Opportunities and challenges of expanded criteria organs in liver and kidney transplantation as a response to organ shortage.

ABSTRACT

In 1989, there were 19,000 patients on the UNOS (United Network of Organ Sharing) wait list for organs compared to 110,000 today. Without an equivalent increase in donors, the patients awaiting these organs for transplant face increasing severity of illness and risk of dying without receiving a transplant. This disparity in supply and demand has led to acceptance of organs with lower than expected success rates compared to previous standard donors variously defined as extended criteria donors in order to increase transplantation. The reluctance to wider use of these types of organs is based on the less than expected transplant center graft and patient survival results associated with their use, as well as the increased resources required to care for the patients who receive these organs. The benefits need to be compared to the survival of not receiving a transplant and remaining on the waiting list rather than on outcomes of receiving a standard donor. A lack of a systematic risk outcomes adjustment is one of the most important factors preventing more extensive utilization as transplant centers are held to patient and graft survival statistics as a performance measure by multiple regulatory organizations and insurers. Newer classification systems of such donors may allow a more systematic approach to analyzing the specific risks to individualized patients. Due to changes in donor policies across the country, there has been an increase in Extended Criteria Donors (ECD) organs procured by organ procurement organizations (OPO) but their uneven acceptance by the transplant centers has contributed to an increase in discards and organs not being used. This is one of the reasons that wider sharing of organs is currently receiving much attention. Transplanting ECD organs presents unique challenges and innovative approaches to achieve satisfactory results. Improved logistics and information technology combined strategies for improving donor quality with may prevent discards while insuring maximal benefit. Transplant centers, organ procurement organizations, third party payers and government agencies all must be involved in maximizing the potential for ECD organs.