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Deceased donor organs for transplantation are costly. Expenses include donor assessment, pre-operative care of acceptable donors, surgical organ recovery, preservation and transport, and other costs. US Organ Procurement Organizations (OPOs) serve defined geographic areas in which each OPO has exclusive organ recovery responsibilities including detailed reporting of costs. We sought to determine the costs of procuring deceased donor livers by examining reported organ acquisition costs from OPO cost reports. Using 6 years of US OPO cost report data for each OPO (2013-2018), we determined the average cost of recovering a viable (i.e., transplanted) liver for each of the 51 independent US OPOs. We examined predictors of these costs including the number of livers procured, the percent of nonviable livers, direct procurement costs, coordinator salaries, professional education, and local cost of living. A cost curve estimated the relationship between the cost of livers and the number of locally procured livers. The average cost of procured livers by individual OPO-year varied widely from $11 393 to $65 556 (average $31 659) over the six study years. An increase in the overall number of procured livers was associated with lower direct costs, administrative, and procurement overhead costs, but this association differed for imported livers. Cost per local liver decreased linearly for each additional liver, while importing more livers was only cost saving until 200 livers, with imported livers costing more ($39K vs. $31.7K). The largest predictor of variation in cost was the aggregate of direct costs (e.g., hospital costs) to recover the organ (57%). Cost increases were 2.5% per year (+$766/year). This information may be valuable in determining how OPOs might improve service to transplant centers and the patients they serve., (© 2024 The Author(s). Clinical Transplantation published by Wiley Periodicals LLC.)

To predict whether the COVID-19 pandemic and transplant center responses could have resulted in preventable deaths, we analyzed registry information of the US end-stage renal disease (ESRD) patient population awaiting kidney transplantation. Data were from the Organ Procurement and Transplantation Network (OPTN), the US Centers for Disease Control and Prevention, and the United States Renal Data System. Based on 2019 OPTN reports, annualized reduction in kidney transplantation of 25%-100% could result in excess deaths of wait-listed (deceased donor) transplant candidates from 84 to 337 and living donor candidate excess deaths from 35 to 141 (total 119-478 potentially preventable deaths of transplant candidates). Changes in transplant activity due to COVID-19 varied with some centers shutting down while others simply heeded known or suspected pandemic risks. Understanding potential excess mortality for ESRD transplant candidates when circumstances compel curtailment of transplant activity may inform policy and procedural aspects of organ transplant systems allowing ways to best inform patients and families as to potential risks in shuttering organ transplant activity. Considering that more than 700 000 Americans have ESRD with 100 000 awaiting a kidney transplant, our highest annual estimate of 478 excess total deaths from postponing kidney transplantation seems modest., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

In order to define current issues and outcomes of living kidney donation, 100 consecutive living donors operated on between July 1996 and March 2001 were evaluated. The 64 women and 36 men ranged in age from 19 to 72 yr (mean 42.5 yr), and 65 were related to the recipient while 35 were unrelated donors. Hospital admission the morning of surgery and use of a minimal open approach to the donor kidney were standard, as were post-operative epidural pain control and plans for short hospital stay. The 100 donors were hospitalized for 2 (25), 3 (48), 4 (18), 5 (8), or 6 (1) days, with an average length of stay of 3.12 d (range 2-6 d). The mean charge for kidney donor hospitalization was 14,470 dollars (range 9671-22,808 dollars). There were no major intra or immediate post-operative complications. Six rehospitalizations occurred for post-donation nausea, vomiting, dehydration (n = 2); spinal headache; pneumonia and wound haematoma; and late wound reexploration (one hernia and one nerve entrapment). All donors returned to pre-operative functional status within 6 d to 6 wk of donation. All kidneys functioned immediately in the 100 recipients (50 women, 50 men) who averaged 46.6 yr of age (range 17-69 yr); recipient length of stay averaged 3.81 d (range 2-15 d). All donors survived in excellent health; recipient graft and patient survival, respectively, are 87 and 90% through the entire 5-yr period. Excellent long-term outcomes for living kidney donors may be accomplished using minimal open surgical technique, post-operative epidural pain control and plans for a brief hospitalization. Expansion of living donor resources in renal transplant programs may grow as unrelated kidney donation and non-directed donation as well as minimally invasive (open and laparoscopic) techniques evolve.

To determine donor nephrectomy outcomes, a one page 20-item survey of 42 cases was reviewed, including demographics, intervals to normal activities (e.g., driving a car, returning to work), and an open inquiry about the donation process. Hospital records were also reviewed. Nephrectomy under general anesthesia was through an anterior flank, extra-retroperitoneal approach with postoperative epidural pain control. Early self-care, progressive ambulation, and prescriptive pulmonary care were undertaken to facilitate recovery. Length of stay averaged 3.4 (range 2-8) d, and mean hospitalization charge was $15 169 (range $10 733-S29 579). Thirty-four donors were employed outside the home; 18 (53%) returned to work within 4 wk, and the average duration away from work was 4.6 wk (range 6 d 10 wk). Within 2 wk, 25 (59%) were driving an automobile. Usual activities of daily living were fully performed by all donors at a mean of 4.8 wk (minimum 5 d). Forty respondents would donate again, and one might; one did not respond to this question. None reported intermediate or long-term disabilities and all reported return to their pre-donation level of activity. With the anterior extra-retroperitoneal nephrectomy, most donors were out of the hospital within 4 d, were driving within 2 wk, and returned to gainful employment within 4 wk. Living kidney donation, as viewed by the donors, was a positive experience, which appeared to disrupt their lives minimally.

