Reframing the impact of combined heart-liver allocation on liver transplant wait-list candidates

Abstract

Simultaneous heart-liver transplantation, although rare, has become more common in the U.S. When the primary organ is a heart or liver, patients receiving an offer for the primary organ automatically receive the second, non-primary organ from that donor. This policy raises issues of equity—i.e. whether liver transplant-alone candidates bypassed by heart-liver recipients are disadvantaged. No prior published analyses have addressed this issue, and few methods have been developed as a means to measure the impact of such allocation policies. We analyzed OPTN match run data from 2007-2013 to determine whether this combined organ allocation policy disadvantages bypassed liver transplant waitlist candidates in a clinically meaningful way. Among 65 heart-liver recipients since May 2007, 42 had substantially higher priority for the heart relative to the liver, and bypassed 268 liver-alone candidates ranked 1-10 on these match runs. Bypassed patients had lower risk of waitlist removal for death or clinical deterioration compared to controls selected by match MELD score (HR: 0.56, 95% CI: 0.40-0.79), and similar risk as controls selected by laboratory MELD score (HR: 0.91, 95% CI: 0.63-1.33) or on match runs of similar graft quality (HR: 0.97, 95% CI: 0.73-1.37). The waiting time from bypass to subsequent transplantation was significantly longer among bypassed candidates versus controls on match runs of similar graft quality (median: 87 (IQR: 27-192) days versus 24 (5-79) days; p<0.001). Although transplant is delayed, liver transplant waitlist candidates bypassed by heart-liver recipients do not have excess mortality compared to three sets of matched controls. These analytic methods serve as a starting point to consider other potential approaches to evaluate the impact of multi-organ transplant allocation policies

Liver transplant center variability in accepting organ offers and its impact on patient survival

“…4,17 Waitlist removal was modeled as a binary outcome given the short time interval from initial organ offer to waitlist removal date (median 10 days; 72.9% of removals for death or clinical deterioration occurring within 30 days of an organ offer being declined, and 81.5% within 60 days) between being ranked first and subsequent outcomes of death or transplantation (the outcome in >95% patients ranked first). 17,18 Lastly, we evaluated the graft-specific outcome of graft failure (recipient death or retransplantation 19 ).…”

Single-Center Long-Term Analysis of Combined Liver-Lung Transplant Outcomes

“…Allograft utilization in particular is a difficult question to objectively address in this small population. However, in heart-liver transplantation, Goldberg et al 28 found that although transplant is delayed for liver transplant waitlist candidates bypassed by heart-liver recipients, they do not have excess mortality compared with 3 sets of matched controls. While bypassing liver-alone patients might not affect their survival, remaining on the waitlist is significantly detrimental to survival for LLT patients compared with either liver- or lung-only waitlist patients.…”

Combined liver-thoracic transplantation: single-center experience with introduction of the‘Liver-first’principle

“…On the other hand, one may argue that isolated transplant candidates could be disadvantaged by prioritization of combined organ transplant candidates. However, based on the OPTN data of 2007–2013, Goldberg concluded that single‐organ candidates — who were bypassed on the waiting list by cLiThTx candidates — did not experience an increased waitlist mortality compared with matched controls .…”