Transplant team should coordinate efforts to keep patients active on the waitlist
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SCOTTSDALE, Ariz. — While the evaluation process and placement of patients on the transplant waitlist can be a challenge, maintaining their readiness has equal importance, a speaker at the Cutting Edge of Transplantation Summit said.
“When you are trying to manage your waitlist, it’s important to start right up front,” Derek A. DuBay, MD, MSPH, a transplant surgeon at the Medical University of South Carolina, said. “Waitlist management really begins at the selection conference.”
When working as a liver transplant surgeon, DuBay said the decision to place a patient on the waitlist was more complex. When he changed his focus to kidney transplants, “the decision was pretty much a ‘yes’ or a ‘no,’” DuBay said, “without a lot of data for those patients” to show why they were unprepared for the surgery.
The transplant program at the university then started to collect data as patients were placed on the waitlist for a kidney. “We asked, ‘What kind of things occur when you are evaluating a patient at a high level that you can write down, so you are prepared when you get the kidney offers in the middle of the night with a donor?’” DuBay said. Those items can include details such as whether a patient is hard to get in contact with, has special medical conditions, including cardiovascular issues, is on specific medications or other factors. “It can also be someone with a complicated social history,” DuBay said. “It could be a case where someone is listed at your center but is 4 hours to 6 hours away,” he said.
Transplant readiness
“I think your goal should be to have every patient on your waitlist ready for transplant at all times,” DuBay told attendees. That approach was influenced by a situation in his transplant program where he had a number of matching organs to transplant — and the 18 potential recipients were deemed not ready. “We sent them home because they weren’t ready,” he said. “It turns out most of those patients never did get a transplant.
“So we sat down as a group and talked about what does it mean in our institution to be ready for a transplant.”
DuBay outlined two key components of transplant readiness, which include the following: a patient needs to have a social evaluation and reevaluation that is updated every 12 months; and an HLA serum lab test within 90 days.
“We toned it down to a set of achievable metrics we could aim for,” DuBay said. As part of the social evaluation workup, patients are asked about their health literacy, caregiver support, finances and transportation.
A transplant coordinator checklist about readiness includes the following steps: ask patients if they have had any recent infections or are currently on antibiotics; list a patient’s last hospitalization and last surgical procedure; and ask if the patient has had any other medical conditions, such as contracting COVID-19, any shortness of breath or dependence on oxygen, and whether the patient is on anticoagulants.
Checks are also made regarding any open wounds or diabetic foot ulcers.
That testing has helped DuBay and his transplant team move from 21% of patients being ready for transplant to 79% at the Medical University of South Carolina.
“We continue to get better each month in reducing the probability of sending patients home who are not ready,” he said.
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DuBay DA. Strategies to overcome transplant center barriers to candidate active waiting list status and/or transplant readiness. Presented at: Cutting Edge of Transplantation Summit. Feb. 23-25, 2023; Scottsdale, Ariz.
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