LIVER TRANSPLANTATION 21:897–903, 2015
ORIGINAL ARTICLE
Recipient Factors Associated With Having a Potential Living Donor For Liver Transplantation Adam Doyle,1,* Rania N. Rabie,1,2,* Arastoo Mokhtari,1 Mark Cattral,1 Anand Ghanekar,1 David Grant,1 Paul Greig,1 Gary Levy,1 Leslie Lilly,1 Ian McGilvray,1 Markus Selzner,1 Nazia Selzner,1 and Eberhard L. Renner1 1 Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada; and 2Department of Medicine, Southlake Regional Health Centre, Newmarket, ON, Canada
Because of a persistent discrepancy between the demand for liver transplantation (LT) and the supply of deceased donor organs, there is an interest in increasing living donation rates at centers trained in this method of transplantation. We examined a large socioeconomically heterogeneous cohort of patients listed for LT to identify recipient factors associated with living donation. We retrospectively reviewed 491 consecutive patients who were listed for LT at our center over a 24-month period. Demographic, medical, and socioeconomic data were extracted from electronic records and compared between those who had a potential living donor (LD) volunteer for assessment and those who did not; 245 patients (50%) had at least 1 potential LD volunteer for assessment. Multivariate logistic regression analysis identified that patients with a LD were more likely to have Child-Pugh C disease (odds ratio [OR], 2.44; P 5 0.02), and less likely to be older (OR, 0.96; P 5 0.002), single (OR, 0.34; P 5 0.006), divorced (OR, 0.53; P 5 0.03), immigrants (OR, 0.38; P 5 0.049), or from the lowest income quintile (OR, 0.44; P 5 0.02). In conclusion, this analysis has identified several factors associated with access to living donation. More research is warranted to define and overcome barriers to living donor liver transplantation through tarC 2015 AASLD. geted interventions in underrepresented populations. Liver Transpl 21:897-903, 2015. V Received January 8, 2015; accepted April 7, 2015. Despite all efforts, the success of liver transplantation (LT) has led to a persistent gap between demand and supply of deceased donor organs in most jurisdictions including Canada.1 Even in the Model for End-Stage Liver Disease (MELD) era, there is still a significant risk of dying or becoming too sick for transplant before a suitable deceased donor liver becomes available.2 Deceased donation remains the primary source of adult liver allografts in Western countries, with living donor liver transplantation (LDLT) accounting overall
for only a few percent of all LTs performed for adult recipients.3 Although recipient and graft survival are similar after deceased and right lobe adult-to-adult LDLT, living donation shortens the median waiting time and decreases the risk of dropping off the waiting list because of death or disease progression. From the time of listing, 5-year recipient survival is approximately 20% higher with LDLT compared to deceased donor LT.4,5 It is estimated that up to 30% of wait-listed recipients might have a potential living donor (LD).6,7
Abbreviations: AIH, autoimmune hepatitis; BMI, body mass index; CI, confidence interval; HCC, hepatocellular carcinoma; GTA, greater Toronto area; LD, living donor; LDLT, living donor liver transplantation; LT, liver transplantation; MELD, Model for EndStage Liver Disease; NAFLD, nonalcoholic fatty liver disease; OR, odds ratio; PBC, primary biliary cirrhosis; PSC, primary sclerosing cholangitis; SD, standard deviation. Grants and financial support: Nothing to report. Potential conflict of interest: Nothing to report. *These authors contributed equally to this work. Address reprint requests to Eberhard L. Renner, M.D., F.R.C.P.(C), Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada 585 University Avenue, NCSB 11C-1238, Toronto, ON M5G 2N2, Canada. Telephone: 416-340-5221; FAX: 416-340-3126; E-mail: [email protected] DOI 10.1002/lt.24148 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2015 American Association for the Study of Liver Diseases. V
898 DOYLE ET AL.
LDLT rates vary widely in North America for reasons that are currently poorly defined. Two studies have reported recipient variables associated with undergoing adult-to-adult LDLT in the United States.6,7 The general applicability of these studies is potentially limited by the patient population who were mostly Caucasian recipients with private health insurance. The present study was therefore undertaken to examine recipient factors associated with having a potential donor volunteering for adult-to-adult LDLT in a highvolume program serving a heterogeneous multiethnic and socioeconomic patient cohort within a publicly funded health care system.
