Financial burden following adult liver transplantation is common and associated with adverse recipient outcomes.

The financial impact of liver transplantation has been underexplored. We aimed to identify associations between high financial burden (≥10% annual income spent on out-of-pocket medical costs) and work productivity, financial distress (coping behaviors in response to the financial burden), and financial toxicity (health-related quality of life, HRQOL) among adult recipients of liver transplant. Between June 2021 and May 2022, we surveyed 207 adult recipients of liver transplant across 5 US transplant centers. Financial burden and distress were measured by 25 items adapted from national surveys of cancer survivors. Participants also completed the Work Productivity and Activity Impairment and EQ-5D-5L HRQOL questionnaires. In total, 23% of recipients reported high financial burden which was significantly associated with higher daily activity impairment (32.9% vs. 23.3%, p =0.048). In adjusted analyses, the high financial burden was significantly and independently associated with delayed or foregone medical care (adjusted odds ratio, 3.95; 95% CI, 1.85-8.42) and being unable to afford basic necessities (adjusted odds ratio, 5.12; 95% CI: 1.61-16.37). Recipients experiencing high financial burden had significantly lower self-reported HRQOL as measured by the EQ-5D-5L compared to recipients with low financial burden (67.8 vs. 76.1, p =0.008) and an age-matched and sex-matched US general population (67.8 vs. 79.1, p <0.001). In this multicenter cohort study, nearly 1 in 4 adult recipients of liver transplant experienced a high financial burden, which was significantly associated with delayed or foregone medical care and lower self-reported HRQOL. These findings underscore the need to evaluate and address the financial burden in this population before and after transplantation.

Evaluating Medical Students' Perceptions of Patient-Led Transplant Surgery Education 1-2 Years Later.

INTRODUCTION: Medical students value the opportunity to learn from patients as a supplement to traditional faculty-led education; however, long-term follow-up to understand the educational impact of these experiences is lacking. We surveyed medical students who conducted non-medical virtual encounters with transplant recipients or living donors to understand the impact on students' patient care approach after 1-2 y. METHODS: Students who completed their surgery clerkship from July 2020 to September 2021 were surveyed about this nonmedical patient encounter in January 2023. Quantitative and qualitative survey data were analyzed using descriptive statistics and inductive thematic analysis, respectively. RESULTS: Of the 27 respondents (46% response rate), 44.4% completed the experience 1 y ago and 55.6% completed the experience 2 y ago. Nearly all respondents (96.3%) agreed that this experience was an effective way to learn about organ donation and transplantation and that learning from patients was beneficial to their development as a doctor. Over 50% felt this experience changed how they provide care to patients. Qualitatively, students reported that this activity cultivated their empathy for patients, provided unique insight into patients' illness experiences, and enhanced their understanding of the longitudinal patient-surgeon relationship. CONCLUSIONS: Utilizing patients as teachers in transplant surgery not only taught medical students more about organ donation and transplantation but also built empathy and highlighted unique, non-clinical aspects of the patient experience that persisted over time. This is one of the first studies to evaluate patient-led teaching of this type over a year later and assess its unique influence on medical student development.

Racial-ethnic differences in liver transplant waitlist outcomes in patients with hepatocellular carcinoma before and after recent changes to allocation policy.

