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We read with interest the study by Wong et al. (1) We congratulate the authors for the commendable work. We would like to share our concerns regarding the study. There were a greater number of patients with hepatorenal syndrome (HRS) in the deceased donor liver transplantation (DDLT) group than living donor liver transplantation (LDLT) group. (1) Presence of HRS, even in a low model for end-stage liver disease (MELD) patient, increases the risk of waitlist mortality which may be one of the reasons for higher waitlist mortality in the DDLT group.

Purpose Priority on waitlist urgency over post-transplant survival has decreased waitlist mortality with no appreciable change in short to mid-term survival. We sought to define the effects of increased pressure to transplant sicker candidates on PGD incidence and mortality as a leading indicator for long-term effects. Methods We used the multi-center prospective Lung Transplant Outcomes Group cohort study, designed to identify risk factors for PGD and mortality. Patients were enrolled from August 2011 to June 2018 at 10 centers. PGD was graded based on the 2016 PGD consensus ISHLT guidelines. Specifically, PGD was defined as grade 3 PGD (PaO2 /FiO2 ratio Results 1,528 subjects were enrolled with a 25.6% incidence of PGD overall. PGD incidence increased from 14.3% to 38.2% over the course of the study. From 2012 to 2018, the median LAS increased from 38.7 to 42.9 and the use of ECMO salvage increased from 5.7% to 20.9% (Fig.1a). PGD was associated with mortality overall (p=0.0001, Fig.1b). Bridging strategies were not associated with mortality (p=0.66); however, salvage ECMO for PGD was significantly associated with mortality (HR 2.1 [1.6; 2.8]; p Conclusion Severity of illness continues to rise in modern surgical practice paralleled by significant increases in PGD incidence. Bridging strategies have increased but appear safe. PGD is highly associated with mortality and is increasingly treated with salvage ECMO. Though early mortality associated with salvage strategies is low, 1-year survival is significantly reduced. Given the increase in use of salvage ECMO, further work is needed on evaluating 2016 PGD definition.

Purpose Studies suggest that pediatric heart transplant (HT) waitlist mortality has declined. The impact of factors like refinements to the heart allocation system, patient selection, greater ABO incompatible (ABO-I) HT and VAD support are unknown. We examined the 20-year trend in waitlist mortality to identify factors associated with declining mortality and whether allocational inefficiencies persist. Methods All children Results Overall 11,374 patients met inclusion criteria (3,248 in Era 1; 5,378 in Era 2; 2,748 in Era 3). Waitlist mortality declined significantly across eras (21%, 17%, 13%, P Conclusion Pediatric HT waitlist mortality has declined significantly over the past 20 years. There is evidence to suggest that greater VAD use, revisions to organ allocation, refinements in patient selection and ABO-I transplant may all contribute. Organ allocation inefficiencies persist under the current allocation system suggesting opportunities for allocation improvement may still exist.

Background & Aim The goal of organ allocation is to distribute a scarce resource equitably to the sickest patients. In the United States, the Model for End-stage Liver Disease (MELD) is used to allocate livers for transplantation. Patients with greater MELD scores are at greater risk of death on the waitlist and are prioritized for liver transplant (LT). The MELD is capped at 40 however, and patients with calculated MELD scores >40 are not prioritized despite increased mortality. We aimed to evaluate waitlist and post-transplant survival stratified by MELD to determine outcomes in patients with MELD >40. Methods Using United Network for Organ Sharing data, we identified patients listed for LT from February 2002 through to December 2012. Waitlist candidates with MELD ⩾40 were followed for 30days or until the earliest occurrence of death or transplant. Results Of 65,776 waitlisted patients, 3.3% had MELD ⩾40 at registration, and an additional 7.3% had MELD scores increase to ⩾40 after waitlist registration. A total of 30,369 (46.2%) underwent LT, of which 2,615 (8.6%) had MELD ⩾40 at transplant. Compared to MELD 40, the hazard ratio of death within 30days of registration was 1.4 (95% CI 1.2–1.6) for patients with MELD 41–44, 2.6 (95% CI 2.1–3.1) for MELD 45–49, and 5.0 (95% CI 4.1–6.1) for MELD ⩾50. There was no difference in 1- and 3-year survival for patients transplanted with MELD >40 compared to MELD=40. A survival benefit associated with LT was seen as MELD increased above 40. Conclusions Patients with MELD >40 have significantly greater waitlist mortality but comparable post-transplant outcomes to patients with MELD=40 and, therefore, should be given priority for LT. Uncapping the MELD will allow more equitable organ distribution aligned with the principle of prioritizing patients most in need. Lay summary: In the United States (US), organs for liver transplantation are allocated by an objective scoring system called the Model for End-stage Liver Disease (MELD), which aims to prioritize the sickest patients for transplant. The greater the MELD score, the greater the mortality without liver transplant. The MELD score, however, is artificially capped at 40 and thus actually disadvantages the sickest patients with end-stage liver disease. Analysis of the data advocates uncapping the MELD score to appropriately prioritize the patients most in need of a liver transplant.

