Offer Acceptance Patterns for Liver Donors Aged 70 and Older.

Abstract

Despite 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 1,113 eventually-transplanted OLD grafts from 2009-2017 using SRTR data and random-intercept multi-level logistic regression. To understand how center-level acceptance of OLD graft offers might be associated with waitlist and post-transplant 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 (post-transplant 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 vs Q1: 14.1% vs. 0.0%, p<0.001) and had higher annual liver transplant volume (Q4 vs Q1: 80 vs. 21,p<0.001). After adjustment, nationally shared OLD offers (adjusted odds ratio[aOR]:0.16, 95%CI:0.13-0.20) and offers to centers with higher median 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 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 post-transplant survival (adjusted hazard ratio:0.93, 95%CI:0.86-1.01) when compared to 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.