Improved posttransplant mortality after share 35 for liver transplantation

Abstract

The Share 35 policy was implemented in June 2013 to improve equity in access to liver transplantation (LT) between patients with fulminant liver failure and those with cirrhosis and severe hepatic decompensation. The aim of this study was to assess post-LT outcomes after Share 35. Relevant donor, procurement, and recipient data were extracted from the Organ Procurement and Transplantation Network/United Network for Organ Sharing database. All adult deceased donor LTs from January 1, 2010, to March 31, 2016, were included in the analysis. One-year patient survival before and after Share 35 was assessed by multivariable Cox proportional hazards analysis, with adjustment for variables known to affect graft survival. Of 34,975 adult LT recipients, 16,472 (47.1%) were transplanted after the implementation of Share 35, of whom 4,599 (27.9%) had a Model for End-Stage Liver Disease (MELD) score ≥35. One-year patient survival improved from 83.9% to 88.4% after Share 35 (P < 0.01) for patients with MELD ≥35. There was no significant impact on survival of patients with MELD <35 (P = 0.69). Quality of donor organs, as measured by a donor risk index without the regional share component, improved for patients with MELD ≥35 (P < 0.01) and worsened for patients with lower MELD (P < 0.01). In multivariable Cox regression analysis, Share 35 was associated with improved 1-year patient survival (hazard ratio, 0.69; 95% confidence interval, 0.60-0.80) in recipients with MELD ≥35.

Conclusion: Share 35 has had a positive impact on survival after transplantation in patients with MELD ≥35, without a reciprocal detriment in patients with lower acuity; this was in part a result of more favorable donor-recipient matching. (Hepatology 2018;67:273-281).

Figure 1

Trends in donor risk index (DRI), stratified by MELD ≥ 35 and < 35. The reference line is drawn at June 18, 2013, and a separate datapoint was created for transplants performed in 2013 but after June 18, 2013 in order to illustrate the trend after the implementation of Share 35. In Figure 1B, the “regional share” component of DRI is taken out of the index, since policy-driven regional sharing in patients with MELD ≥ 35 makes that variable no longer relevant from the standpoint of organ quality.

Figure 2

Kaplan-Meier survival curves for 1-year patient survival and graft survival by MELD category, stratified by pre-Share 35 (dashed line) and post- Share 35 (solid line).