PROviding Better ACcess To ORgans: A comprehensive overview of organ-access initiatives from the ASTS PROACTOR Task Force.

The American Society of Transplant Surgeons (ASTS) PROviding better Access To Organs (PROACTOR) Task Force was created to inform ongoing ASTS organ access efforts. Task force members were charged with comprehensively cataloguing current organ access activities and organizing them according to stakeholder type. This white paper summarizes the task force findings and makes recommendations for future ASTS organ access initiatives.

Depression and Frailty in Patients With End-Stage Liver Disease Referred for Transplant Evaluation.

End-stage liver disease (ESLD) patients are believed to have a high prevalence of depression, although mental health in ESLD has not been studied comprehensively. Further, the relationship between depression and severity of liver disease is unclear. Using baseline data from a large prospective cohort study (N = 500) of frailty in ESLD patients, we studied the association of frailty with depression. Frailty was assessed with the five-component Fried Frailty Index. Patients were assigned a composite score of 0 to 5, with scores ≥3 considered frail. Depression was assessed using the 15-question Geriatric Depression Scale, with a threshold of ≥6 indicating depression; 43.2% of patients were frail and 39.4% of patients were depressed (median score 4, range 0-15). In multivariate analysis, frailty was significantly associated with depression (odds ratio 2.78, 95% confidence interval 1.87-4.15, p < 0.001), whereas model for ESLD score was not associated with depression. After covariate adjustment, depression prevalence was 3.6 times higher in the most-frail patients than the least-frail patients. In conclusion, depression is common in ESLD patients and is strongly associated with frailty but not with severity of liver disease. Transplant centers should address mental health issues and frailty; targeted interventions may lower the burden of mental illness in this population.

Time-trends in publication productivity of young transplant surgeons in the United States.

To further clarify whether the transplant surgical research workforce is adequately poised to further scientific achievement, we have investigated the publication productivity of young transplant surgeons. Our hypothesis is that recent young transplant surgeons write fewer academic manuscripts than their senior colleagues did when they were young surgeons. We compared the number of first and senior author publications in the first 5 years after completion of fellowship among recent transplant surgeons (completed fellowship 2000-2004) and former young surgeons (completed fellowship 1990-1994). Recent young surgeons wrote fewer overall manuscripts (0.94 vs. 1.67, p < 0.05), as well as basic science manuscripts (0.21 vs. 0.54, p < 0.05) and clinical manuscripts (0.73 vs. 1.14, p < 0.05). Adjusting for the number of trainees, we note that recent young surgeons published 59% fewer basic science publications (IRR 0.41, 95% CI 0.29-0.57, p < 0.001) and 33% fewer clinical publications (IRR 0.67, 95% CI 0.56-0.82, p < 0.001). Among fellows in the 2000-2004 cohort, there was a 32% lower chance of publishing at least one paper compared with fellows in the 1990-1994 cohort (IRR 0.68, 95% CI 0.51-0.89, p = 0.006). These findings raise concerns about the future place of transplant surgeons within the science that shapes our own field.

Reducing pediatric liver transplant complications: a potential roadmap for transplant quality improvement initiatives within North America.

Though robust clinical data are available within transplantation, these data are not used for broad-based, multicentered quality improvement initiates. This article describes a targeted quality improvement initiative within the Studies of Pediatric Liver Transplantation (SPLIT) Registry. Using standard statistical techniques and clinical expertise to adjust for data and statistical reliability, we identified the pediatric liver transplant centers in North America with the lowest hepatic artery thrombosis rate and biliary complication rates. A survey was completed to establish current practices within the entire SPLIT group. Surgeons from the highest performing centers presented a detailed, technically oriented overview of their current practices. The presentations and discussion that followed were recorded and form the basis of the best practices described herein. We frame this work as a unique six-step approach roadmap that may serve as an efficient and cost effective model for novel broad-based quality improvement initiatives within transplantation.

Solid-organ transplantation in older adults: current status and future research.

