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Center-level variances affect pediatric liver transplant offer acceptance

Researchers observed significant variability in liver offer acceptance rates for pediatric transplant candidates within individual centers that were not explained by donor or recipient factors, according to recently published data.

“We observed an almost threefold difference in center-level liver offer acceptance for pediatric patients,” Ellen Mitchell, MD, from the Children’s Hospital of Pittsburgh at the University of Pittsburgh Medical Center, and colleagues wrote. “Being listed at a center with a low acceptance rate considerably increases a child’s probability of dying prior to receiving a transplant. While it would be infeasible to discuss every offer with the patient or family, there should be shared decision making when possible.”

Mitchell and colleagues accessed the United Network for Organ Sharing and collected data on pediatric match runs between May 1, 2007, and Dec. 31, 2015. They included data in the study if an organ was accepted and transplanted in a pediatric patient ranked between 1 and 40 on a match run and the liver was from a brain-dead deceased donor.

The researchers reviewed 4,088 pediatric patients, which encompassed a total of 27,094 match runs.

Factors associated with organ offer acceptance included higher MELD or PELD score (OR = 1.01; 95% CI, 1.01-1.02), no history of exception points (OR = 0.67; 95% CI, 0.59-0.75), larger body surface area in recipient (OR = 2.51; 95% CI, 1.76-3.58), and smaller body surface area in donor (OR = 0.46; 95% CI, 0.4-0.53). Other factors included if the recipient ranked in the first four positions on the match run and whether the organ distribution unit was local, regional or national.

After adjusting for patient, donor and match characteristics, the researchers found significant among-center variation in organ offer acceptance rates (P < .001), which was not explained by the number of centers in the designated donor service area, center volume or having a living donor liver transplant program.

Among-center acceptance rates ranged from 5.1% to 14.6% and were different at centers within a geographic region. Liver acceptance rates at a center also correlated significantly with a patient’s individual risk for waitlist mortality (OR = 1.1; 95% CI, 1.01-1.19).

“It is necessary to standardize the acceptance process so that all children have equal opportunity for transplantation,” the researchers wrote. “Future work should explore factors that impact decision making which can’t be discerned from the UNOS database. These data also could be considered in future transplant center benchmarking as a means to increase organ acceptance and decrease mortality of pediatric patients waitlisted for a liver transplant.” – by Talitha Bennett

Disclosure: Healio.com/Hepatology was unable to determine relevant financial disclosures at the time of publication.