Aim Geographic disparities persist in the U.S. despite locoregional organ sharing policies. The impact of national organ sharing policies on waiting-list mortality on a regional basis remains unknown. Methods Data on all adult liver transplants between February 1, 2002 and March 31, 2015 were obtained from UNOS/OPTN. Multivariable Cox proportional hazards models were constructed in a time-to-event analysis to estimate waiting-list mortality for the pre- and post-Share35 eras. Results 134,247 patients were listed for transplantation and 54,510 received organs (42.8%). Listing volume increased following Share35 (15,976 candidates pre- vs. 18,375 post) without significant regional changes as did number of transplants (7,210 pre- vs. 8,224 post). Waiting-list mortality improved from 12.2% to 8.1% (p35 candidates. The disparities highlighted by our findings imply a need to review current allocation policies to best balance local, regional, and national transplant environments.

Considerable strides have been made over the last several decades toward improving outcomes in pediatric liver transplantation. Refinements in surgical technique has allowed for the use of living donor and deceased donor split-liver grafts, thus expanding the pool of available organs and reducing waitlist mortality. The use of a multidisciplinary team continues to be paramount in the care of the transplant recipient. With improvements in overall graft and survival, indications for liver transplantation have also broadened. Currently, pediatric transplant patients have a 5-year survival of over 85%. Long-term morbidity is mainly associated with complications from immunosuppression and chronic rejection. Here we review indications for liver transplantation in children, surgical considerations, post-operative complications, and long-term outcomes.

This article reviews the historical evolution of the current deceased donor liver allocation and distribution policy in the USA and describes the continued efforts to address limitations within our current allocation system. Due to the finding that hyponatremia is an independent predictor of mortality, since January 2016, the Model for End-stage Liver Disease (MELD)-Na score incorporating serum sodium is now used for patients with MELD score

The purpose of this review is to discuss the current state of donor lung allocation in the United States and future opportunities to increase the efficiency of donor lung allocation. The current donor lung allocation system prioritizes clinical acuity by the use of the lung allocation score (LAS) which has reduced waitlist mortality since its implementation in 2005. Access to donor lungs can be further improved through policy changes using broader geographic sharing and developing new technology such as ex vivo lung perfusion to recover marginal donor lungs. The number of lung transplants in the US continues to increase annually. However, the demand for donor lungs continues to be outpaced by an ever-growing waitlist. Efficient allocation can be achieved through improved allocation policies and new technology.

Purpose Transplant demand continues to exceed supply. With advances in hepatitis C virus (HCV) treatment, HCV+ donors have recently been considered suitable for select recipients; here we investigate the effects of transplantation of HCV+ donors on waitlist mortality and transplant survival. Methods Retrospective review of the Organ Procurement and Transplantation Network database was performed across two time periods - HCV+ donor era (6/'17-6/'19) and control (1/'13-1/'15). UNOS regions 1, 2, 5, 9 and 11 were analyzed as the highest volume HCV+ donor transplantation regions. Baseline characteristics were compared across periods and between transplants from HCV+ donors, as well as outcomes related to waitlist mortality, adverse events, graft failure and patient survival. Results 3,880 patients were included in the HCV+ donor era, of which 2,007 (51.7%) were transplanted. 232 (11.6%) received organs from HCV+ donors. 3688 patients underwent listing from the control era, of which 2,085 (56.5%) were transplanted. Baseline characteristics across eras demonstrated a greater proportion of HCV+ donor era transplants performed for restrictive cardiomyopathy (9.3% vs. 6.7%, p =0.012) and as multi-organ transplants (10.2% vs. 5.5%, p Conclusion Transplantation of HCV+ donor hearts safely and effectively expands the donor pool, and shows promise in decreasing both waitlist time and mortality without compromising graft quality. Continued re-assessment is essential to ensure long-term safety and efficacy of utilizing HCV+ donors.

