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Align units of distribution in closed variance for split liver transplantation

Proposal Overview

Status: Public Comment

Sponsoring Committee: Liver & Intestinal Organ Transplantation Committee

Strategic Goal: Increase the number of transplants

Read the policy notice (PDF; 12/2019)

View the Board Briefing Paper (11/2019)

Read the proposal (PDF; 10/2019)

Read the proposal that passed the underlying variance (PDF; 6/2019)

Contact: Elizabeth Miller

Executive Summary

The OPTN Board of Directors (the Board) approved a new closed variance for the allocation of the second segment of split livers on June 10, 2019. The variance permits participating transplant programs to offer the second segment of the split liver to a candidate at the same transplant program or an affiliated transplant program once the segment has been offered to candidates with a model for end-stage liver disease (MELD) or pediatric end-stage liver disease (PELD) score of at least 33 and Status 1 candidates listed at liver transplant programs within 500 nautical miles (NM) of the donor hospital.

Under the proposed changes, the second segment of the liver would be offered to transplant programs within the same region as the donor hospital, rather than within 500 NM and with a MELD or PELD of at least 35 instead of at least 33. The resolution will also allow these changes to automatically revert to 500 NM and MELD or PELD of 33 upon implementation of the Acuity Circles policy. The proposed changes would allow the units of distribution used in the variance to align with the units of distribution used in the allocation of deceased donor livers.

Comments

Joan Keiser | 10/16/2019

Support and appreciate the proposal.

Pati Hughes-Fudge | 10/30/2019

I agree that (within reasonable limits) split livers need to be allocated as often as possible to those who fall into the required position of the rules. I am doing great after 4 years o a split liver donation.

Stephanie Whitehead | 11/03/2019

I strongly support to receive a transplant whether it be a living donor organ donor whatever the case may be I believe I'm a good candidate I'm only 50 years old recently diabetic 25 I had my gallbladder and a piece of my liver taken out two weeks after delivering my son he now has his first child born 3 months ago my granddaughter Amara I would really like to see her grow up and be able to enjoy being a grandmother I've waited so long for this I've been in pain for quite a while and it would be nice to be able to enjoy the last part of my life please help

Society of Pediatric Liver Transplantation | 11/04/2019

The Society of Pediatric Liver Transplantation previously stated strong support in favor of effective measures to increase overall number of transplants and increase utilization of appropriate grafts. SPLIT previously supported the Board approved variance intending for the receiving program or center to incentivize the utilization of the graft for more than one patient. These proposed changes allow the variance to still stand for regional allocation with the caveat that they will automatically revert upon implementation of the Acuity Circles Policy. SPLIT supports these changes.

Carolina Donor Services | 11/06/2019

Carolina Donor Services supports these proposed changes.

American Society of Transplant Surgeons | 11/07/2019

The American Society of Transplant Surgeons (ASTS) supports the OPTN policy proposal’s new language that aligns with subsequent changes in liver allocation. We recommend the OPTN take an iterative approach to all new organ allocation policies by taking small steps with regular reassessments (e.g., one year, etc.) to identify successes and unintended consequences, particularly concerning logistical issues.

NATCO | 11/13/2019

NATCO supports the OPTN policy proposal to offer the second segment of a liver to transplant programs within the same region as the donor hospital, rather than within 500 NM and with a MELD or PELD of at least 35 instead of at least 33. We also agree to the resolution allowing these changes to automatically revert to 500 NM and MELD or PELD of 33 upon implementation of the Acuity Circles policy. As with other recommendations, we continue to recommend the implementation of regular assessments to identify any potential unintended consequences that may arise due to logistical issues, or unintended consequences to pediatric patients on the wait list.

Starzl Network for Excellence in Pediatric Transplantation | 11/13/2019

The Starzl Network for Excellence in Pediatric Transplantation (www.starzltransplantnetwork.com) strongly supports the proposed resolution allowing for the second segment from a technical variant liver to be offered to transplant programs within the same region as the donor hospital, rather than 500 nautical miles from the donor hospital, and with a MELD or PELD of at least 35. The proposed changes allow the regional variance to stand until the acuity circles policy is implemented. It is the belief of the Starzl Network collaborative participants that utilization of the second segment from technical variant livers, within the same region as the donor hospital, would observe significantly shorter cold ischemic times. Ultimately, the Liver & Intestinal Organ Transplantation Committee’s goal of increasing the number of organ transplants would be achieved through higher utilization of the second segment by local and regional transplant programs observing lower cold ischemic times. Finally, we agree that the resolution should allow for these changes to automatically revert to 500 NM and MELD or PELD of 33 upon implementation of the Acuity Circles policy.

Association of Organ Procurement Organizations | 11/14/2019

The Association of Organ Procurement Organizations (AOPO) appreciates the opportunity to provide comment on the proposal to Align units of distribution in closed variance for split liver transplantation. Consistent with our comment 3/18/2019 regarding the proposed Split Liver Variance, UNOS data demonstrate that less than 1.5% of donor livers are split for transplant. Also, not all the remaining segments from a split liver are transplanted because of logistical reasons related to the current allocation policy. AOPO supports this proposal to align distribution units for the variance with distribution units for liver policy and continues to support the variance with the goal of increasing the number of split liver transplants and reducing segment discards. AOPO reiterates our concern that: A. The liver split be completed such that there is appropriate vasculature to support transplant of both segments, and B. request that UNOS aggressively monitor the variance to ensure that participating liver transplant programs are accepting livers to split for the appropriate patients and transplanting both segments in the appropriate candidates.

American Society of Transplantation | 11/14/2019

The American Society of Transplantation supports the proposed changes to this Board-approved variance, which is intended to maximize the utilization of liver allografts for more than one patient if possible. While intended to use the acuity circle model, making this change is practical when considering the delay in the implementation of changes to the liver allocation policy. The proposed closed variance provides a roadmap to guide and promote the practice of splitting and utilizing two liver segments while providing a framework for deterring preventable discard of any portion of a precious gift. The AST supports this strategy concept to increase opportunities for small children to benefit from transplantation.