An increasing number of patients older than 65 years are referred for and have access to organ transplantation, and an increasing number of older adults are donating organs. Although short-term outcomes are similar in older versus younger transplant recipients, older donor or recipient age is associated with inferior long-term outcomes. However, age is often a proxy for other factors that might predict poor outcomes more strongly and better identify patients at risk for adverse events. Approaches to transplantation in older adults vary across programs, but despite recent gains in access and the increased use of marginal organs, older patients remain less likely than other groups to receive a transplant, and those who do are highly selected. Moreover, few studies have addressed geriatric issues in transplant patient selection or management, or the implications on health span and disability when patients age to late life with a transplanted organ. This paper summarizes a recent trans-disciplinary workshop held by ASP, in collaboration with NHLBI, NIA, NIAID, NIDDK and AGS, to address issues related to kidney, liver, lung, or heart transplantation in older adults and to propose a research agenda in these areas.

Young transplant surgeons and NIH funding.

Transplant surgeons have historically been instrumental in advancing the science of transplantation. However, research in the current environment inevitably requires external funding, and the classic career development pathway for a junior investigator is the NIH K award. We matched transplant surgeons who completed fellowships between 1998 and 2004 with the NIH funding database, and also queried them regarding research effort and attitudes. Of 373 surgeons who completed a fellowship, only 6 (1.8%) received a K award; of these, 3 subsequently obtained R-level funding. An additional 5 individuals received an R-level grant within their first 5 years as faculty without a K award, 3 of whom had received a prior ASTS-sponsored award. Survey respondents reported extensive research experience during their training (78.8% spent median 24 months), a high proportion of graduate research degrees (36%), and a strong desire for more research time (78%). However, they reported clinical burdens and lack of mentorship as their primary perceived barriers to successful research careers. The very low rate of NIH funding for young transplant surgeons, combined with survey results that indicate their desire to participate in research, suggest institutional barriers to access that may warrant attention by the ASTS and the transplant surgery community.

Centers for Disease Control 'high-risk' donors and kidney utilization.

The aims of this study were to determine whether Centers for Disease Control high risk (CDCHR) status of organ donors affects kidney utilization and recipient survival. Data from the Scientific Registry of Transplant Recipients were used to examine utilization rates of 45,112 standard criteria donor (SCD) deceased donor kidneys from January 1, 2005, and February 2, 2009. Utilization rates for transplantation were compared between CDCHR and non-CDCHR kidneys, using logistic regression to control for possible confounders. Cox regression was used to determine whether CDCHR status independently affected posttransplant survival among 25,158 recipients of SCD deceased donor kidneys between January 1, 2005, and February 1, 2008. CDCHR kidneys were 8.2% (95% CI 6.9-9.5) less likely to be used for transplantation than non-CDCHR kidneys; after adjusting for other factors, CDCHR was associated with an odds ratio of utilization of 0.67 (95% CI 0.61-0.74). After a median 2 years follow-up, recipients of CDCHR kidneys had similar posttransplant survival compared to recipients of non-CDCHR kidneys (hazard ratio 1.06, 95% CI 0.89-1.26). These findings suggest that labeling donor organs as 'high risk' may result in wastage of approximately 41 otherwise standard kidneys per year.

Improving organ procurement travel practices in the United States: proceedings from the Michigan Donor Travel Forum.

There are significant risks and inefficiencies associated with organ procurement travel. In an effort to identify, quantify, and define opportunities to mitigate these risks and inefficiencies, 25 experts from the transplantation, transportation and insurance fields were convened. The forum concluded that: on procurement travel practices are inadequate, there is wide variation in the quality of aero-medical transportation, current travel practices for organ procurement are inefficient and there is a lack of standards for organ procurement travel liability coverage. The forum concluded that the transplant community should require that air-craft vendors adhere to industry quality standards compatible with the degree of risk in their mission profiles. Within this context, a purchasing collaborative within the transplant community may offer opportunities for improved service and safety with lower costs. In addition, changes in travel practices should be considered with broader sharing of procurement duties across centers. Finally, best practice standards should be instituted for life insurance for transplant personnel and liability insurance for providers. Overall, the aims of these proposals are to raise procurement travel standards and in doing so, to improve the transplantation as a whole.

Should heart, lung, and liver transplant recipients receive immunosuppression induction for kidney transplantation?