Purpose In adults, female (F) and African American (AA) heart transplant (HT) recipients have higher waitlist (WL) and post-transplant (PT) mortality. Our study aims to evaluate gender and racial disparities in pediatric recipients and its effect on survival in the WL and PT period in the current era. Methods Pediatric ( Results 1435 (44%) F were listed for HT during the study period. Compared to males (M), F recipients listed for HT were younger, more likely AA (19 vs. 22%), and cardiomyopathy [CMP] (41.3 vs. 51.4%) [p 0.05 for all]. 663 (20%) AA HT candidates were listed. Compared to Caucasian, AA recipients more likely had CMP (41.3 vs. 49.5%), listed Status 1A (68.7 vs. 72.9%), had renal dysfunction (47.4 s. 53.4%) and were on Medicaid (33.3 vs. 65%) [p Conclusion In the current era, pediatric heart transplant recipients who are F and AA continue to have higher waitlist mortality. Such disparities do not exist post-transplant.

Purpose Ventricular assist device (VAD) support has drastically improved waitlist mortality for pediatric patients awaiting heart transplant (HT). However, VAD support for single ventricle (SV) patients remains challenging, particularly in smaller patients with non-Fontan physiology. Unfortunately, waitlist mortality and morbidity are also significant in this subset of SV patients, and the risks of VAD support should be examined in the context of waitlist risks. We examined clinical deterioration while on the waitlist for a subset of SV patients for whom VAD support remains challenging. Methods We performed a retrospective review of all single ventricle patients listed for HT at a single pediatric center from 2012-2018. Patients Results Thirty-three SV patients were included. Median weight was 7.6 kg (IQR 5.1, 11.5), 58% were s/p Glenn, 21% Norwood, 18% hybrid or banding, and 3% unrepaired. Over a median 89 day (43, 206) of waitlist time, 21 (64%) were transplanted, 8 (24%) died or were removed for deterioration, and 4 (12%) were alive waiting or removed for improvement. Of the 21 transplanted, 7 had escalation of support by time of HT, for an overall waitlist deterioration of 45% (n=15/33, Figure 1A). From listing to HT, inotrope use increased from 48% to 71%, intubation 19% to 24%, and VAD 5% to 19%. At time of HT, 43% were in ICU and 29% were NPO for feeding intolerance. Survival to HT was similar between patients on VAD versus not on VAD support (67% vs 78%, p-value = 0.65, Figure 1B). Conclusion Single ventricle infants are at high risk for death and clinical deterioration while waiting for HT. While VAD support remains challenging for this population, it can be a successful means of bridging to transplant.

On November 24, 2017, a change in lung allocation policy was initiated to replace the donor service area with a 250-nautical-mile radius circle around the donor hospital. We aim to analyze the consequences of this change, including organ acquisition cost and transplant outcomes, at the national level.Data on adult patients undergoing lung transplantation between April 27, 2017, and June 22, 2018 (30 weeks before to 30 weeks after allocation policy change) were extracted from the Scientific Registry of Transplant Recipients database. Patients were classified into pre-change and post-change subgroups. Six-month overall survival was evaluated by Kaplan-Meier analysis. Organ acquisition costs were compared between the pre-change and post-change groups.Of the 3317 adult patients removed from the waiting list during the study period (pre-change 1637 vs post-change 1680), 2734 underwent transplantation (pre-change 1371 of 1637 [83.8%] vs post-change 1363 of 1680 [81.1%]), and 382 died or became too sick to be transplanted (pre-change 168 of 1637 [10.3%] vs post-change 214 of 1680 [12.7%], P = .077). Six-month survival rates of transplanted patients were similar between the two groups. However, average organ acquisition costs increased after policy change (pre-change $50,735 ± $10,858 vs post-change $53,440 ± $10,247, P.001) with an increase in nonlocal donors (pre-change 44.3% vs post-change 68.9%, P.001).Organ acquisition costs and resource utilization increased with the new lung allocation policy, whereas deaths on the waiting list or after transplantation did not decrease. Further optimization of the allocation policy is necessary to balance access to transplant and proper stewardship of human and financial resources.