BACKGROUND: In May 2019, liver transplant (LT) allocation policy changed to limit MELD exception points for hepatocellular carcinoma (HCC) to median MELD at transplant minus three (MMaT-3). We evaluated this policy's impact on waitlist outcomes for HCC candidates, by race and ethnicity, hypothesizing that the introduction of the MMaT-3 reduced inequities in waitlist outcomes. METHODS: Retrospective cohort study of the Scientific Registry for Transplant Recipients, including all adult LT candidates (N = 10 751) who received HCC exception points from May 17, 2017 to May 18, 2019 (pre-policy; N = 6627) to May 19, 2019 to March 1, 2021 (post-policy; N = 4124). We compared incidence of LT and waitlist removal for death or becoming too sick pre- and post-policy for non-Hispanic White, non-Hispanic Black, Hispanic/Latinx, and Asian patients using competing risk regression adjusted for candidate characteristics. RESULTS: One-year cumulative incidence of LT decreased significantly pre-/post-policy among White (77.4% vs. 64.5%; p < .01) and Black (76.2% vs. 63.1%; p < .01) candidates only, while a 1-year incidence of death/non-LT waitlist removal decreased significantly only among Hispanics (13.4% vs. 7.5%; p < .01). After covariate adjustment, the effect of the policy change was a significantly decreased incidence of LT for White (SHR: .63 compared to pre-policy; p < .001), Black (SHR: .62; p < .001), and Asian (SHR: .68; p = .002), but no change for Hispanic patients. Only Hispanic patients had a significant decrease in death/waitlist removal after the policy change (SHR:  .69; p = .04). Compared to White patients in the pre-policy era, Hispanic (SHR:  .88, p < .007) and Asian candidates (SHR:  .72; p < .001) had lower unadjusted incidence of LT. This disparity was mitigated in the post-policy era where Hispanic patients had higher likelihood of LT than Whites (SHR: 1.22; p = .002). For the outcome of death/non-LT waitlist removal, the only significant difference was a 42% lower incidence of waitlist removal for Asian compared to White patients in the post-policy era (SHR:  .58; p = .03). CONCLUSION: Among LT recipients with HCC, racial/ethnic subpopulations were differentially affected by the MMAT-3 policy, resulting in a post-policy reduction of some of the previous disparities.

Elements of Weight Management Among Pre-Kidney Transplant Candidates: The Patient Perspective.

Obesity and related comorbidities heighten risks for complications in kidney transplant settings. While pre-transplant patients often have access to nutrition counseling and health support, literature is limited on patients' perceptions of weight and motivation to lose weight prior to transplantation. We conducted a survey among ≥18-year-old patients on the kidney transplant waitlist at a single center. Questions addressed weight perception, motivation for weight loss, available resources, and engagement in physical activity. Medical records provided demographic and clinical data. Statistical tests analyzed quantitative data, while free-text responses were thematically grouped and described. Of 1055 patients, 291 responded and were matched with demographic data. Perceived weight changes correlated with actual changes in body mass index (BMI) (<24.9) were more receptive to weight center resources (<30 kg/m2) are most interested in weight loss resources and demonstrate motivation. Furthermore, pre-transplant nutrition counseling correlates with healthier behaviors. Integrating patients' perspectives enhances pre-transplant protocols by encouraging active involvement in health decisions.

Impact of Portable Normothermic Machine Perfusion for Liver Transplantation From Adult Deceased Donors.

OBJECTIVE: To assess how liver allografts preserved using portable normothermic machine perfusion (NMP) compare against those that underwent ischemic cold storage (ICS) in the setting of donation after brain death (DBD) and donation after circulatory death (DCD) liver transplantation (LT). BACKGROUND: Compared with conventional ICS, NMP may offer more homeostatic preservation, permit physiological assessment of organ function, and provide opportunities for graft improvement/modification. We report a single-center US experience of liver NMP. METHODS: A single-center, retrospective analysis of collected data on 541 adult whole LTs from 469 DBD donors [NMP (n = 58) vs ICS (n = 411)] and 72 DCD donors [NMP (n = 52) vs ICS (n = 20)] between January 2016 and December 2022. RESULTS: In DBD LT, male sex [odds ratio (95% CI): 1.83 (1.08-3.09)] and >10% macrosteatosis of the donor liver [1.85 (1.10-3.10)] were statistically significant independent risk factors of early allograft dysfunction (EAD). Donor age >40 years and cold ischemia time >7 hours were independent risk factors of reperfusion syndrome (RPS). One-year, 3-year, and 5-year incidences of ischemic cholangiopathy (IC) did not differ significantly in DBD cases between the NMP and ICS cohorts. In DCD LT, NMP was an independent protective factor against EAD [0.11 (0.03-0.46)] and RPS [0.04 (0.01-0.25)]. The incidence of IC in the DCD cases at 1-year and 3-year time points was significantly lower in the NMP cohort (1.9% compared with 20% in the ICS group). CONCLUSIONS: Compared with conventional ICS, NMP can significantly reduce the incidence of EAD, RPS, and IC after DCD LT.