As the outcomes of heart, liver, and lung transplantation continue to improve, more patients will present for subsequent renal transplantation. It remains unclear whether these patients benefit from induction immunosuppression. We retrospectively reviewed induction on solid organ graft recipients who underwent renal transplant at our center from January 1, 1995 to March 30, 2007. Induction and the non-induction groups were compared by univariate and Kaplan-Meier analyses. There were 21 patients in each group, with mean follow-up of 4.5-6.0 years. Forty-seven percent of patients receiving induction had a severe post-operative infection, compared with 28.6% in the non-induction group (p = NS). The one yr rejection rate in the induction group was 9.5% compared with 14.3% for non-induction (p = NS). One-yr graft survival was 81.0% and 95.2% in the induction and non-induction group (p = NS). In summary, there is a trend toward lower patient and graft survival among patients undergoing induction. These trends could relate to selection bias in the decision to prescribe induction immunosuppression, but further study is needed to better define the risks and benefits of antibody-induction regimens in this population.

The riskiest job in medicine: transplant surgeons and organ procurement travel.

Transplant surgeons are exposed to workplace risk due to the urgent nature of travel related to organ procurement. A retrospective cohort study was completed using data from the Scientific Registry of Transplant Recipients and the National Transportation Safety Board. A web-based survey was administered to members of the American Society of Transplant Surgeons. The survey response rate was 38% (281/747). Involvement in > or =1 procurement-related travel accident was reported by 15% of respondents; surgeons reported 61 accidents and 11 fatalities. Air travel was used in 26% of procurements and was involved in 56% of accidents. The risk of fatality while traveling on an organ procurement flight was estimated to be 1000 times higher than scheduled commercial flight. Involvement in a 'near miss accident' was reported by 80.8%. Only 16% of respondents reported feeling 'very safe' while traveling. Procurement of organs by the geographically closest transplant center would have reduced the need for air travel (>100 nautical miles) for lung, heart, liver and pancreas procurement by 35%, 43%, 31% and 49%, respectively (p < 0.0001). These reductions were observed in each Organ Procurement and Transplantation Network region. Though these data have important limitations, they suggest that organ procurement travel is associated with significant risk. Improvements in organ procurement travel are needed.

Case mix, quality and high-cost kidney transplant patients.

A better understanding of high-cost kidney transplant patients would be useful for informing value-based purchasing strategies by payers. This retrospective cohort study was based on the Medicare Provider Analysis and Review (MEDPAR) files from 2003 to 2006. The focus of this analysis was high-cost kidney transplant patients (patients that qualified for Medicare outlier payments and 30-day readmission payments). Using regression techniques, we explored relationships between high-cost kidney transplant patients, center-specific case mix, and center quality. Among 43 393 kidney transplants in Medicare recipients, 35.2% were categorized as high-cost patients. These payments represented 20% of total Medicare payments for kidney transplantation and exceeded $200 million over the study period. Case mix was associated with these payments and was an important factor underlying variation in hospital payments high-cost patients. Hospital quality was also a strong determinant of future Medicare payments for high-cost patients. Compared to high-quality centers, low-quality centers cost Medicare an additional $1185 per kidney transplant. Payments for high-cost patients represent a significant proportion of the total costs of kidney transplant surgical care. Quality improvement may be an important strategy for reducing the costs of kidney transplantation.

Marijuana use in potential liver transplant candidates.

Concern exists that liver transplant center substance abuse policies may have an inappropriate and disproportionate impact on marijuana users. Our hypothesis is that patients with chronic liver disease who were marijuana users will have inferior survival. This is a retrospective (1999-2007) cohort study. The primary outcome measure is time-dependent, adjusted patient survival from the time of liver transplant evaluation. The primary exposure variable is a positive cannabinoid toxicology screen during the liver transplant evaluation period. Overall, 155 patients qualified as marijuana users while 1334 patients were marijuana non-users. Marijuana users were significantly (p < 0.05) younger (48.3 vs. 52.1), more likely to be male (78.1% vs. 63.0%), have hepatitis C (63.9% vs. 40.6%) and were less likely to receive a transplant (21.8% vs. 14.8%). Marijuana users were more likely to use tobacco, narcotics, benzodiazepines, amphetamines, cocaine or barbiturates (p < 0.05). Unadjusted survival rates were similar between cohorts. Upon multivariate analysis, MELD score, hepatitis C and transplantation were significantly associated with survival, while marijuana use was not (HR 1.09, 95% CI 0.78-1.54). We conclude that patients who did and did not use marijuana had similar survival rates. Current substance abuse policies do not seen to systematically expose marijuana users to additional risk of mortality.