Canadian lung transplant centers currently use a subjective and dichotomous "Status" ranking to prioritize waitlisted patients for lung transplantation. The lung allocation score (LAS) is an objective composite score derived from clinical parameters associated with both waitlist and post-transplant survival. We performed a retrospective cohort study to determine whether clinical judgment (Status) or LAS better predicted waitlist mortality. All adult patients listed for lung transplantation between 2007 and 2012 at three Canadian lung transplant programs were included. Status and LAS were compared in their ability to predict waitlist mortality using Cox proportional hazards models and C-statistics. Status and LAS were available for 1122 patients. Status 2 patients had a higher LAS compared to Status 1 patients (mean 40.8 (4.4) vs 34.6 (12.5), P = .0001). Higher LAS was associated with higher risk of waitlist mortality (HR 1.06 per unit LAS, 95% CI 1.05, 1.07, P < .001). LAS predicted waitlist mortality better than Status (C-statistic 0.689 vs 0.674). Patients classified as Status 2 and LAS ≥ 37 had the worst survival awaiting transplant, HR of 8.94 (95% CI 5.97, 13.37). LAS predicted waitlist mortality better than Status; however, the best predictor of waitlist mortality may be a combination of both LAS and clinical judgment.

Outcomes for advance heart failure have improved more with the development of mechanical circulatory support devices and improved transplantation techniques. 3D modeling has been instrumental in the sizing of large devices, expanding the treatment pool to smaller adults and children. In addition, 3D computational modeling techniques have aided in the design of smaller devices, enabling placement in smaller spaces and/or in patients with complex congenital heart disease. Virtual implantation of devices has extended into virtual heart transplantation with the hopes of expanding the donor pool and minimizing waitlist mortality.

Heart transplant waitlist mortality remains high in infants1 year of age and among those with CHD. Currently, the median accepted donor-to-recipient weight percentage is approximately 130% of the recipient's weight. We hypothesized that patients with CHD may accept a larger organ using novel 3D-derived imaging data to estimate donor and recipient TCV.A single-center, retrospective study was performed using CT data for 13 patients with CHD and 94 control patients. 3D visualization software was used to create digital 3D heart models that provide an estimate of TCV. In addition, echocardiograms obtained prior to cross-sectional imaging were reviewed for presence of ventricular chamber dilation.Sixty-two percent (8/13) of patients with CHD had 3D-derived TCV resulting in a weight that was130% larger than their actual weight. This was seen in single-ventricle patients following Blalock-Taussig shunt and Fontan palliation, and patients with biventricular repair. Of those, 75% (6/8) had reported moderate-to-severe ventricular chamber dilation by echocardiogram or cardiac magnetic resonance imaging.In a large portion of patients with CHD, 3D-derived TCV place the recipient at a higher listing weight than their actual weight. We propose obtaining cross-sectional imaging to better assess TCV in a recipient, which may increase the donor range for CHD recipients and improve organ utilization in pediatrics.

Cardiac transplantation for children with end-stage cardiac disease with no other medical or surgical options is now standard. The number of children in need of cardiac transplant continues to exceed the number of donors considered "acceptable." Therefore, there is an urgent need to understand which recipients are in greatest need of transplant before becoming "too ill" and which "marginal" donors are acceptable in order to reduce waitlist mortality. This article reviewed primarily pediatric studies reported over the last 15 years on waitlist mortality around the world for the various subgroups of children awaiting heart transplant and discusses strategies to try to reduce the cardiac waitlist mortality.

