, which has urged policymakers to take action to optimize the use of DCD livers. In this issue of the American Journal of Transplantation, Allen et al provide data regarding waitlist and retransplant outcomes for previous DCD and DBD recipients (3). In their analysis of the Scientific Registry of Transplant Recipients (SRTR) the authors identified superior waitlist survival among previous DCD (HR 0.43, 95% CI 0.25–0.74) compared to DBD liver recipients and a similar mode of graft failure due to either biliary or vascular complications. In addition, 1-year patient (DCD 75% vs. DBD 72%) and graft (DCD 72% vs. DBD 70%) survival following retransplantation were similar between the groups (3). Taken together, these data suggest, and the authors imply, that access to and outcomes of retransplantation for recipients of failing DCD livers are satisfactory, thus obviating the need for additional allocation policy development.
However, while the authors’ focus in this study is strictly on patients who are placed on the waiting list and transplanted following a failed DCD liver transplant, there are factors identified by Allen et al (3) and others that merit careful and further consideration, and that clearly support the need for allocation policy reform. For instance, the lack of inclusion of all DCD recipients with failing grafts in the waitlist analysis falls short of intention-to-treat principles and likely underestimates the DCD waitlist mortality. Although it remains an incomplete cohort, once early (
C
Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12701
Editorial
Access to Retransplantation After Failed Donation After Circulatory Death Liver Transplantation: Eo Ire Itum A. I. Skaro1,*, L. Zhao2, L. B. VanWagner3 and M. M. Abecassis1 1
Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL 2 Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 3 Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL Corresponding author: Anton I. Skaro, [email protected]
Received and revised 14 January 2014 and accepted for publication 28 January 2014
Donation after circulatory death (DCD) has emerged as an important strategy to address the ongoing challenge of insufficient organ supply to meet waitlist demand. Federal mandates by the Health Resources and Services Administration and the Centers for Medicare and Medicaid Services (CMS) have resulted in a dramatic increase in the rate of transplants with DCD organs during the preceding decade (1). However, concerns over worse outcomes of DCD compared to donation after brain death (DBD) liver transplant have more recently led to a plateau in DCD liver utilization (2). This disturbing trend has initiated a dialogue within the transplant community, which has urged policymakers to take action to optimize the use of DCD livers. In this issue of the American Journal of Transplantation, Allen et al provide data regarding waitlist and retransplant outcomes for previous DCD and DBD recipients (3). In their analysis of the Scientific Registry of Transplant Recipients (SRTR) the authors identified superior waitlist survival among previous DCD (HR 0.43, 95% CI 0.25–0.74) compared to DBD liver recipients and a similar mode of graft failure due to either biliary or vascular complications. In addition, 1-year patient (DCD 75% vs. DBD 72%) and graft (DCD 72% vs. DBD 70%) survival following retransplantation were similar between the groups (3). Taken together, these data suggest, and the authors imply, that access to and outcomes of retransplantation for recipients of failing DCD livers are satisfactory, thus obviating the need for additional allocation policy development.
However, while the authors’ focus in this study is strictly on patients who are placed on the waiting list and transplanted following a failed DCD liver transplant, there are factors identified by Allen et al (3) and others that merit careful and further consideration, and that clearly support the need for allocation policy reform. For instance, the lack of inclusion of all DCD recipients with failing grafts in the waitlist analysis falls short of intention-to-treat principles and likely underestimates the DCD waitlist mortality. Although it remains an incomplete cohort, once early (