Improving organ procurement practices in Michigan.

Travel to procure deceased donor organs is associated with risk to transplant personnel. In many instances, multiple teams are present for a given operation. We studied our statewide experience to determine how much excess travel this redundancy entails, and generated alternate models for organ recovery. We reviewed our organ procurement organization's experience with deceased donor operations between 2002 and 2008. Travel was expressed as cumulative person-miles between procurement team origin and donor hospital. A model of minimal travel was created, using thoracic and abdominal teams from the closest in-state center. A second model involved transporting donors to a dedicated procurement facility. Travel distance was recalculated using these models, and mode and cost of travel extrapolated from current practices. In 654 thoracic and 1469 abdominal donors studied, the mean travel for thoracic teams was 1066 person-miles and for abdominal teams was 550 person-miles. The mean distance traveled by thoracic and abdominal organs was 223 miles and 142 miles, respectively. Both hypothetical models showed reductions in team travel and reliance on air transport, with favorable costs and organ transport times compared to historical data. In summary, we found significant inefficiency in current practice, which may be alleviated using new paradigms for donor procurement.

Comparison of histidine-tryptophan-ketoglutarate and University of Wisconsin preservation in renal transplantation.

Histidine-tryptophan-ketoglutarate (HTK) is replacing University of Wisconsin (UW) solution as the preservation fluid for renal allografts in many centers, but recent large-scale data to support this transition are lacking. We conducted a retrospective analysis of patient and graft outcomes after renal transplantation at our center, comparing 475 consecutive living donor and 317 deceased donor transplants since the adoption of HTK with equal numbers of grafts preserved using UW solution. Data collected included donor and recipient age, race, sex, comorbidities and graft ischemia time. Graft and patient survival, as well as the incidence of delayed graft function (DGF), were studied by Kaplan-Meier and Cox regression analysis. No significant difference was seen in either patient or graft survival. Deceased donor kidneys in the HTK group had a higher incidence of DGF than the UW cohort, whereas this trend was reversed in the case of living donor organs. In multivariate analysis, HTK was associated with a significant risk reduction on the incidence of DGF. Prolonged preservation with HTK compared to UW was not associated with excess risk to the graft or patient. In summary, HTK demonstrated efficacy similar to UW in terms of patient and graft survival.

The effects of donor and recipient practices on transplant center finances.

Over the past several years we have noted a marked decrease in this profitability of our kidney transplant program. Our hypothesis is that this reduction in kidney transplant institutional profitability is related to aggressive donor and recipient practices. The study population included all adults with Medicare insurance who received a kidney transplant at our center between 1999 and 2005. Adopting the hospital perspective, multi-variate linear regression models to determine the independent effects of donor and recipient characteristics and era effects on total reimbursements and total hospital margin. We note statistically significant decreased medical center incremental margins in cases with ECDs (-$5887) and in cases of DGF (-4937). We also note an annual change in the medical center margin is independently associated with year and changes at a rate of -$5278 per year, related to both increasing costs and decreasing Medicare reimbursements. The financial loss associated with patient DGF and the use of ECD kidneys may resonate with other centers, and could hinder efforts to expand kidney transplantation within the United States. The Centers for Medicare and Medicaid Services (CMS) should consider risk-adjusted reimbursement for kidney transplantation.

Preliminary analysis of early outcomes of a prospective, randomized trial of complete steroid avoidance in liver transplantation.

