Variation in adult living donor liver transplantation in the United States: Identifying opportunities for increased utilization

Abstract

In the United States, living donor liver transplantation (LDLT) is limited to transplant centers with specific experience. However, the impact of recipient characteristics on procedure selection (LDLT vs. deceased donor liver transplant [DDLT]) within these centers has not been described. Transplant registry data for centers that performed ≥1 LDLT in 2002–2019 were analyzed using hierarchal regression modeling to quantify the impact of patient and center factors on the adjusted odds ratio (aOR) of LDLT (vs DDLT). Among 73,681 adult recipients, only 4% underwent LDLT, varying from <1% to >60% of total liver transplants. After risk adjustment, the likelihood of receiving an LDLT rose by 73% in recent years (aOR 1.73 for 2014‐2019 vs. 2002‐2007) but remained lower for older adults, men, racial and ethnic minorities, and obese patients. LDLT was less commonly used in patients with hepatocellular carcinoma or alcoholic cirrhosis, and more frequently in those with hepatitis C and with lower severity of illness (Model for End‐Stage Liver Disease (MELD) score < 15). Patients with public insurance, lower educational achievement, and residence in the Northwest and Southeast had decreased access. While some differences in access to LDLT reflect clinical factors, further exploration into disparities in LDLT utilization based on center practice and socioeconomic determinants of health is needed.

Living donor liver transplantation: A multi‐disciplinary collaboration towards growth, consensus, and a change in culture

“…Workgroup 1 was tasked with (1) developing and disseminating a pre-conference survey to liver transplantation centers across the US assessing attitudes toward LDLT, and barriers to and facilitators of LDLT utilization and expansion; and (2) examining national transplant registry data to describe the epidemiology of US LDLT and to identify variation in access to LDLT across centers and patient groups that may inform strategies for reducing access disparities. 20,21 The six other workgroups focused on selected domains encompassing the entire process of LDLT. The conference roster is provided in Responses were based upon a nine-point scale, ranging from 1 = Unimportant to 9 = Very Important.…”

“…20 Secondly, an analysis of national transplant registry data was conducted and demonstrated that liver transplant candidate access to LDLT varies across transplant centers, and with patient factors correlated with access that include both social determinants of health and clinical characteristics. 21 As outlined in Figure 1, data from both were presented at the start of the consensus conference meeting.…”

“…The conference leadership group, composed of five co‐chairs representing the LDCOP, LICOP, and PSECOP of the AST, formed seven workgroups to address the consensus conference goals outlined in Table 1. Workgroup 1 was tasked with (1) developing and disseminating a pre‐conference survey to liver transplantation centers across the US assessing attitudes toward LDLT, and barriers to and facilitators of LDLT utilization and expansion; and (2) examining national transplant registry data to describe the epidemiology of US LDLT and to identify variation in access to LDLT across centers and patient groups that may inform strategies for reducing access disparities 20,21 . The six other workgroups focused on selected domains encompassing the entire process of LDLT.…”

“…Prior to the consensus conference meeting, a survey of US liver transplant centers regarding attitudes, barriers, and facilitators of LDLT revealed that many centers are interested in starting or expanding LDLT programs, provided initial data on perceived barriers to and facilitators of broader expansion, and began to examine center specific practice across the process of LDLT 20 . Secondly, an analysis of national transplant registry data was conducted and demonstrated that liver transplant candidate access to LDLT varies across transplant centers, and with patient factors correlated with access that include both social determinants of health and clinical characteristics 21 . As outlined in Figure 1, data from both were presented at the start of the consensus conference meeting.…”

Policy Strategies to Reduce Financial Risks for Living Donors

“…4 In addition to harming donors directly, these costs pose financial barriers to living donation that reduce the number of available donors, particularly those whose potential recipients have sociodemographic characteristics associated with disparities in access to living donor transplantation. 2,5 Several pathways to achieving financial neutrality for living donors require increased support to fulfill their intended goals (Figure 1). 6 One straightforward mechanism of eliminating the direct costs incurred by living donors is prepayment or reimbursement by government-or transplant system-funded entities.…”