Should we use liver grafts repeatedly refused by other transplant teams?

Audrey Winter; Paul Landais; Daniel Azoulay; Mara Disabato; Philippe Compagnon; Corinne Antoine; Christian Jacquelinet; Jean-Pierre Daurès; Cyrille Féray

doi:10.1016/j.jhepr.2020.100118

Should we use liver grafts repeatedly refused by other transplant teams?

JHEP Rep. 2020 May 4;2(4):100118. doi: 10.1016/j.jhepr.2020.100118. eCollection 2020 Aug.

Authors

Audrey Winter^{1

2

3}, Paul Landais¹, Daniel Azoulay⁴, Mara Disabato⁵, Philippe Compagnon⁵, Corinne Antoine⁶, Christian Jacquelinet⁶, Jean-Pierre Daurès^{1

2}, Cyrille Féray⁴

Affiliations

¹ Department of Biostatistics, UPRES EA2415, Clinical Research University Institute, University of Montpellier, France.
² Beau Soleil Clinic, Languedoc Mutualité, Montpellier, France.
³ Medical Imaging & Informatics, Department of Radiological Sciences, University of California, Los Angeles, CA, USA.
⁴ Centre Hépato-Biliaire, Hôpital Paul Brousse, APHP, Villejuif, France.
⁵ Department of Surgery, Henri Mondor University Hospital, Créteil, France.
⁶ Agence de Biomédecine, Saint-Denis, France.

Abstract

Background & aims: In France, liver grafts that have been refused at least 5 times can be "rescued" and allocated to a centre which chooses a recipient from its own waiting list, outside the patient-based allocation framework. We explored whether these "rescued" grafts were associated with worse graft/patient survival, as well as assessing their effect on survival benefit.

Methods: Among 7,895 candidates, 5,218 were transplanted between 2009 and 2014 (336 centre-allocated). We compared recipient/graft survival between patient allocation and centre allocation, considering a selection bias and the distribution of centre-allocation recipients among the transplant teams. We used a propensity score approach and a weighted Cox model using the inverse probability of treatment weighting method. We also explored the survival benefit associated with centre-allocation grafts.

Results: There was a significantly higher risk of graft loss/death in the centre allocation group compared to the patient allocation group (hazard ratio 1.13; 95% CI 1.05-1.22). However, this difference was no longer significant for teams that performed more than 7% of the centre-allocation transplantations. Moreover, receiving a centre-allocation graft, compared to remaining on the waiting list and possibly later receiving a patient-allocation graft, did not convey a poorer survival benefit (hazard ratio 0.80; 95% CI 0.60-1.08).

Conclusions: In centres which transplanted most of the centre-allocation grafts, using grafts repeatedly refused for top-listed candidates was not detrimental. Given the organ shortage, our findings should encourage policy makers to restrict centre-allocation grafts to targeted centres.

Lay summary: "Centre allocation" (CA) made it possible to save 6 out of 100 available liver grafts that had been refused at least 5 times for use in the top-listed candidates on the national waiting list. In this series, the largest on this topic, we showed that, in centres which transplanted most of the CA grafts, using grafts repeatedly refused for top-listed candidates did not appear to be detrimental. In the context of organ shortage, our results, which could be of interest for any country using this CA strategy, should encourage policy makers to reassess some aspects of graft allocation by restricting CA grafts to targeted centres, fostering the "best" matching between grafts and candidates on the waiting list.

Keywords: CA, centre allocation; Centre allocation; DCD, donation after cardiac death; DQI, donor quality index; ES, effect size; HCC, hepatocellular carcinoma; HR, hazard ratio; ICU, intensive care unit; IPTW, inverse probability of treatment weighting; LT, liver transplantation; Liver transplantation; MELD, model for end-stage liver disease; PA, patient allocation; Patient allocation; Patient and graft survival; Survival benefit.