Toward a strategy to use more organs and distribute them to those in need

Jean EmondNew York

Considerations for allocation

• DSA based allocation results in vastly disparate silos of supply and demand

• Donation rates can not correct variations in the incidence of liver disease need

• Medical geography of patient care does not correlate with DSA boundaries

• The current system results in high organ wastage• Marginal organs are the ones being shipped the

farthest• Centers must be incentivized to use the organs

0 10 20 30 40 50 60 70 800

2000000

4000000

6000000

8000000

10000000

12000000

14000000

16000000

18000000

20000000

Population

Population

Populations of US OPO’s

N=59Mean 5.22 mMinimum: 1.28 mMaximum: 18.99 mRation of min to max15.75

Waitlist size by OPO (2009)

0 10 20 30 40 50 60 70 800

20

40

60

80

100

120

140

160PT/million

PT/million

N= 50Mean = 49.8/millionMinimum=5.25Maximum=134.2Ratio of smallest to biggest 25.5

Medical geography does not equal either political geography or DSA’s

Liver donation rate by OPO

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

40

45

50

liver rate

liver rate

N= 58Mean =22.2Minimum 12.8Maximum 43.05Ratio: 3.5

Liver gap by allocation unit

0 10 20 30 40 50 60

-200

0

200

400

600

800

1000

1200

1400

1600

Series1

Minimum = -99Maximum = 1395

Livers procured per donor by allocation unit

Liver discard rate not correlated with donor rate or waitlist rate

Factors in discard

• Low incentive to use (small waitlist)• Aggressive evaluation of high risk donors may

increase discard rate• Poor placement strategies/timing and cold

ischemia• Pre-donation biopsy• Lack of commitment to use by recipient center– Centers rewarded for cherry picking

Liver potential 2009

• Total donors 8022• Total liver donors 6739• Livers transplanted 6016• Livers not transplanted 723• Total net potential for better use and

innovation: 2006

12

ECD livers and living donors account for the majority of transplants since 2004 at NYP Hospital

0

10

20

30

40

50

60

70

80

90

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

LDLT

Import

Region 9

*2009 volume is through 8/31/09

Machine preservation of the human liver:Potential for selecting high risk grafts and Optimizing function: James Guarrera

Liver imports by OPO 2009

Fraction of ECD by DSA:Not all donating populations are equal

1998 Cirrhosis Discharge vs. Death Rate

y = 0.0527x + 4.1959

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0

Discharge Rate (Cases/100,000 population)P-value=0.0068 R2=0.116

Death

Rate

(C

ases/1

00

,00

0 p

op

ula

tio

n)

NY Counties

Linear (NY Counties)

Linear (NY Counties)