Frailty in liver transplant (LT) waitlisted patients has been shown to predict waitlist mortality. While not currently used to allocate organs, the relationship between preoperative frailty and postoperative outcomes following orthotopic LT needs further elucidation. We determined the frailty status of 50 OLT candidates listed for hepatocellular carcinoma (HCC) and examined relationships between frailty and outcomes on the waitlist and, if transplanted, 30-day mortality, hospital length of stay (LOS), ICU LOS, and several other secondary outcomes. The overall prevalence of frailty was 30%, and the median natural MELD score for patients was 13. The overall hospital LOS for the frail group was longer (14.5 days [IQR 12-19]) as compared to the non-frail group (8 days [IQR 7-13]); P = .015. Groups also differed in the time to their first PT session (6 days [IQR 4-15] for the frail vs 4 days [IQR 3-7] for the non-frail patients; P = .042). There was no statistically significant difference in other outcomes measures, including ICU LOS and 30-day mortality. Frailty in OLT patients with diagnosed HCC is a predictor of longer hospital stay and longer time to the first completed PT session independent of preoperative MELD scores.

Rapid advances in the field of mechanical circulatory support (MCS) have dramatically changed the management of pediatric patients with heart failure. There is now emphasis on timely implantation of ventricular assist devices (VADs) to preserve or recover end-organ function, and increased focus on post-implant management to improve the stroke rate. Transplant waitlist mortality has significantly decreased in the era of VAD use. Devices approved for adults are being used off-label in children with excellent outcomes, allowing chronic therapy and discharge home to become part of pediatric VAD therapy.

The development of frailty and sarcopenia has many shared risk factors with the occurrence of cirrhosis. In turn, cirrhosis influences the course of frailty and sarcopenia. Frailty and sarcopenia metrics can be used to enhance current recipient selection and prioritization tools such as the MELD score, in order to reduce waitlist mortality and improve long-time prognosis for transplanted patients. Both syndromes may be influenced by interventions prior to and after transplantation. Strategies should be multidimensional and, at least, be a combination of nutrition, exercise, and ammonia-lowering therapies with or without novel pharmacological therapy. In order to enhance selection of patients and enact interventions, a standardized and practical definition of frailty and sarcopenia is required. Only in this way can the prognostic implications of these syndromes be employed to their full potential to improve care in transplantation patients.

Heart transplant providers often focus on post-transplant outcomes when making donor decisions, potentially at the expense of higher waitlist mortality. This study aimed to assess public opinion regarding the selection of donor hearts and the balance between pre- and post-transplant risk. The authors generated a survey to investigate public opinion regarding donor acceptance. The survey was shared freely online across social media platforms in April-May 2019. A total of 718 individuals responded to the survey, with an equal distribution between patients and family members. Respondents consistently favored post-transplant outcomes over waitlist outcomes. About 83.9% of respondents favored a hospital with longer waitlist times, worse waitlist outcomes, but excellent post-transplant survival over a hospital with short waitlist times, a high waitlist survival, and inferior post-transplant survival. This preference was no different between pediatric and adult populations (P = .7), patient and family members (P = .935), or those with a pre- vs post-transplant perspective (P = .985). Patients and their family members consistently favor improved post-transplant survival over waitlist survival when considering the risks of accepting a donor organ. These findings suggest that current practice patterns of donor selection align with the opinions of patients and family members with heart failure or who have undergone heart transplantation.

Graft allocation rules for heart transplantation are necessary because of the shortage of heart donors, resulting in high waitlist mortality. The Agence de la biomedecine is the agency in charge of the organ allocation system in France. Assessment of the 2004 urgency-based allocation system identified challenging limitations. A new system based on a score ranking all candidates was implemented in January 2018. In the revised system, medical urgency is defined according to candidate characteristics rather than the treatment modalities, and an interplay between urgency, donor-recipient matching, and geographic sharing was introduced. In this article, we describe in detail the new allocation system and compare these allocation rules to Eurotransplant and US allocation policies.

Background The number of adult congenital heart disease (CHD) patients undergoing heart transplantation is increasing rapidly. CHD patients have higher surgical risk at transplantation. High-volume adult CHD transplant centers may have better transplant outcomes. Objectives This study aimed to evaluate the effect of center CHD transplant volume and expertise on transplant outcomes in CHD patients. Methods The authors studied heart transplantations in CHD patients age ≥18 years using the United Network of Organ Sharing (UNOS) database for the primary outcomes of waitlist mortality and post-transplant outcomes at 30 days and 1 year. Transplant centers were assessed by status as the highest CHD transplant volume center in a UNOS region versus all others, presence of Adult Congenital Heart Association accreditation, and adult versus pediatric hospital designation. Results Between January of 2000 and June of 2018, 1,746 adult CHD patients were listed for transplant; 1,006 (57.6%) of these underwent heart transplantation. After adjusting for age, sex, listing status, and inotrope requirement, waitlist mortality risk was lower at Adult Congenital Heart Association accredited centers (hazard ratio: 0.730; p = 0.020). Post-transplant 30-day mortality was lower at the highest volume CHD transplant center in each UNOS region (hazard ratio: 0.706; p = 0.014). Conclusions Designated expertise in CHD care is associated with improved waitlist outcomes for CHD patients listed for transplantation. Post-transplant survival was improved at the highest volume regional center. These findings suggest a possible advantage of regionalization of CHD transplantation.

