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The Authors’ Reply

Barbier, Louise MD1,2,3; Bucur, Petru MD, PhD1,2,3; Salamé, Ephrem MD1,2,3

doi: 10.1097/TP.0000000000002365
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1 Department of Digestive Surgery, Hepatobiliary Surgery and Liver Transplantation, University Hospital of Tours; CHU Tours, Tours, France, INSERM, Poitiers, France, FHU SUPORT, Tours, France.

2 CHU Tours, Tours, France, INSERM, Poitiers, France, FHU SUPORT, Tours, France.

3 INSERM, Poitiers, France, FHU SUPORT, Tours, France.

Received 26 June 2018. Revision received 9 July 2018.

Accepted 9 July 2018.

L.B., P.B., and E.S. wrote the response letter together.

The authors declare no funding or conflicts of interest.

Correspondence: Ephrem Salamé, MD, Department of Digestive Surgery, Hepatobiliary Surgery and Liver Transplantation, University Hospital of Tours, CHU Tours, Avenue de la République, 37042 Tours, France. (e.salame@chu-tours.fr).

We would like to thank Dr. Andrea Lauterio and colleagues1 for their comment on our data published in Transplantation by Giretti et al.2 Together with the recently published study of Halazun et al,3 we agree with Dr. Lautorio that the concept of marginal graft might be replaced by an evaluation of the graft quality and the risk associated with its utilization that would allow a better matching of the graft with the recipient. Indeed, previously called “marginal grafts” are associated with an increased rate of retransplantation and should be better allocated to low-Model for End Stage Liver Disease (MELD) recipients with hepatocellular carcinoma (HCC) who do not have easy access to transplantation with the MELD-based allocation system. The strategy of “marginal” grafts for low-MELD HCC patients seems to decrease mortality on the waiting list and to provide a better survival in intention-to-treat.1,2 However, a multidisciplinary approach for patients selection and matching with the proposed grafts is necessary.

The French definition of marginal grafts based on the graft refusal by 5 teams is based on the allocation system and not specifically on the graft quality. When the graft has been refused at least 5 times for a dedicated donor, the graft is proposed to the closest transplant team, with the recipient’s choice being at the team's discretion. The French national transplant agency is currently developing a “French” donor risk index in order to select the recipients more adequately and to propose a score and an allocation system that would be less subjective than the rule of the 5 teams refusal.

In the context of organ shortage utilization of “marginal” grafts for liver transplantation is imperative, particularly in HCC patients population in order to reduce drop out and waiting list mortality.

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REFERENCES

1. Lauterio A, Di Sandro S, De Carlis R, et al. Every liver graft should be evaluated for transplantation. Transplantation. 2018;102:e456–e457.
2. Giretti G, Barbier L, Bucur P, et al. Recipient selection for optimal utilization of discarded grafts in liver transplantation. Transplantation. 2018;102:775–782.
3. Halazun KJ, Quillin RC, Rosenblatt R, et al. Expanding the margins: high volume utilization of marginal liver grafts among >2000 liver transplants at a single institution. Ann Surg. 2017;266:441–449.
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