Donor-derived disorders of hemostasis and thrombosis in liver transplantation: Considerations for deceased donor liver selection.

OLT is known to be associated with a precarious perioperative hemostatic state due to dysregulation of procoagulant and anticoagulant factors, endothelial injury, and inflammation. Transmission of inherited bleeding and clotting disorders from the liver donor to the recipient may further complicate hemostasis during and after transplantation. As a result, consideration of congenital coagulation disorders in the liver donor is a practical concern for donor selection. However, there is no clear consensus regarding the selection of donors with known or suspected thrombophilia or bleeding disorders. While multiple case reports and retrospective studies, subject to reporting bias, describe donor-derived thrombophilic and bleeding disorders, there are no large-scale studies in the adult liver transplant literature that examine the frequency of transmission, utility of donor screening, or clinical impact of donor hemostatic disorders. Based on the reported literature, we summarize our approach for donor selection with an aim to balance improved organ utility and optimal post-transplant outcomes.

Kidney injury and status 1 liver transplantation: Outcomes, kidney function, and listing for kidney transplantation.

BACKGROUND: Effects of kidney injury (KI) at the time of liver transplantation (LT) for acute liver failure (ALF) remain poorly described. We hypothesized that patients with ALF and KI who undergo LT have persistent post-transplant KI, inferior survival, and increased rate of kidney transplantation (KT). METHODS: The US Scientific Registry of Transplant Recipients database was queried for patients transplanted with status 1 listing for LT between 2002 and 2021. KI was defined as estimated glomerular filtration rate (eGFR) ≤ 30 mL/min/1.73 m2 or dialysis in the week prior to LT. Outcomes evaluated were post-LT eGFR, listing for subsequent KT, and overall survival (OS) after LT. RESULTS: A total of 2984 patients underwent LT for ALF with 1241 (41.6%) having KI. KI patients had lower eGFR at 6 months post-LT (57.8 vs. 68.7, p < .001) that persisted out to 5 years (59.9 vs. 69.7, p < .001). KI patients were more likely to be listed for KT (4.3% vs. 1.9%, p < .001) and undergo listing sooner after LT (.8 vs. 3.7 years, p < .001). Patients without KI had higher adjusted post-transplant OS compared to those with KI (HR .75, p < .001). CONCLUSION: KI in the setting of ALF portends a worse prognosis for both kidney recovery and OS.

Impact of donor sex on hepatocellular carcinoma recurrence in liver transplantation after brain death.

BACKGROUND: Hepatocellular carcinoma (HCC) is predominantly seen in males but has a better prognosis in females. No prior studies have investigated HCC recurrence based on sex combination following liver transplant donated after brain death (DBDLT). This study sought to elucidate the effects of donor and recipient sex on HCC recurrence rates. METHODS: 9232 adult recipients from the United Network for Organ Sharing (UNOS) database who underwent DBDLT for HCC from 2012 to 2018 were included. Donor-recipient pairs were divided into (1) female donor/female recipient (F-F) (n = 1089); (2) male donor/female recipient (M-F) (n = 975); (3) female donor/male recipient (F-M) (n = 2691); (4) male donor/male recipient (M-M) (n = 4477). The primary prognostic outcome was HCC recurrence. A multivariable competing risk regression analysis was used to assess prognostic influences. RESULTS: The median recipient age and model for end-stage liver disease (MELD) scores were similar among the four groups. Livers of male recipients demonstrated greater in size and number of HCC (both p-values were <.0001). There was also a higher rate of vascular invasion in male recipients compared to female (p < .0001). Competing risk analyses showed that the cumulative HCC recurrence rate was significantly lower in the M-F group (p = .013). After adjusting for tumor characteristics, liver grafts from male donors were associated with a lower HCC recurrence rate in female recipients (HR: .62 95%CI: .42-.93) (p = .021). CONCLUSION: In DBDLT, male donor to female recipient pairing exhibited lower HCC recurrence rates. SUMMARY: Lowest rates of HCC recurrence were confirmed among the female recipients of male donor grafts group in the deceased donor LT cohort. A competing risk multivariable regression analysis demonstrated that male donor sex was significantly associated with low HCC recurrence in female but not male recipients.

