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Solid Organ Transplantation Overview and Selection Criteria

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Solid Organ Transplantation Overview and Selection Criteria n REPORTS n Solid Organ Transplantation Overview and Selection Criteria Cesar A. Keller, MD ver the past 6 decades, solid organ trans- Abstract plantation has evolved from an experimen- tal procedure to a standard-of-care, lifesaving The field of solid organ transplantation has seen significant advances in surgical procedure, and survival rates have improved Oin a relatively short time frame. The field has come a long techniques, medical diagnosis, selection process, and pharmacotherapy over the past way since the first documented successful kidney trans- 6 decades. Despite these advances, how- plantation was performed between living identical twins ever, there remains a significant imbalance by Joseph Murray, MD, and John Merrill, MD, in 1954.1,2 between the supply of organs available for transplant and the number of patients reg- Unfortunately, similar© Managed operations Care in nonmatched & pairs did istered on transplant waiting lists. Notably, not yield similarHealthcare success. Communications, The field of transplantation LLC con- the past decade has shown gradual increases tinued in this manner, hindered by rejection and multiple in the number of candidates waiting for a complications, resulting in only minor success and limited kidney, while the number of transplants 1-year survivals in nonmatched recipients. Subsequent fail- performed in the United States has declined ures and successes demonstrated a need for refined, targeted, every year for the past 3 years. The waiting list for heart transplants has been the most and titratable immunosuppression, as well as recognition, rapidly growing list. Fortunately, policies management, and prophylaxis of secondary infection com- designed to improve procurement, screen- plications to propel the field forward. It was not until cyclo- ing, and distribution are helping to make sporine was introduced in the 1980s that the modern era of transplantation more efficient and organs solid organ transplantation began. more accessible, allowing sicker patients to undergo transplants more quickly. This arti- Over the past 3 decades, success in the refinement of anti- cle presents an overview of the most com- microbial agents, development of preemptive and prophylaxis mon solid organ transplantations performed strategies, enhancement in monitoring methods, and advance- (kidney, liver, heart, and lung), along with the ment of immunosuppressive induction have significantly requirements, risks, and complications asso- improved the success rates of solid organ transplantation.1,2 A ciated with them. confluence of legal parameters facilitating ethical organ dona- Am J Manag Care. 2015;21:S4-S11 tion, procurement, and allocation; advances in organ preserva- tion; and surgical, medical, and pharmacological advances in the management of infections have left cultural acceptance and supply, demand, and distribution as the biggest hurdles to overcome in the field.1-11 Solid organ transplantations are now near-routine surgical procedures in hospitals across the United States. There were 18,048 kidney transplants alone performed in the United States in 2012 (Figure 1).12 Other types of solid organ transplants For author information and disclosures, see end of text. include liver (6781), heart (2407), lung (1795), pancreas (1043), and intestine (106).12 Unfortunately, challenges continue with the procurement and distribution of organs and post opera- S4 n www.ajmc.com n JANUARY 2015 Solid Organ Transplantation Overview and Selection Criteria n Figure 1. Adult and Pediatric Transplants Performed per Year12 20 3 Kidney Heart 15 2 Lung 10 Pancreas Liver 1 5 Patients Patients in Thousands Intestine 0 0 98 00 02 04 06 08 10 12 98 00 02 04 06 08 10 12 Year n Figure 2. Number of Patients on Waiting Lists for Donor Organs (on December 31 of each respective year, active listings only)12 60 3 Kidney Heart 40 2 Kidney/ Pancreas Lung 20 1 Liver Pancreas (PTA & PAK) Patients Patients in Thousands Intestine 0 0 98 00 02 04 06 08 10 12 98 00 02 04 06 08 10 12 Year Kidney: patients receiving a kidney alone or simultaneous kidney-pancreas transplant. Lung: patients receiving a lung alone or simultaneous heart-lung transplant. Other organs: patients receiving a transplant. Retransplants are counted. PAK indicates pancreas and kidney transplant; PTA, pancreas transplant alone. tive management: in 2012, almost 58,000 active candi- Kidney Transplantation: Overview and Selection dates were on the kidney transplant waiting list, a 3.5% Overview increase from 2011 (Figure 2).12 Also, the number of Kidney transplant is one of the most cost-effective heart transplants performed increased by 2.0% between surgical interventions and, by far, the most common type 2011 and 2012, but the number of patients on the wait- of transplant procedure performed. Consequently, it is ing list increased by 10.4%. And although the numbers