PATIENTS AND METHODS Design and Patient Selection This is a retrospective analysis of prospectively collected data of all adult LT candidates listed for transplantation in our program between January 1, 2009, and December 31, 2011. The study was approved by our institution’s ethics committee and conducted according to the 1975 Declaration of Helsinki.8 Patients of both sexes aged 18 to 75 years with complete socioeconomic data were eligible for the study. Exclusion criteria included listing for liver retransplantation or combined solid organ or multiorgan transplant.
Data Collection Patients were identified and screened for inclusion/ exclusion criteria using an electronic transplant database (OTTR: Transplant Care Platform 6, OTTR Chronic Care Solutions, Omaha, NE) containing the records of all potential recipients referred to our program for transplant assessment, as well as those of all potential LDs submitting a health questionnaire to our LD office, which is the first step of donor evaluation in our program. The following predefined parameters at time of listing were then extracted from the electronic records: age, sex, height, weight and body mass index (BMI), ABO blood group, underlying liver disease, absence/ presence of hepatocellular carcinoma (HCC), ChildPugh class, and MELD score. In addition, the following predefined parameters were extracted from the prospectively collected, templated report of our systematic social work assessment performed immediately before listing: marital status, ethnicity, native language, immigration status (immigrants were defined as persons born outside of Canada now permanently residing in Canada), residency (defined as rural versus urban, or within versus outside the greater Toronto area [GTA], based on postal code), neighborhood income quintile (derived from the Statistics Canada Postal Code Conversion File Plus, version 5F, Statistics Canada, Ottawa, ON, Canada), smoking status (current, former, or never), history of alcohol and/or illicit drug use, history of psychiatric illness, and occupation skill level (based
LIVER TRANSPLANTATION, July 2015
on the patient’s last occupation). Occupation skill levels were categorized on the basis of the international standard classification of occupations9: managers and professionals, level 1; technicians and associate professionals, level 2; clerks and service workers, level 3; craft and trade workers/machine operators, level 4; cleaning, agricultural, mining, transport, and refuse workers, level 5; and other occupations, level 6.
Informing Recipients About LDLT Regardless of the recipient’s age, disease etiology, or severity of illness (MELD score), all patients referred to our institution for LT assessment are systematically informed of the potential advantages of living donation during and after their work-up. At the time of their first visit, recipients are provided with a brochure with written information on LDLT and instructions on how a potential donor can contact our LD team to initiate donor work-up. Everyone is offered the opportunity to discuss LDLT with a physician independent of the LT team.
Outcome Measure A recipient for whom our LD office received at least 1 potential donor’s health questionnaire was regarded as a recipient with a potential LD, regardless of whether the donor turned out to be suitable and the LDLT proceeded or not. Conversely, recipients for whom no health questionnaire was received by our LD office were regarded as recipients without a potential LD (non-LD). As the focus of this study was strictly on donor volunteer rates, data on eventual donor candidacy and transplantation outcomes were not recorded.