Steroids are a mainstay in liver transplantation for induction and maintenance immunosuppression but are associated with significant adverse effects. While prior studies have successfully limited the use of steroids, whether complete steroid avoidance will improve outcomes remains unclear. To further evaluate the need for steroids, consenting patients who underwent liver transplantation between June 2002 and May 2004 were entered into a prospective, randomized trial to receive either standard therapy (tacrolimus, mycophenolate mofetil, steroid induction/maintenance) or complete steroid avoidance (standard therapy without steroid induction/maintenance). Clinically suspected rejection was confirmed by biopsy and treated with pulse steroid therapy. Outcomes were compared on an intention to treat basis. Of the 72 patients enrolled, 36 (50%) were randomized to the steroid avoidance group with a mean follow up of 412 +/- 41 days. Donor and recipient characteristics were similar between groups. The steroid avoidance group was more likely to have significant infections (52% vs 28%, P = .03). There was a trend toward an increased rate of acute rejection (25% vs 14%, P = .23). Twelve of 36 recipients (33%) enrolled in the steroid avoidance group later received steroids. The incidence of recurrent hepatitis C was similar between groups. The 1-year patient (90% vs 83%, P = .44) and graft survivals (90% vs 81%, P = .27) were similar between groups. These data suggest complete steroid avoidance in liver transplantation results in acceptable patient and graft survival. However, the potential long-term benefits of steroid avoidance, including a decrease in severity of recurrent hepatitis C, remain under investigation.

Risk factors for urinary complications after renal transplantation.

Urinary complications are common following renal transplantation. The aim of this study is to evaluate the risk factors associated with renal transplant urinary complications. We collected data on 1698 consecutive renal transplants patients. The association of donor, transplant and recipient characteristics with urinary complications was assessed by univariable and multivariable Cox proportional hazards models, fitted to analyze time-to-event outcomes of urinary complications and graft failure. Urinary complications were observed in 105 (6.2%) recipients, with a 2.8% ureteral stricture rate, a 1.7% rate of leak and stricture, and a 1.6% rate of urine leaks. Seventy percent of these complications were definitively managed with a percutaneous intervention. Independent risk factors for a urinary complication included: male recipient, African American recipient, and the "U"-stitch technique. Ureteral stricture was an independent risk factor for graft loss, while urinary leak was not. Laparoscopic donor technique (compared to open living donor nephrectomy) was not associated with more urinary complications. Our data suggest that several patient characteristics are associated with an increased risk of a urinary complication. The U-stitch technique should not be used for the ureteral anastomosis.

Financial implications of pancreas transplant complications: a business case for quality improvement.

We quantified the financial implications of surgical complications following pancreas transplantation. We reviewed medical and financial records of 49 pancreas transplant recipients at the University of Michigan Health System (UMHS) between 1/6/2002 and 11/22/2004. The association of donor, transplant recipient and financial variables was assessed. The median costs to UMHS of procedures and follow-up were $92,917 for recipients without surgical complications versus $108,431 when a surgical complication occurred, a difference of $15,514 (p = 0.03). Median reimbursement by the payer was $17,363 higher in patients with a surgical complication (p = 0.001). Similar trends (higher insurer costs) were noted when stratifying by payer (public and private) and specific procedure (SPK and PAK). All parties (patient, physician, payer and medical center) should benefit from quality improvement, with payers having a financial interest in pancreas transplant surgical quality initiatives.

A call for a national transplant surgical quality improvement program.

The severity of illness in transplant patients and the complexity of transplant operations results in significant postoperative morbidity and mortality. Remarkable efforts have been made by transplant physicians to study and improve organ allocation, graft and patient survival, immunosuppression and the long-term management of post-transplant complications. Less effort has been spent studying the actual transplant operation and systems of acute transplant care. The National Surgical Quality Improvement Program (NSQIP) has provided a standardized approach to quality improvement and has demonstrated significant potential for a reduction in postoperative morbidity and mortality in other surgical disciplines. Medical centers are under increasing pressure to measure surgical quality and the nexus of transplant surgical quality improvement should not lie in the hands of CMS or JACHO, but rather it should be created and developed within the transplant community. The time has come for a national transplant surgical quality improvement program based on the NSQIP infrastructure. Such a proactive approach toward quality improvement from the transplant community is an excellent investment for patients, providers and health care payers.