Offer Acceptance Patterns for Liver Donors Aged 70 and Older

Abstract

Despite a documented survival benefit, older liver donor (OLD, age ≥70) graft offers are frequently declined, with utilization worsening over the last decade. To understand how offer acceptance varies by center, we studied 1113 eventually transplanted OLD grafts from 2009 to 2017 using Scientific Registry of Transplant Recipients (SRTR) data and random-intercept multilevel logistic regression. To understand how center-level acceptance of OLD graft offers might be associated with waitlist and posttransplant outcomes, we studied all adult, actively listed, liver-only candidates and recipients during the study period using Poisson regression (transplant rate), competing risks regression (waitlist mortality), and Cox regression (posttransplant mortality). Among 117 centers, OLD offer acceptance ranged from 0 (23 centers) to 95 acceptances, with a median odds ratio of 2.88. Thus, a candidate may be three times as likely to receive an OLD graft simply by listing at a different center. Centers in the highest quartile (Q4) of OLD acceptance (accepted 39% of OLD offers) accepted more nationally shared organs (Q4 versus Q1: 14.1% versus 0.0%, P < 0.001) and had higher annual liver transplant volume (Q4 versus Q1: 80 versus 21, P < 0.001). After adjustment, nationally shared OLD offers (adjusted odds ratio [aOR]: 0.16, 95% confidence interval [CI]: 0.13-0.20) and offers to centers with higher median Model for End-Stage Liver Disease (MELD) at transplant (aOR: 0.74, 95% CI: 0.62-0.87) were less likely to be accepted. OLD offers to centers with higher annual transplant volume were more likely to be accepted (aOR: 1.21, 95% CI: 1.14-1.30). Additionally, candidates listed at centers within the highest quartile of OLD graft offer acceptance had higher deceased donor liver transplantation (DDLT) rates (adjusted incidence rate ratio: 1.45, 95% CI: 1.41-1.50), lower waitlist mortality (adjusted subhazard ratio: 0.76, 95% CI: 0.72-0.76), and similar posttransplant survival (adjusted hazard ratio: 0.93, 95% CI: 0.86-1.01) when compared with those listed at centers in the lowest quartile of OLD graft offer acceptance. The wide variation in OLD offer acceptance supports the need for optimizing the organ offer process and efficiently directing OLD offers to centers more likely to use them.

FIG. 1.

(A) The number and percentage of accepted OLD offers over 117 transplant centers from 2009 to 2017 by quartile. Among the 117 transplant centers, 23 centers accepted zero OLD offers over the study period. (B) The number and percentage of accepted OLD offers over 117 transplant centers from 2009 to 2017 by UNOS region. (C) The number of accepted OLD offers by transplant center within the 11 UNOS regions. Each dot represents a transplant center within each region.

FIG. 2.

Relative odds of OLD graft offer acceptance by transplant center compared with the national average (horizontal line). Each dot represents the relative odds of OLD offer acceptance for each transplant center in the United States with 95% confidence interval.

FIG. 3.

Kaplan-Meier following adult DDLT (donor age >18) by quartile of OLD graft offer acceptance.