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Expedited Liver Placement

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Background

Organ Procurement Organizations (OPOs) have utilized various methods of expedited organ allocation for years. At its December 2019 meeting, the OPTN Board of Directors approved a policy establishing a system for the expedited placement of livers.

The goal is to address the lack of transparency, guidance for OPOs and transplants hospitals, and consistent practice in addressing the issue of late liver turndowns. This policy was implemented in two phases: Phase 1 on Feb. 25, 2021; and Phase 2 on March 25, 2021.

Policy

Summary of policy changes

The policy changes establish a system for the expedited placement of livers.

  • Transplant hospitals will be required to “opt-in” to receive expedited liver offers on a candidate by candidate basis.
  • OPOs can initiate expedited liver offers when the donor is in the OR, or in the case of a DCD donor, when withdrawal of support has been initiated, and the OPO has been notified by the primary transplant hospital that they can no longer accept the liver. OPOs must enter the date/time for each of these events. Criteria are established for when OPOs can initiate expedited liver placement, as well as required information that needs to be entered by the OPO before sending electronic expedited livers offers.
  • Transplant hospitals must respond with a provisional “yes” to expedited offers within 30 minutes in order to be eligible to receive the liver for their candidate.
  • After the 30-minute period, OPOs must place the liver with the candidate with a provisional “yes” that appears highest on the match run.

Policy documents

Expedited Placement of Livers

Post-implementation monitoring

The OPTN will assess the impact of these policy changes at 6-months and 12-months post implementation. Analyses beyond 12-months will be performed at the request of the Committee.

There is currently no accurate way in the OPTN system to assess how often a liver is turned down in the OR. As a result, much of the analyses will be “point forward” analyses and can be used as a benchmark to assess changes in the future. The OPTN will perform analyses to study the following:

  • Overall
    • The number and percent of in-OR refusals
    • The number and percent of in-OR refusals that result in a transplanted liver
    • The number and percent of in-OR refusals that result in a liver recovered but not transplanted
    • The reasons reported for the in-OR refusal
    • The demographics of liver donors that have an in-OR refusal
  • By OPO
    • The number and percent of in-OR refusals
    • The number and percent of in-OR refusals that result in a transplanted liver
    • The number and percent of in-OR refusals that result in a liver recovered but not transplanted
    • The reasons reported for the in-OR refusal
  • By Transplant Center
    • The number and percent of livers refused in-OR
    • Refusal reasons for livers refused in-OR
    • Distribution of candidates listed as willing to accept an expedited (in-OR) liver
    • Number and percent of expedited acceptances transplanted
    • Number and percent of expedited acceptances not transplanted
    • Acceptance rates for expedited (in-OR) liver offers

The OPTN will assess the overall impact of these policy changes using a pre vs. post analysis at 6- months and 12-months after implementation. Analyses beyond 12-months will be performed at the request of the Committee.

  • Liver utilization rates pre vs. post implementation
  • Liver discard rates pre vs. post implementation
  • Liver transplant volumes pre vs. post implementation
  • Out of sequence liver placements pre vs. post implementation

FAQs & resources

Instructional offering:

SYS164 Expedited Liver Placement for OPOs and TXCs; this offering provides separate pathways for OPOs and liver transplant programs to learn the process for expediting placement of livers. Learners may explore both pathways to see how their colleagues experience the process from a different perspective.

Frequently asked questions

  1. How do transplant hospitals indicate which candidates receive expedited liver offers
    Transplant hospitals must:
    • Agree to accept a liver recovered by any procurement team
    • Opt in for each individual candidate
    • Indicate donor type - donation at circulatory death (DCD), donation after brain death (DBD) or both
    • Enter acceptance criteria for expedited offers
      • Minimum and maximum age
      • Maximum body mass index (BMI)
      • Maximum distance from the donor hospital
      • Minimum and maximum height
      • Percentage of macrosteatosis
      • Minimum and maximum weight
  2. Who will receive expedited liver offers for the transplant hospitals?
    • Transplant hospitals need to specify who receives expedited liver offers.
  3. Who can initiate expedited liver placement?
    • Only the organ procurement organization (OPO) that recovers the organ can initiate expedited liver placement.
  4. When can OPOs initiate expedited livers?
    • OPOs may initiate expedited liver offers when the donor is in the OR, or in the case of a DCD donor, when withdrawal of support has been initiated, and the OPO has been notified by the primary transplant hospital that they can no longer accept the liver.
    • This information must be entered by the OPO prior to sending expedited offers.
    • OPOs may also choose to allocate the liver according to the original match run.
  5. How long does a transplant hospital have to respond to expedited offers?
    • In order to be eligible to receive an expedited liver, a transplant center must notify the host OPO within 30 minutes that they have evaluated the offer and are interested in accepting the organ.
  6. How does the OPO determine which candidate receives the expedited liver?
    • Once the time limit has expired and responses have been received, the OPO must place the liver with the candidate that appears highest on the expedited match run.