encountered more often in clinical practice than other of patients on the wait lists for liver and lung trans- solid organ transplantations and is the most researched plants decreased by 1.8% and 2.9%, respectively, this still solid organ transplant (Figure 1).12 Compared with dialy- resulted in a disparity with the number of transplants sis, successful kidney transplantation improves long-term performed (declines of 3.9% and 6.2% for lung and liver survival and quality of life for most end-stage renal transplants, respectively). Overall, a shortage of deceased disease patients. And for patients under 70 years of age, donor organs for transplantation has led to the disparity post transplant outcomes are better when the transplant between patients in need and organs available.12 This is performed prior to initiation of dialysis (as outcomes section provides an overview of the most common solid decline with each additional year of pre-transplant dialy- organ transplantations performed (kidney, liver, heart, sis).12 Despite this successful track record, The Organ and lung) and describes changes in waiting list and alloca- Procurement and Transplantation Network (OPTN) tion requirements that will make the process more effec- database shows that the number of candidates added to tive, improve outcomes, and reduce complications. the wait list for a kidney transplant has increased every VOL. 21, NO. 1 n THE AMERICAN JOURNAL OF MANAGED CARE n S5 Reports n Figure 3. Kidney Transplant Waiting List: Trends Over Time (in years)12 Time on wait list Time on dialysis 100 80 11 + 5+ 6-<11 60 4-<5 4-<6 3-<4 3-<4 40 2-<3 2-<3 1-<2 20 1-<2 <1y <1y 0 98 00 02 04 06 08 10 12 98 00 02 04 06 08 10 12 Year year for the past decade, while the number of transplants ing their cost savings for the healthcare system, make performed each year has declined. effective procurement and distribution of organs equally In 2011, approximately 40% of adult patients on the critical in optimizing the transplant system from both a kidney transplant wait list were aged between 50 and 64 patient and a managed care perspective.12 years, 34% between 35 and 49 years, and 14% between 18 and 34 years. About one-third of the patients remained Selection Criteria on the list for less than a year, and more than 42% Kidney transplant candidates have irreversible remained on the list for more than 2 years (Figure 3).12 chronic kidney disease with estimated glomerular fil- The median time to transplant for the adult patients tration rates less than 30 mL/min per 1.73 m2 without on the wait list was 4.2 years in 2008, an increase known contraindications such as active infection, active from 2.7 years in 1998.12 Of the 26,263 adult patients neoplastic disease, significant systemic illnesses with taken off the transplant list in 2012, 20% died prior to limited survival, and active substance abuse. The major- receiving a transplant and 8% were removed because ity of kidney transplants in the United States come from they were too sick to undergo a transplant. Between deceased donors; however, a sizable number of kidney 2010 and 2012, more than 21,000 adult patients were transplants are conducted using living donors, related or taken off the wait list due to death or being too sick to unrelated to the recipient.12 undergo a transplant. Unfortunately, despite the need Organ supply is the primary rate-limiting factor affect- for kidney donation, the rate of discarded kidneys has ing the number of transplant procedures that can be increased over the past decade, and the rate of living performed. Therefore, limiting the discard rate and opti- donor transplants has decreased from 6674 in 2004 to mizing the longevity of the organ is critically important to 5622 in 2012.12 the individual patient, particularly those on the waiting In 2013, this continued disparity led the OPTN to list, as well as the overall population.12 The changes in the introduce a new kidney allocation system, which is kidney allocation system should further decrease access expected to assist in the allocation of organs to broaden variability by candidate blood type, sensitization level, patient access, limit discard rates, and improve sur- and geographic location.12 vival—although it will not be able to solve the problem A point system will be used to assign donor kidneys of a shortage in the supply of donor kidneys.12 Despite and candidates a score12: donor kidneys will be assigned these limitations and the challenges of immunosuppres- a Kidney Donor Profile Index (KDPI) score, ranging sive therapy and related complications such as infection, from 0% to 100%, that is associated with the functional- cardiovascular disease, and neoplasia, kidney transplant ity of the kidney relative to other kidneys. The receiving remains the treatment of choice for end-stage renal dis- candidate will be assigned an Estimated Post Transplant ease and offers significant survival benefits compared Survival (EPTS) score, also ranging from 0% to 100%, with other renal replacement therapies (eg, dialysis).
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