Acceptability and utility of a virtual pediatric transplant peer mentoring program: A mixed-methods analysis of a novel quality improvement program.

BACKGROUND: Adolescent transplant patients are at increased risk for graft loss at a period when they also suffer from illness-related social isolation, which has been exacerbated by the COVID-19 pandemic. The Peer Mentoring Program (PMP), developed in 2018, was adapted to a virtual format in 2020 due to COVID-19. Our objective is to evaluate the acceptability, utility, and potential impact of the in-person and virtual versions of the PMP on participants. METHODS: We performed convergent mixed-methods analysis of the experiences of patients participating in the PMP for quality improvement purposes. RESULTS: Surveys and focus group invitations were sent to 18 current program participants, with 17 patients responding to the survey and 13 patients participating in focus groups. In this study, 82% were satisfied and 88% would recommend PMP; 76% identified other PMP members as people they would like to keep in touch with. Qualitative analysis revealed three themes: (1) a supportive community of peers, (2) reduced isolation, and (3) receiving accurate information from providers. CONCLUSIONS: There is a prominent need for greater peer support among adolescent transplant patients transitioning to adulthood, especially with the increased isolation associated with COVID-19. The virtual adaptation could be an important, permanent supplement to in-person events.

The impact of race and comorbid conditions on adult liver transplant outcomes in obese recipients.

Many prior studies comparing liver transplant outcomes between obese and nonobese recipients found no significant differences in survival. However, obesity is intrinsically associated with demographic factors such as race and comorbidities. Thus, this work aimed to analyze the effects of obesity, in conjunction with these factors, on liver transplant outcomes. OPTN data was analyzed to identify adult-only, first-time liver transplants between 1995 and 2019. Obesity was defined by the CDC obesity classification. Race, insurance status, age, and comorbidities were analyzed together with patient survival and graft survival using a multivariable Cox Proportional-Hazards model and long-term survival with Kaplan-Meier curves. The multivariable models found that being black, older than 50 years, having diabetes, or having nonprivate insurance were all risk factors for both patient survival and graft survival after liver transplant. Adjusting for obesity class, black recipients had a 20% lower patient survival and 23% lower graft survival compared with nonblack recipients. Survival curves verified that obese black liver transplant recipients had poorer long-term patient survival and graft survival compared with both obese nonblack and nonobese recipients. In conclusion, obesity compounds known factors associated with poor outcomes after liver transplantation. Further work is critical to understand why these discrepancies persist.

Immediate administration of antiviral therapy after transplantation of hepatitis C-infected livers into uninfected recipients: Implications for therapeutic planning.

The practice of transplanting hepatitis C (HCV)-infected livers into HCV-uninfected recipients has not previously been recommended in transplant guidelines, in part because of concerns over uncontrolled HCV infection of the allograft. Direct-acting antivirals (DAAs) provide an opportunity to treat donor-derived HCV-infection and should be administered early in the posttransplant period. However, evidence on the safety and efficacy of an immediate DAA treatment approach, including how to manage logistical barriers surrounding timely DAA procurement, are required prior to broader use of HCV-positive donor organs. We report the results of a trial in which 14 HCV-negative patients underwent successful liver transplantation from HCV-positive donors. Nine patients received viremic (nucleic acid testing [NAT]-positive) livers and started a 12-week course of oral glecaprevir-pibrentasvir within 5 days of transplant. Five patients received livers from HCV antibody-positive nonviremic donors and were followed using a reactive approach. Survival in NAT-positive recipients is 100% at a median follow-up of 46 weeks. An immediate treatment approach for HCV NAT-positive liver transplantation into uninfected recipients is safe and efficacious. Securing payer approval for DAAs early in the posttransplant course could enable need-based allocation of HCV-positive donor organs irrespective of candidate HCV status, while averting chronic HCV allograft infection.

