We project a marked increase in demand for LT for NASH given population obesity trends. Continued public health efforts to curb obesity prevalence are needed to reduce the projected future burden of NASH. (Hepatology 2017).

We have characterized several important predictors of deceased donor kidney discard. Better understanding of factors that lead to increased deceased donor kidney discard can allow for targeted interventions to reduce discard.

IMPORTANCEOrgan transplant is a life-saving procedure for patients with end-stage organ failure. In the US, organ procurement organizations (OPOs) are responsible for the evaluation and procurement of organs from donors who have died; however, there is controversy regarding what measures should be used to evaluate their performance.OBJECTIVE To evaluate OPO performance metrics using combined mortality and donation data and quantify the associations of population demographics with donation metrics. DESIGN, SETTING, AND PARTICIPANTSThis national cohort study includes data from the US organ transplantation system from January 2008 through December 2017. All individuals who died within the US, as reported by the National Death index, were included.EXPOSURES Death, organ donation, and donation eligibility. MAIN OUTCOMES AND MEASURESEvaluation of the variation in donation metrics and the use of ineligible donors by OPO and demographic subgroup. RESULTSThis study included 17 501 742 deaths and 75 769 deceased organ donors (45 040 men [59.4%]; 51 908 White individuals [68.5%]). Of these donors, 15 857 (20.9%) were not eligible, as defined by the OPOs. The median donation metrics by OPO were 0.004 (range, 0.002-0.012) donors per death, 0.89 (range, 0.68-1.30) donors per eligible death, and 0.72 (range, 0.57-0.86) eligible donors per eligible death. The OPOs in the upper quartile of the overall eligible donors per eligible death metric were in the upper quartile of annual rankings on 90 of 140 occasions (64.3%). There was little overlap in top-performing OPOs between metrics; an OPO in the upper quartile for 1 metric was also in the upper quartile for the other metrics on 37 of 570 occasions (6.5% of the time). The median donor eligibility rate, defined as the number of eligible donors per donor, was 0.79 (range, 0.61-0.95) across OPOs. Age (eg, 65 to 84 years, coefficient, −0.55 [SE, 0.03]; P < .001; vs those aged 18 to 34 years), sex (male individuals, −0.09 [SE, 0.02]; P < .001; vs female individuals), race (eg, Black individuals, 0.35 [SE, 0.02]; P < .001; vs White individuals), cause of death (eg, central nervous system tumor, 0.48 [SE, 0.08]; P < .001; vs anoxia), year (eg, 2016-2017: −0.10 [SE, 0.03]; P < .001; vs 2008-2009), and OPO were associated with the use of ineligible donors; OPO was a significant factor associated with performance in all metrics (χ 2 56 , 500.5; P < .001; coefficient range across individual OPOs, −0.15 [SE, 0.09] to 0.75 [SE, 0.09]), even after accounting for population differences. Female and non-White individuals were significantly less likely to be used as ineligible donors. CONCLUSIONS AND RELEVANCEWe demonstrate significant variability in OPO performance rankings, depending on which donation metric is used. There were significant differences in OPO performance, even after accounting for differences in potential donor populations. Our data suggest significant variation in use of ineligible donors among OPOs, a source for increased donors. The performance of OPOs should be evaluated usin...

With the aging US population, demographic shifts, and obesity epidemic, there is potential for further exacerbation of the current liver donor shortage. We aimed to project the availability of liver grafts in the United States. We performed a secondary analysis of the Organ Procurement and Transplantation Network database of all adult donors from 2000 to 2012 and calculated the total number of donors available and transplanted donor livers stratified by age, race, and body mass index (BMI) group per year. We used National Health and Nutrition Examination Survey and Centers for Disease Control and Prevention historical data to stratify the general population by age, sex, race, and BMI. We then used US population age and race projections provided by the US Census Bureau and the Weldon Cooper Center for Public Service and made national and regional projections of available donors and donor liver utilization from 2014 to 2025. We performed sensitivity analyses and varied the rate of the rise in obesity, proportion of Hispanics, population growth, liver utilization rate, and donation after cardiac death (DCD) utilization. The projected adult population growth in the United States from 2014 to 2025 will be 7.1%. However, we project that there will be a 6.1% increase in the number of used liver grafts. There is marked regional heterogeneity in liver donor growth. Projections were significantly affected by changes in BMI, DCD utilization, and liver utilization rates but not by changes in the Hispanic proportion of the US population or changes in the overall population growth. Overall population growth will outpace the growth of available donor organs and thus potentially exacerbate the existing liver graft shortage. The projected growth in organs is highly heterogeneous across different United Network for Organ Sharing regions. Liver transplantation (LT) is a lifesaving therapy for patients with end-stage liver disease and hepatocellular carcinoma. Over the last decade, there has been a decrease in the availability of donor organs for deceased donor LT in the United States, and this has resulted in a plateau in the number of LTs performed.1 The absolute number of organ donors has steadily increased over the years; however, there has not been a commensurate increase in the number of liver donors. The principal cause of this trend has been a decrease in the utilization of grafts, partially due to an increase in the number of graft discards. 2This plateau has profound implications because the decrease in donor availability has exacerbated the disparity in the number of patients listed for LT and LTs performed.3 This has resulted in prolonged waiting times for LT and higher rates of wait-list dropout due to patient death or a deteriorating medical condition. 4 More than 20% of patients listed for LT will drop off the wait list while they are awaiting LT. 5 Attempts toAdditional Supporting Information may be found in the online version of this article.

Key PointsQuestionWhat are the plausible implications of a presumed consent transplant policy for waiting list outcomes in the United States?FindingsIn this simulation study of 524 359 potential organ recipients in a decision analytical model, a presumed consent policy was estimated to be associated with a reduction in waiting list removals. This estimation translated to an increase in life-years gained for patients in this simulation.MeaningThis study suggests that implementation of a presumed consent policy could be the most immediate way to expand organ donation, although presumed consent alone is not likely to solve organ shortages in the United States.

Background: Markov decision process (MDP) models are powerful tools. They enable the derivation of optimal treatment policies but may incur long computational times and generate decision rules that are challenging to interpret by physicians. Methods: In an effort to improve usability and interpretability, we examined whether Poisson regression can approximate optimal hypertension treatment policies derived by an MDP for maximizing a patient’s expected discounted quality-adjusted life years. Results: We found that our Poisson approximation to the optimal treatment policy matched the optimal policy in 99% of cases. This high accuracy translates to nearly identical health outcomes for patients. Furthermore, the Poisson approximation results in 104 additional quality-adjusted life years per 1000 patients compared to the Seventh Joint National Committee’s treatment guidelines for hypertension. The comparative health performance of the Poisson approximation was robust to the cardiovascular disease risk calculator used and calculator calibration error. Limitations: Our results are based on Markov chain modeling. Conclusions: Poisson model approximation for blood pressure treatment planning has high fidelity to optimal MDP treatment policies, which can improve usability and enhance transparency of more personalized treatment policies.

The 8-region allocation model will reduce geographic variation in donor supply to a significant extent; however, we project that geographic disparity will marginally increase over time. Though challenging, interventions to better standardize donation and utilization rates would be impactful in reducing geographic heterogeneity in organ supply.

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