Data Analysis and Statistics Continuous variables are presented as mean 6 standard deviation (SD) if normally distributed, and median and interquartile range if not normally distributed. Normality of continuous factors was assessed using the Shapiro-Wilk test. Differences between LD and non-LD groups were evaluated using Student t tests for normally distributed continuous variables, Mann-Whitney U tests for nonnormally distributed continuous variables, and chi-square tests for categorical variables. Fisher’s exact tests were used as an alternative test of association for categorical variables when cell counts were small. Multivariate logistic regression analysis was performed using a stepwise backward selection model and entering all variables that were associated with LD with a P value of 0.10 on univariate analysis. Among variables that exhibited collinearity, only the most clinically relevant variable was retained in the model. For categorical variables, odds ratios (ORs) for each outcome were calculated relative to the most common outcome for each variable (OR, 1.0). A P value of
ORIGINAL ARTICLE
Recipient Factors Associated With Having a Potential Living Donor For Liver Transplantation Adam Doyle,1,* Rania N. Rabie,1,2,* Arastoo Mokhtari,1 Mark Cattral,1 Anand Ghanekar,1 David Grant,1 Paul Greig,1 Gary Levy,1 Leslie Lilly,1 Ian McGilvray,1 Markus Selzner,1 Nazia Selzner,1 and Eberhard L. Renner1 1 Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada; and 2Department of Medicine, Southlake Regional Health Centre, Newmarket, ON, Canada
Because of a persistent discrepancy between the demand for liver transplantation (LT) and the supply of deceased donor organs, there is an interest in increasing living donation rates at centers trained in this method of transplantation. We examined a large socioeconomically heterogeneous cohort of patients listed for LT to identify recipient factors associated with living donation. We retrospectively reviewed 491 consecutive patients who were listed for LT at our center over a 24-month period. Demographic, medical, and socioeconomic data were extracted from electronic records and compared between those who had a potential living donor (LD) volunteer for assessment and those who did not; 245 patients (50%) had at least 1 potential LD volunteer for assessment. Multivariate logistic regression analysis identified that patients with a LD were more likely to have Child-Pugh C disease (odds ratio [OR], 2.44; P 5 0.02), and less likely to be older (OR, 0.96; P 5 0.002), single (OR, 0.34; P 5 0.006), divorced (OR, 0.53; P 5 0.03), immigrants (OR, 0.38; P 5 0.049), or from the lowest income quintile (OR, 0.44; P 5 0.02). In conclusion, this analysis has identified several factors associated with access to living donation. More research is warranted to define and overcome barriers to living donor liver transplantation through tarC 2015 AASLD. geted interventions in underrepresented populations. Liver Transpl 21:897-903, 2015. V Received January 8, 2015; accepted April 7, 2015. Despite all efforts, the success of liver transplantation (LT) has led to a persistent gap between demand and supply of deceased donor organs in most jurisdictions including Canada.1 Even in the Model for End-Stage Liver Disease (MELD) era, there is still a significant risk of dying or becoming too sick for transplant before a suitable deceased donor liver becomes available.2 Deceased donation remains the primary source of adult liver allografts in Western countries, with living donor liver transplantation (LDLT) accounting overall
for only a few percent of all LTs performed for adult recipients.3 Although recipient and graft survival are similar after deceased and right lobe adult-to-adult LDLT, living donation shortens the median waiting time and decreases the risk of dropping off the waiting list because of death or disease progression. From the time of listing, 5-year recipient survival is approximately 20% higher with LDLT compared to deceased donor LT.4,5 It is estimated that up to 30% of wait-listed recipients might have a potential living donor (LD).6,7
Abbreviations: AIH, autoimmune hepatitis; BMI, body mass index; CI, confidence interval; HCC, hepatocellular carcinoma; GTA, greater Toronto area; LD, living donor; LDLT, living donor liver transplantation; LT, liver transplantation; MELD, Model for EndStage Liver Disease; NAFLD, nonalcoholic fatty liver disease; OR, odds ratio; PBC, primary biliary cirrhosis; PSC, primary sclerosing cholangitis; SD, standard deviation. Grants and financial support: Nothing to report. Potential conflict of interest: Nothing to report. *These authors contributed equally to this work. Address reprint requests to Eberhard L. Renner, M.D., F.R.C.P.(C), Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada 585 University Avenue, NCSB 11C-1238, Toronto, ON M5G 2N2, Canada. Telephone: 416-340-5221; FAX: 416-340-3126; E-mail: [email protected] DOI 10.1002/lt.24148 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2015 American Association for the Study of Liver Diseases. V
898 DOYLE ET AL.
LDLT rates vary widely in North America for reasons that are currently poorly defined. Two studies have reported recipient variables associated with undergoing adult-to-adult LDLT in the United States.6,7 The general applicability of these studies is potentially limited by the patient population who were mostly Caucasian recipients with private health insurance. The present study was therefore undertaken to examine recipient factors associated with having a potential donor volunteering for adult-to-adult LDLT in a highvolume program serving a heterogeneous multiethnic and socioeconomic patient cohort within a publicly funded health care system.