Organ procurement center allows for daytime liver transplantation with less resource utilization: May address burnout, pipeline, and safety for field of transplantation.

Abdominal organ transplantation faces several challenges: burnout, limited pipeline of future surgeons, changes in liver allocation potentially impacting organ procurement travel, and travel safety. The organ procurement center (OPC) model may be one way to mitigate these issues. Liver transplants from 2009 to 2016 were reviewed. There were 755 liver transplants performed with 525 OPC and 230 in-hospital procurements. The majority of transplants (87.4%) were started during daytime hours (5 am-7 pm). Transplants with any portion occurring after-hours were more likely to have procurements in-hospital (P < .001). Daytime cases (n = 400) had more OPC procured livers and hepatitis C recipients and were less likely to have a donation after circulatory death donor (all P < .05). In adjusted analyses, daytime cases were independently associated with extubation in the operating room and less postoperative transfusion. There were no significant differences in short- or long-term postoperative outcomes. For exported livers, 54.3% were procured by a local team, saving 137 flights (151 559 miles). The OPC resulted in optimally timed liver transplants and decreased resource utilization with no negative impact on patient outcomes. It allows for ease in exporting organs procured by local surgeons, and potentially addresses provider burnout, the transplant surgery pipeline, and surgeon travel.

Liver transplantation for hepatocellular carcinoma: current update on treatment and allocation.

PURPOSE OF REVIEW: This review discusses the current imaging modalities and criteria used to diagnose, and the role of liver transplantation as well as nonsurgical hepatic-directed therapies to treat hepatocellular carcinoma in the setting of chronic liver disease. RECENT FINDINGS: There has been continual evolution of guidelines, policies, and algorithms for the imaging diagnosis of hepatocellular carcinoma, particularly the Liver Imaging Reporting and Data System. The use of liver-directed therapy as a bridge to transplant is now common practice. Recently, patients have waited 6 months from listing before being granted a Model for End-Stage Liver Disease exception score of 28, with an increase every 3 months to a maximum score of 34. This policy change was developed to reduce disparities in outcomes for patients undergoing liver transplantation. SUMMARY: The use of liver transplantation to treat hepatocellular carcinoma within the Milan criteria has good outcomes with a 5-year disease-free survival rate comparable to patients transplanted without malignancy. The development of guidelines both for the radiologic diagnosis and staging of the primary tumor and guidelines for assessing response to treatment allows for a more unified approach to the management of patients. With the partnership of oncologists, hepatologists, radiologists, pathologists, and surgeons, the outcomes of liver transplantation as treatment for hepatocellular continue to improve.

Increased minimum vein diameter on preoperative mapping with duplex ultrasound is associated with arteriovenous fistula maturation and secondary patency.

