Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana...
-
Upload
gina-aspell -
Category
Documents
-
view
220 -
download
4
Transcript of Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana...
![Page 1: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/1.jpg)
Maximizing the Yield from the Liver Donor Pool
A. Joseph Tector MD PhDDepartment of Surgery
Indiana University School of Medicine
![Page 2: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/2.jpg)
Situation in Indianapolis
• DSA has only one liver transplant program– 5 million people
• Central geographic location• Transplant Rate 2.43 vs. 0.38 for USA
![Page 3: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/3.jpg)
Situation in Indianapolis
• Local donors 562 (66% vs 73% national data)• Regional import 126 (15% vs 21% national
data)• National import 157 (19% vs 5.5% national
data)
![Page 4: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/4.jpg)
Graft Survival by Geographic Origin of Donor Liver
![Page 5: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/5.jpg)
Graft Survival Eliminating MELD at Transplant and Donor Age as Variables
![Page 6: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/6.jpg)
Why Are These Livers Available?
• High donor Sodium (>170)• CNS Tumors• HCV/HbC/HTLV 1 & 2• Trauma• High BMI• Frightening history
![Page 7: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/7.jpg)
Patient Survival Using Livers from Donors with CNS Tumors
![Page 8: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/8.jpg)
Graft Survival for HCV Positive Donors
![Page 9: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/9.jpg)
Can Our Situation Be Reproduced?
![Page 10: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/10.jpg)
First Steps
• Identify high performing OPOs– Determine which factors make them able to
produce more livers– Implement those practices for lower performing
OPOs
![Page 11: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/11.jpg)
First Steps
• Identify high performing transplant programs with regards to effective utilization– Determine which factors make them able to utilize
more livers– Implement those practices for lower performing
transplant programs
![Page 12: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/12.jpg)
Problem with Focusing Solely on Allocation
• Will not increase total number of livers available for transplant
• Fails to identify and capitalize on practices that maximize liver yield– Best OPOs– Best programs
![Page 13: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/13.jpg)
Broader Sharing Does Not Promote
• Local involvement to fix issues regarding:– OPO performance– Transplant program performance• Procuring surgeon• Travel policies
![Page 14: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/14.jpg)
Factors That Impact Liver Yield
• OPO performance• Donor Hospital performance • Donor Surgeon Experience
![Page 15: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/15.jpg)
OPO Performance
• Consent rates• Willingness to work with you and go the extra
mile– Biopsies– Travel– Waivers
![Page 16: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/16.jpg)
Donor Hospital Performance
• Liver biopsy available 24/7/365• Radiology images available to assess liver by
CT for– Trauma– masses
![Page 17: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/17.jpg)
Donor Hospital Performance
• Digital imaging capabilities– Biopsy – Intraoperative photos
• Dermatology/neurosurgery for cancer risk evaluation
• Operating room availability
![Page 18: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/18.jpg)
Procurement Surgeon Experience
• Minimum standards should include– Attending surgeon– Member of a liver transplant program• Not a nephrectomist/willing urologist/general surgeon• Not a fellow
• Ideally – Should be from program that has accepted liver– Perform large number of liver procurements
![Page 19: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/19.jpg)
Difficult Decisions for Liver Transplantation
• Donor livers without a home in the OR, which is worse?– Placing the liver with a center you are confident
will use the liver and “jumping the list”– Attempting to allocate by the list and in the
process you accrue too much cold time for the liver to be used
![Page 20: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/20.jpg)
Barriers to Maximizing Liver Utilization
• Allocating by Donor Net eliminates the ability of OPO coordinators to bypass programs that they know will not use a given liver and burns up valuable cold time– We need to decrease the amount of time a
program is given to respond to an offer for a liver that is on ice
![Page 21: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/21.jpg)
Barriers to Maximizing Liver Utilization
• Make reasonable times from cross clamp to airport for livers procured by local centers
![Page 22: Maximizing the Yield from the Liver Donor Pool A.Joseph Tector MD PhD Department of Surgery Indiana University School of Medicine.](https://reader038.fdocuments.net/reader038/viewer/2022110116/551c5a60550346a5458b5198/html5/thumbnails/22.jpg)
Take Home Message
• There are good livers throughout the USA that are not being used in their region of origin
• Maximal use of organs locally within each DSA should be achieved before moving livers to more remote locations
• There are practices that can be put into place that can maximize local liver utilization