Understanding factors that contribute to liver discards and nonusage is urgently needed to improve organ utilization.
Using Scientific Registry of Transplant Recipient data, we studied a national cohort of all US adult, deceased brain dead donor, isolated livers available for transplantation from 2003 to 2016, including organ-specific and system-wide factors that may affect organ procurement and discard rates.
Of 73 686 available livers, 65 316 (88.64%) were recovered for transplant, of which 6454 (9.88%) were ultimately discarded. Livers that were not procured or, on recovery, discarded were more frequently from older, heavier, hepatitis B virus (HCV)+, and more comorbid donors (P < 0.001). However, even after adjustment for organ quality, the odds of liver nonusage were 11% higher on the weekend (defined as donor procurements with cross-clamping occurring from 5:00 PM Friday until 11:59 AM Sunday) compared with weekdays (P < 0.001). Nonuse rates were also higher at night (P < 0.001), defined as donor procurements with cross-clamping occurring from 5:00 PM to 5:00 AM; however, weekend nights had significantly higher nonuse rates compared with weekday nights (P = 0.005). After Share 35, weekend nonusage rates decreased from 21.77% to 19.51% but were still higher than weekday nonusage rates (P = 0.065). Weekend liver nonusage was higher in all 11 United Network of Organ Sharing regions, with an absolute average of 2.00% fewer available livers being used on the weekend compared with weekdays.
Although unused livers frequently have unfavorable donor characteristics, there are also systemic and operational factors, including time of day and day of the week a liver becomes available, that impact the chance of liver nonprocurement and discard.
1 Division of General Surgery, Department of Surgery, Columbia University Medical Center, New York, NY.
2 Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY.
3 Department of Medicine, Division of Digestive and Liver Diseases, Center for Liver Disease and Transplantation, Columbia University Medical Center, New York, NY.
4 Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, Weil Cornell Medical Center, New York, NY.
5 Division of Transplantation, Department of Surgery, Columbia University Medical Center, New York, NY.
6 Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY.
7 The Columbia University Renal Epidemiology (CURE) Group, New York, NY.
Received 30 May 2017. Revision received 21 October 2018.
Accepted 23 October 2018.
This work was supported in part by Health Resources and Services Administration contract 234-2005-37011C. S.M. was supported by grant (R01-DK114893-01); S.M. and M.C.C. was supported by grant (U01-DK116066-01) and received funding from the American Society of Transplantation as well as the Laura and John Arnold Foundation. D.J.C. is supported by National Institutes of Health training grant (T32HL007854).
The authors declare no conflicts of interest.
The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.
D.J.C. wrote and edited first and subsequent drafts of the paper as well as performed all statistical analyses. M.C.C. helped acquire data, helped with critical revision of drafts of the paper as well as helped perform and guide statistical analyses. E.C.V. helped guide study design and the analysis and interpretation of data, as well as performed critical revision of drafts of the paper. K.J.H. helped conceptualize portions of the study and selection of patients and covariates. He also contributed critical analysis to key facets of the paper. J.C.E. performed critical revision of drafts of the paper and helped with the analysis and interpretation of data. L.E.R. conceived of the idea of the paper, performed critical revision of drafts of the paper, and helped with the analysis and interpretation of data. S.M. helped with study concept and design, oversaw all statistical analyses, and performed critical revision of drafts of the paper.
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Correspondence: Dustin J. Carpenter, MD, Division of General Surgery, Department of Surgery, Columbia University Medical Center, Milstein Hospital Building, 177 Fort Washington Avenue, Floor 7GS-313, New York, NY 10032. (firstname.lastname@example.org).