In heart transplantation (HT), although blood type O organs can go to any blood type, non-O organs may not be allocated to adult O recipients. Therefore, O candidates wait longer than non-O candidates and frequently require bridging with left ventricular assist devices (LVADs). The effects of this discrepancy are rarely investigated in a large registry. The purpose of this study was to assess the association between candidates' blood type and their outcomes after HT listing.This is a retrospective cohort study using the United Network for Organ Sharing Registry, including 34,352 candidates listed for a single-organ, primary HT from January 2000 through December 2015. Main outcome measures were waitlist mortality and post-HT mortality, using blood type A as reference. We conducted inverse-probability weighting to adjust for baseline profiles.Among 34,352 candidates (median age 55, interquartile range 46-62; female 24.8%; blood type A: 13,258, AB: 1,572, B: 4,599, O:14,923), 22,714 candidates (A: 71.5%, AB: 82.1%, B: 73.0%, O: 57.5%; p0.001) underwent HT during the study period. Among recipients, bridging LVAD rate was highest in O recipients (A: 23.0%, AB: 15.3%, B: 23.4%, O: 32.1%; p0.001). After inverse-probability weighting, O patients demonstrated a significantly higher hazard of death after listing (adjusted hazard ratio 1.11, 95% confidence interval [CI] 1.07-1.16) and after HT (adjusted hazard ratio 1.07, 95% CI 1.01-1.13) as compared with A.There is a survival discrepancy among blood types. Our findings should facilitate more prospective studies to revisit current policies regarding equity in allocation, where possible.

Height explains a substantial proportion of gender-based disparity in waitlist mortality among liver transplant candidates. We sought to identify a clinically relevant height cutoff below which waitlist mortality increases significantly. We examined all nonstatus one adult liver transplant candidates from 2010 to 2014. We used a recursive application of the minimum P value approach with univariate competing risk regressions (deceased donor liver transplantation as the competing risk) to detect differences in waitlist mortality with regards to height. Of 69 883 candidates, 36% (24 819) were women and 64% (45 064) were men. Median height for all was 173 cm: 163 cm in women, 178 cm in men. The optimal search method of recursively evaluating smaller height intervals yielded 166 cm as the optimal height cutoff. Using height

Purpose We sought to determine whether the presence of a systemic SA with potential complicating factors affects waitlist and post-HT outcomes in pediatric patients. Methods This is a single-center retrospective review of pediatric patients listed for HT between January 1, 2009, and July 1, 2018. Patients were selected based on the presence of any underlying syndromes, which included chromosomal anomalies, skeletal myopathies, connective tissue disorders, mitochondrial disease,and other systemic disorders. Waitlist and post-HT outcomes were compared to those without SA. Results A total of 243 patients were listed for HT, of which 21 (9%) patients had associated SA. Of those, 16 (76%) survived to transplant, 3 (14%) died while on the waitlist, 1 (5%) improved and was removed from the waitlist, and 1 (5%) patient is currently listed. Waitlist survival was not different between those with/without an associated syndrome (P = 1.0). Among those who survived to HT, there was no difference in listing days (70 vs 90, P = .8), survival to hospital discharge [14 (93%) vs 150 (95%), P = .6], post-HT intubation days (2 vs 2 days, P = .6), or post-HT hospital length of stay (18 vs 18 days, P = .8). Overall survival during the study period post-HT was not different between groups (P = .8). Conclusion A SA was present in 9% of pediatric patients wait-listed for HT, but was not associated with an increased waitlist mortality or post-HT hospital morbidity or long-term survival. For several anomalies, HT is safe and feasible.

