Jones-Carr Maggie E, Dayala Hiren, McLeod M Chandler, MacLennan Paul, Sheikh Saulat, Rabbani M Umaid, Pozo Marcos E, Acuna Sergio A, Emamaullee Juliet, Goldberg David, Cannon Robert M
Division of Transplantation, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL.
Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Keck School of Medicine, University Southern California, Los Angeles, CA.
Liver Transpl. 2025 Jul 15. doi: 10.1097/LVT.0000000000000687.
Understanding the geographic variation in deceased donor liver utilization can guide allocation policy and technology implementation. Using US transplant registry data, we evaluated geographic differences in utilization by donor quality, policy era, and uptake of advanced perfusion (AP). This retrospective cohort included all liver donors and waitlisted patients from 2010 to Sept. 2024. Donors were aggregated by Hospital Referral Region (HRR) and stratified by quality using the liver discard risk index (DSRI). Exposures included allocation policy era and increased use of AP technology (July 2022-onward). Observed to expected (O:E) ratios of liver non-utilization were calculated by HRR and modeled to reveal geographically contiguous Low Utilization Clusters (LUCs). The proportion of HRRs within LUCs increased from 24% in Share 15 (S15), to 25% in Share 35 (S35), 32% in Acuity Circles (AC), then decreased to 21% in the AP era ( p =0.01). There were 7 distinct LUCs in S15 (median non-utilization=33%), 7 LUCs in S35 (non-utilization=32%), 7 LUCs in AC (non-utilization=41%), and 3 LUCs in the AP era (non-utilization=46%). Donor quality by HRR decreased over time, with a median DSRI of 2.56 (IQR: 1.25-5.79) in S15 to 5.69 (2.01-35.30) in AP ( p <0.001). Accounting for DSRI, odds of non-utilization were highest in AC ( ref. Share 35 , OR=1.27, p <0.001), which decreased in AP (OR=1.06, p =0.001). Utilization of normothermic machine perfusion was associated with a markedly lower odds of discard (OR=0.03, 0.03-0.04; p <0.001). Livers originating from LUCs traveled shorter distances in each era other than S35. The number of net exporter HRRs in LUCs was equivalent to non-LUCs in each era other than AP, where LUCs contained fewer net exporter HRRs (2 [3.2%] vs. 42 [17.4%], p =0.004). On adjusted analysis, candidates in LUCs had lower likelihood of transplant (HR=0.88, p <0.001) but also lower waitlist mortality (HR=0.95, p <0.001). The advent of advanced perfusion was associated with utilization of otherwise marginal liver allografts and ameliorating geographic imbalances in discard seen with successive allocation policy eras.
了解已故供体肝脏利用的地理差异可以指导分配政策和技术实施。利用美国移植登记数据，我们评估了供体质量、政策时代和先进灌注（AP）应用情况方面的利用地理差异。这项回顾性队列研究纳入了2010年至2024年9月的所有肝脏供体和等待名单上的患者。供体按医院转诊区域（HRR）进行汇总，并使用肝脏丢弃风险指数（DSRI）按质量分层。暴露因素包括分配政策时代和AP技术使用增加（2022年7月起）。通过HRR计算肝脏未利用的观察与预期（O:E）比率，并进行建模以揭示地理上相邻的低利用集群（LUC）。LUC内HRR的比例从共享15（S15）的24%增加到共享35（S35）的25%、急性病区域（AC）的32%，然后在AP时代降至21%（p =0.01）。S15中有7个不同的LUC（未利用率中位数=33%），S35中有7个LUC（未利用率=32%），AC中有7个LUC（未利用率=41%），AP时代有3个LUC（未利用率=46%）。按HRR划分的供体质量随时间下降，S15中DSRI中位数为2.56（四分位间距：1.25 - 5.79），到AP时为5.69（2. .01 - 35.30）（p <0.001）。考虑到DSRI，AC中未利用的几率最高（参照共享35，OR =1.27，p <0.001），在AP时代降低（OR =1.06，p =0.001）。常温机器灌注的应用与明显更低的丢弃几率相关（OR =0.03，0 .03 - 0.04；p <0.001）。除S35外，每个时代来自LUC的肝脏运输距离较短。除AP时代外，LUC中净出口HRR的数量与非LUC相当，AP时代LUC中净出口HRR较少（2 [3.2%] 对42 [17.4%]，p =0.004）。经调整分析，LUC中的候选者移植可能性较低（HR =0.88，p <0.001），但等待名单死亡率也较低（HR =0.95，p <0.001）。先进灌注的出现与原本边缘性肝脏同种异体移植物的利用以及缓解连续分配政策时代所见的丢弃地理不平衡相关。