OBJECTIVE: Autogenous arteriovenous hemodialysis accesses (arteriovenous fistulas [AVFs]) are preferred for chronic hemodialysis access. Preoperative vein mapping by duplex ultrasound is recommended before AVF creation, but there are few data correlating vein diameter with postoperative outcomes. Also, vein diameter has not been included in prior predictive models of fistula maturation. This study aims to test whether preoperative vein diameter is associated with failure of AVF maturation and long-term (secondary) patency. METHODS: We performed a retrospective analysis of clinical variables of patients undergoing brachiobasilic or brachiocephalic AVF creation. Kaplan-Meier and multivariate Cox regression models tested whether preoperative minimum vein diameter (MVD) and clinical covariates were associated with failure of AVF maturation and secondary patency. RESULTS: The sample included 158 adults (54 ± 14 years; 45% male; 61% white; 56% diabetes; body mass index, 32 ± 8; MVD, 3.4 ± 1.1 mm; follow-up, 12 ± 9 months [range, <1-40 months]). Increased MVD was associated with decreased risk of AVF failure. More than one third of AVFs with MVD <2.7 mm failed to mature within 6 months. Multivariate models that adjusted for age, diabetes, race, gender, body mass index, and preoperative dialysis status demonstrated that increased MVD was associated with decreased risk of failure of maturation and better long-term patency overall (P = .005 and P = .001, respectively). CONCLUSIONS: Patients with a larger MVD on preoperative vein mapping are at lower risk for failure of fistula maturation and have increased long-term AVF patency. MVD is the only clinical or demographic factor associated with both AVF maturation and long-term patency. MVD is an important preoperative indicator of fistula success in assessment of potential AVF sites. Future predictive models of fistula maturation and patency should include MVD.

Validation of the Written Administration of the Short Literacy Survey.

Most health literacy assessments are time consuming and administered verbally. Written self-administration of measures may facilitate more widespread assessment of health literacy. This study aimed to determine the intermethod reliability and concurrent validity of the written administration of the 3 subjective health literacy questions of the Short Literacy Survey (SLS). The Rapid Estimate of Adult Literacy in Medicine (REALM) and the shortened test of Functional Health Literacy in Adults (S-TOFHLA) were the reference measures of health literacy. Two hundred ninety-nine participants completed the written and verbal administrations of the SLS from June to December 2012. Intermethod reliability was demonstrated when (a) the written and verbal SLS score did not differ and (b) written and verbal scores were highly correlated. The written items were internally consistent (Cronbach's α = .733). The written total score successfully identified persons with sixth-grade equivalency or less for literacy on the REALM (AUROC = 0.753) and inadequate literacy on the S-TOFHLA (AUROC = 0. 869). The written administration of the SLS is reliable, valid, and is effective in identifying persons with limited health literacy.

Laparoscopic versus open peritoneal dialysis catheter insertion cost analysis.

BACKGROUND: Peritoneal dialysis (PD) is a cost-effective alternative to hemodialysis (HD). PD catheters have traditionally been inserted through a small open incision, but insertion using laparoscopic visualization has become increasingly popular and is associated with less catheter malfunction. The aim of this study was to compare costs of laparoscopic and open insertion strategies while taking into account postoperative complications and future salvage procedures. METHODS: A decision analysis model was constructed to simulate 1 y outcomes after PD catheter insertion by either the open or laparoscopic approach. Possible outcomes after PD catheter placement included functional catheter, infection, and catheter malfunction. Ultimately, patients continued with successful PD or switched to HD. Baseline probabilities, costs, and ranges were determined from a critical review of the literature. Sensitivity analyses were performed to determine the model strength over a range of clinically relevant probabilities. RESULTS: The total annual costs, including postoperative management and dialysis treatment, were $69,491 for laparoscopic insertion and $69,960 for open insertion. In case of a catheter malfunction, an initial attempt at salvage by fluoroscopy-guided wire manipulation cost less than a first attempt by laparoscopic repositioning. CONCLUSIONS: When accounting for a year of postoperative management and treatment, laparoscopic insertion can be less costly than open insertion in the hands of an experienced surgeon. Despite higher initial costs, PD catheter insertion under laparoscopic visualization can have lower total costs due to fewer postoperative complications. With increasing emphasis on cost-effective care, laparoscopic insertion is a valuable tool for initiating PD.

Impact of Median MELD at Transplant Minus 3 National Policy on Quality of Transplanted Livers for Patients With and Without Hepatocellular Carcinoma.