For 140 consecutive renal transplants performed from January 1995 to October 1997, 25 (18%) were from living-unrelated donors (15 women, 10 men, aged 25-63, mean 43 yr). All donors had pre-transplant imaging evaluation of renal anatomy following renal function assessment (minimal creatinine clearance 75 cm3/min). Admission to the hospital on the day of donation preceded nephrectomy under general anesthesia using an anterior flank, extra-retroperitoneal approach (no rib resection). Post-operative epidural pain control was used for all but 1 donor. The 25 kidney donors were hospitalized for 2 (n = 1), 3 (n = 12), 4 (n = 7), or 5-8 d (n = 5) (average 3.9 d) and had a mean hospitalization charge of $15,501 (range $10,808-$29,579). One intra-operative hemorrhage required transfusion; 1 late neural-related pain syndrome required outpatient wound exploration. Two kidneys were lost: a husband recipient from repetitive acute rejections at 3 months; a friend recipient from chronic rejection at 2.5 yr; both await cadaver transplant. The other 23 kidneys are functioning with a mean serum creatinine of 1.8 (range 1.0-3.3) at 3-36 months (patient survival 100%; graft survival 92%). While most donors were spouses (8 husbands and 10 wives), friends, distant cousins, in-laws, and adoptive relatives did well as donors and recipients. Transplantation may increase by 20% or more at centers which encourage broad application of living donor nephrectomy.

Of 96 consecutive renal transplants in 2 years, 50 (52%) were living donor grafts. Donor demographics, treatment plans, length of stay (LOS), charges, and complications were reviewed. Donors included 27 women and 23 men aged 22 to 61 (mean 42.2) years; 33 were living related and 17 living unrelated donors. Racial distribution included 1 Hispanic, 2 Asian, 8 black, and 39 white donors. Pretransplant evaluation defined renal anatomy and function (minimal creatinine clearance 75 cc/min). Hospital admission occurred the morning of donation. Nephrectomy under general anesthesia entailed an anterior flank, extra-retroperitoneal approach (no rib resection); and postoperative epidural pain control was standard. Progressive early ambulation and pulmonary self-care optimized recovery. The 50 donors were hospitalized for 2 (n = 7), 3 (n = 18), 4 (n = 15), 5 (n = 6), and 6-8 (n = 4) days (mean LOS: 3.74 +/- 0.17, range 2-8 days). The mean charge for donor hospitalization was $15,415 +/- $397 (range $10,808-$29,579). One major intraoperative hemorrhage required transfusion; 1 patient was readmitted for wound drainage and pneumonia treated medically. While 40 of 50 patients (80%) were hospitalized for 4 days or less, there was no readmission because of short hospital stay. One early graft loss (3 days) occurred from technical problems; all others gained excellent life sustaining function. Three additional kidneys failed from rejection, noncompliance, and systemic coagulopathy. One recipient died at 8 months (CVA) with normal renal function. Current strategies for successful living kidney donation are thorough patient and family education, ambulatory preoperative testing, morning of surgery admission, and discharge planning beginning before hospitalization. Excellent outcomes may be accompanied by a brief LOS, epidural pain management, and liberal use of willing and healthy related and unrelated living donors.

To determine if repeated HLA mismatches and other putative risk factors were predictive of second graft failure in second grafts performed at Southeastern Organ Procurement Foundation (SEOPF) members centers, we identified a cohort of 753 retransplants in which one or more HLA antigens were mismatched in primary grafts. Of this group, 158 (21.1%) received second grafts with repeated mismatches of one or more HLA-A, B, or DR antigens that were previously mismatched in the primary graft (RMMs). All regrafts were cadaveric kidneys transplanted between 1982 and 1995. Multivariate analysis of 19 covariates in 438 regrafts identified four independent factors that were predictive of graft survival frequency in second transplants. Three of the four factors were associated with a reduced risk for graft loss in retransplants: cyclosporin A (CsA) use in graft (p = 0.0001, RR = 0.26), peak PRA < 50% (p = 0.008, RR = 0.52) and white donor race (p = 0.035, RR = 0.63). One factor was associated with an increased risk of second graft failure, namely, blood transfusion prior to the first graft (p = 0.026, RR = 5.14). None of the other 15 factors exerted significant additional risk to regraft survival frequency in these SEOPF data. In multivariate analysis, RMMs were not associated with altered graft survival frequency in regrafts (p = 0.944, RR = 0.99). We than used univariate analyses to determine whether RMMs had adverse effects on GS in particular subsets of recipients that were thought to be at increased risk for the second transplant failure. Univariate analyses were performed with methods that are sensitive to early events (Wilcoxon) and late events (log-rank). The variables tested were CsA use for the regraft, duration of primary graft function, panel reactive antibody levels (PRA), immunopathologic cause of first graft failure, and HLA mismatch of the second graft. These analyses indicated that repeated HLA mismatches were not an associated risk factor in any of these subgroups. These SEOPF data indicate that RMMs are not predictive of increased frequency of graft loss in cadaveric donor second transplants. We conclude that our results do not support a policy of routine avoidance of RMMs, which may result in increased waiting time for a second donor without providing an improved graft survival rate. The available literature suggests that HLA antibody identification, the use of sensitive flow cytometric and antiglobulin-augmented cross-match tests, together with appropriate donor selection, optimal immunosuppression and patient management may be sufficient to avoid the early loss of second grafts.