PATIENTS AND METHODS Design and Patient Selection This is a retrospective analysis of prospectively collected data of all adult LT candidates listed for transplantation in our program between January 1, 2009, and December 31, 2011. The study was approved by our institution’s ethics committee and conducted according to the 1975 Declaration of Helsinki.8 Patients of both sexes aged 18 to 75 years with complete socioeconomic data were eligible for the study. Exclusion criteria included listing for liver retransplantation or combined solid organ or multiorgan transplant.
Data Collection Patients were identified and screened for inclusion/ exclusion criteria using an electronic transplant database (OTTR: Transplant Care Platform 6, OTTR Chronic Care Solutions, Omaha, NE) containing the records of all potential recipients referred to our program for transplant assessment, as well as those of all potential LDs submitting a health questionnaire to our LD office, which is the first step of donor evaluation in our program. The following predefined parameters at time of listing were then extracted from the electronic records: age, sex, height, weight and body mass index (BMI), ABO blood group, underlying liver disease, absence/ presence of hepatocellular carcinoma (HCC), ChildPugh class, and MELD score. In addition, the following predefined parameters were extracted from the prospectively collected, templated report of our systematic social work assessment performed immediately before listing: marital status, ethnicity, native language, immigration status (immigrants were defined as persons born outside of Canada now permanently residing in Canada), residency (defined as rural versus urban, or within versus outside the greater Toronto area [GTA], based on postal code), neighborhood income quintile (derived from the Statistics Canada Postal Code Conversion File Plus, version 5F, Statistics Canada, Ottawa, ON, Canada), smoking status (current, former, or never), history of alcohol and/or illicit drug use, history of psychiatric illness, and occupation skill level (based
LIVER TRANSPLANTATION, July 2015
on the patient’s last occupation). Occupation skill levels were categorized on the basis of the international standard classification of occupations9: managers and professionals, level 1; technicians and associate professionals, level 2; clerks and service workers, level 3; craft and trade workers/machine operators, level 4; cleaning, agricultural, mining, transport, and refuse workers, level 5; and other occupations, level 6.
Informing Recipients About LDLT Regardless of the recipient’s age, disease etiology, or severity of illness (MELD score), all patients referred to our institution for LT assessment are systematically informed of the potential advantages of living donation during and after their work-up. At the time of their first visit, recipients are provided with a brochure with written information on LDLT and instructions on how a potential donor can contact our LD team to initiate donor work-up. Everyone is offered the opportunity to discuss LDLT with a physician independent of the LT team.
Outcome Measure A recipient for whom our LD office received at least 1 potential donor’s health questionnaire was regarded as a recipient with a potential LD, regardless of whether the donor turned out to be suitable and the LDLT proceeded or not. Conversely, recipients for whom no health questionnaire was received by our LD office were regarded as recipients without a potential LD (non-LD). As the focus of this study was strictly on donor volunteer rates, data on eventual donor candidacy and transplantation outcomes were not recorded.
Data Analysis and Statistics Continuous variables are presented as mean 6 standard deviation (SD) if normally distributed, and median and interquartile range if not normally distributed. Normality of continuous factors was assessed using the Shapiro-Wilk test. Differences between LD and non-LD groups were evaluated using Student t tests for normally distributed continuous variables, Mann-Whitney U tests for nonnormally distributed continuous variables, and chi-square tests for categorical variables. Fisher’s exact tests were used as an alternative test of association for categorical variables when cell counts were small. Multivariate logistic regression analysis was performed using a stepwise backward selection model and entering all variables that were associated with LD with a P value of 0.10 on univariate analysis. Among variables that exhibited collinearity, only the most clinically relevant variable was retained in the model. For categorical variables, odds ratios (ORs) for each outcome were calculated relative to the most common outcome for each variable (OR, 1.0). A P value of