BACKGROUND: Patients with hepatocellular carcinoma (HCC) have been overprioritized in the deceased donor liver allocation system. The United Network for Organ Sharing adopted a policy in May 2019 that limited HCC exception points to the median Model for End-Stage Liver Disease at transplant in the listing region minus 3. We hypothesized this policy change would increase the likelihood to transplant marginal quality livers into HCC patients. METHODS: This was a retrospective cohort study of a national transplant registry, including adult deceased donor liver transplant recipients with and without HCC from May 18, 2017, to May 18, 2019 (prepolicy) to May 19, 2019, to March 1, 2021 (postpolicy). Transplanted livers were considered of marginal quality if they met ≥1 of the following: (1) donation after circulatory death, (2) donor age ≥70, (3) macrosteatosis ≥30% and (4) donor risk index ≥95th percentile. We compared characteristics across policy periods and by HCC status. RESULTS: A total of 23 164 patients were included (11 339 prepolicy and 11 825 postpolicy), 22.7% of whom received HCC exception points (prepolicy versus postpolicy: 26.1% versus 19.4%; P = 0.03). The percentage of transplanted donor livers meeting marginal quality criteria decreased for non-HCC (17.3% versus 16.0%; P < 0.001) but increased for HCC (17.7% versus 19.4%; P < 0.001) prepolicy versus postpolicy. After adjusting for recipient characteristics, HCC recipients had 28% higher odds of being transplanted with marginal quality liver independent of policy period (odds ratio: 1.28; confidence interval, 1.09-1.50; P < 0.01). CONCLUSIONS: The median Model for End-Stage Liver Disease at transplant in the listing region minus 3 policy limited exception points and decreased the quality of livers received by HCC patients.

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

Objective: To assess the effects of the 2020 United States Public Health Service (PHS) "Increased Risk" Guidelines update. Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Recruiting women to vascular surgery and other surgical specialties.

Vascular surgery is a subspecialty that attracts future surgeons with challenging technical procedures and complex decision making. Despite its appeal, continued promotion of the field is necessary to recruit and retain the best and brightest candidates. Recruitment of medical students and residents may be limited by the lifestyle inherent to vascular surgery and the length of residency training. The young adults of the current applicant and resident pool differ from prior generations in their desire for hands-on mentoring, aspirations to affect change daily, a penchant for technology, and strong emphasis on work-life balance. Furthermore, the percentage of women pursuing careers in vascular surgery is not representative of the eligible workforce. Women are now the majority of graduates in all of higher education, and thus, vascular surgery may need to make a concerted effort to appeal to women in order to attract the most talented young professionals to the field. Recruiting strategies for both men and women of Generation Y should target a diverse group of potential candidates with an awareness of the unique characteristics and needs of this generation of rising surgeons.

Is liver transplantation using organs donated after cardiac death cost-effective or does it decrease waitlist death by increasing recipient death?

OBJECTIVES: The aim of this study was to evaluate the cost-effectiveness in liver transplantation (LT) of utilizing organs donated after cardiac death (DCD) compared with organs donated after brain death (DBD). METHODS: A Markov-based decision analytic model was created to compare two LT waitlist strategies distinguished by organ type: (i) DBD organs only, and (ii) DBD and DCD organs. The model simulated outcomes for patients over 10 years with annual cycles through one of four health states: survival; ischaemic cholangiopathy; retransplantation, and death. Baseline values and ranges were determined from an extensive literature review. Sensitivity analyses tested model strength and parameter variability. RESULTS: Overall survival is decreased, and biliary complications and retransplantation are increased in recipients of DCD livers. Recipients of DBD livers gained 5.6 quality-adjusted life years (QALYs) at a cost of US$69 000/QALY, whereas recipients on the DBD + DCD LT waitlist gained 6.0 QALYs at a cost of US$61 000/QALY. The DBD + DCD organ strategy was superior to the DBD organ-only strategy. CONCLUSIONS: The extension of life and quality of life provided by DCD LT to patients on the waiting list who might otherwise not receive a liver transplant makes the continued use of DCD livers cost-effective.