The Organ Procurement and Transplantation Network implemented the Collaborative Improvement and Innovation Network (COIIN) to improve the use of donors with kidney donor profile index >50%. COIIN recruited 2 separate cohorts of kidney transplant programs. Cohort A included 19 programs of 44 applicants (January 1, 2017, to September 30, 2017), and cohort B included 39 programs of 47 applicants (October 1, 2017, to June 30, 2018). We investigated the effect of COIIN on kidney yield (number of kidneys transplanted from donors from whom any organ was recovered), offer acceptance, deceased donor transplant rates, and waitlist mortality rates for January 1, 2016, to March 31, 2019. COIIN did not notably affect kidney yield or waitlist mortality rates. Cohort A, but not cohort B, had significantly higher deceased donor transplant and offer acceptance rates during its intervention period than programs not in COIIN (adjusted transplant rate ratio: cohort A, 1.08 1.171.27 , cohort B, 0.94 1.011.08 ; adjusted offer acceptance ratio: cohort A, 1.08 1.181.29 , cohort B, 0.93 1.001.08 ). Thus, COIIN improved the use of kidneys at programs in cohort A but not at those in cohort B. Further research is necessary to understand the different effects for cohorts A and B, and further monitoring of posttransplant outcomes is required.

There is considerable variability in donor acceptance practices among adult heart transplant providers; however, pediatric data are lacking. The aim of this study was to assess donor acceptance practices among pediatric heart transplant professionals. The authors generated a survey to investigate clinicians' donor acceptance practices. This survey was distributed to all members of the ISHLT Pediatric Council in April 2018. A total of 130 providers responded from 17 different countries. There was a wide range of acceptable criteria for potential donors. These included optimal donor-to-recipient weight ratio (lower limit: 50%-150%, upper limit: 120%-350%), maximum donor age (25-75 years), and minimum acceptable left ventricular EF (30%-60%). Non-US centers demonstrated less restrictive donor selection criteria and were willing to accept older donors (50 vs 35 years, P < 0.001), greater size discrepancy (upper limit weight ratio 250% vs 200%, P = 0.009), and donors with a lower EF (45% vs 50%, P < 0.001). Recipient factors were most influential in the decision to accept marginal donors including recipients requiring ECMO support, ventilator support, and highly sensitized patients with a negative XM. However, programmatic factors impacted the decision to decline marginal donors including recent programmatic mortalities and concerns for programmatic restrictions from regulatory bodies. There is significant variation in donor acceptance practices among pediatric heart transplant professionals. Standardization of donor acceptance practices through the development of a consensus statement may help to improve donor utilization and reduce waitlist mortality.

BACKGROUND. In the United States, 1 in 10 infants and 1 in 20 older children die on the liver transplant waiting list. Increasing split liver transplantation could increase organ availability for these children, without decreasing transplants in adults. METHODS. Using United Network for Organ Sharing Standard Transplant Analysis and Research data, we identified livers transplanted 2010 to 2015 that could potentially have been used for split transplant, based on strict criteria. Livers not suitable for pediatric patients or allocated to high-risk recipients were excluded. Number and distribution of potentially “split-able” livers were compared to pediatric waitlist deaths in each region. RESULTS. Of 37 333 deceased donor livers transplanted, 6.3% met our strict criteria for utilization in split liver transplant. Only 3.8% of these were actually utilized for split liver transplantation. 96% were used for a single adult recipient. Of the 2253 transplanted as whole livers, 82% of their recipients were listed as willing to accept a segmental liver, and only 3% were listed as requiring a cold ischemia time less than 6 hours. Over the same 5 years, 299 children died on the waitlist. In every United Network for Organ Sharing region, there were more potentially “split-able” livers than pediatric waitlist deaths. Thirty-seven percent of pediatric waitlist deaths occurred at transplant centers that averaged 1 or less pediatric split liver transplantation annually during the study period. CONCLUSIONS. This comparison, although not conclusive, suggests that we might be missing opportunities to reduce pediatric waitlist mortality without decreasing access for adults—using split liver transplant. Barriers are significant, but further work on strategies to increase split liver transplant is warranted.

