Declining liver graft quality threatens the future of liver transplantation in the United States

Abstract

National liver transplantation (LT) volume has declined since 2006, in part because of worsening donor organ quality. Trends that degrade organ quality are expected to continue over the next 2 decades. We used the United Network for Organ Sharing (UNOS) database to inform a 20-year discrete event simulation estimating LT volume from 2010 to 2030. Data to inform the model were obtained from deceased organ donors between 2000 and 2009. If donor liver utilization practices remain constant, utilization will fall from 78% to 44% by 2030, resulting in 2230 fewer LTs. If transplant centers increase their risk tolerance for marginal grafts, utilization would decrease to 48%. The institution of "opt-out" organ donation policies to increase the donor pool would still result in 1380 to 1866 fewer transplants. Ex vivo perfusion techniques that increase the use of marginal donor livers may stabilize LT volume. Otherwise, the number of LTs in the United States will decrease substantially over the next 15 years. In conclusion, the transplant community will need to accept inferior grafts and potentially worse posttransplant outcomes and/or develop new strategies for increasing organ donation and utilization in order to maintain the number of LTs at the current level.

Figure 1

DES simulation framework. Dependent variable relationships, represented by lines, modeled via logistic regressions using UNOS data. Shaded variables are also dependent on the passage of time. 100,000 potential donors simulated with 15 replications for each scenario. Odds ratios adapted from Orman, et al¹⁰, from prior work in UNOS database and used to inform model.

Figure 2

Using a population based estimate, the total number of donors will increase by 2030, but the corresponding increases in DCD, donor obesity and diabetes will increase the discard rate and reduce the total number of adult whole liver transplants over the next 20 years