Purpose Patients awaiting heart transplant (HTx) with temporary mechanical circulatory support (tMCS) are at high risk of waitlist mortality and are accorded higher priority under the 2018 US adult heart allocation system. To examine the effect of policy changes on racial equity, we examined outcomes based on race in these high risk patients. Methods UNOS registry was queried for adults listed for heart transplant (HTx) 1-year before and after the October 18, 2018 policy change. We examined association of race with use of tMCS (IABP+ ECMO+ percutaneous LVAD+ surgical temporary LVAD), access to transplant organs within 1-year of listing in the pre- and post-era, and 1-year post-transplant mortality. Results Of 8,015 patients listed for HTx, 62.7 % were White and 37.3% Non-White. In the pre-policy era, 290 of 4,027 (7.2%) were listed with tMCS vs 649 of 3,988 (16.3%) in the post era (p Conclusion In the current allocation policy era, the proportion of non-White patients listed for HTx with tMCS appears to be lower compared to Non-White patients, the reasons for which need to be further elucidated. However, in patients who receive tMCS bridge, waitlist mortality, transplant rate, and 1-year post-transplant survival are similar, regardless of race.

Purpose Pediatric heart transplant (PHT) patients have the highest waitlist mortality of all solid organ transplants yet more than 40% of viable hearts are unutilized. A tool for risk prediction is therefore necessary to improve organ matching in PHT. This study aims to compare and validate the PHT risk scores found in the literature. Methods The literature was searched for PHT risk prediction models. The UNOS registry was used to validate the models with a pediatric cohort ( Results Five recipient and one donor risk scores were published between 2008-2019 (Davies et al 2008, Almond et al 2012, Butts et al 2015, Zafar et al 2018, Fraser III et al 2019 and Choudhry et al 2019). The validation cohort included 1,003 PHT identified in UNOS. 50.5% of patients had a diagnosis of CHD and 42.8% of cardiomyopathy. With exception of Butts et al's model, all other models significantly predicted 1-year mortality for low- vs high-risk patients. Choudhry et al (ROC=0.70) and Davies et al (ROC=0.66) models had the highest predictive power (figure 1). Fraser III et al model was the best predictor for non-CHD patients (ROC=0.71) compared to Choudhry et al (ROC= 0.68) and Davies et al (ROC=0.67) models. Conclusion The risk model by Choudhry et al provided the best prediction for 1-year mortality. However, all published validated studies lacked advanced analytical approaches in their models. Using machine learning algorithms is important to develop an advanced tool that can risk stratify a given donor-to-recipient match for any PHT candidate.

Purpose Post heart transplantion (HT) outcomes of patients with body mass index ≥ 40 kg/m2 (morbidly obese) remain suboptimal. However, outcomes of morbidly obese patients listed for heart transplant (HT) is unknown. We sought to examine the characteristic and outcome of such patients who were listed for HT in the United States. Methods Adults listed for HT with BMI information on the Scientific Registry of Transplant Recipients database between 2000 and 2018 were included. Characteristics and outcomes of patients with BMI≥ 40 kg/m2 or = 18.5-39.99 kg/m2 were compared. The patients were followed until death, transplant or end of data availability. Waitlist mortality and successful HT were compared between groups using a Fine and Gray competing risk hazard regression model adjusted for known risk factors. Results 55,717 patients identified: 656 (1.2%) had a BMI ≥ 35 kg/m2; 13,058 (23.4%) were female. The median (25th, 75th percentile) age was 55 (45, 61) years, and the median waitlist time was 101 (27, 299) days. Severely obese patients were significantly younger (46 vs. 55 years; p Conclusion Listing of patients with BMI≥ 40 kg/m2 is declining. This cohort is at significantly higher risk for death and lower HT rates.

Purpose The use of temporary mechanical circulatory support (tMCS) as a bridge to transplant (BTT) has increased after the 2018 UNOS heart allocation policy. To understand the influence of these policy changes on sex equity, we examined outcomes based on sex in these high-risk patients. Methods UNOS registry was queried for adults listed for heart transplant (HTx) with a tMCS device (IABP+ ECMO+ percutaneous LVAD+ surgical temporary LVAD) 1-year before and after the October 2018 policy change. We examined association of sex with use of tMCS, time to transplant, waitlist mortality or delisting due to worsening clinical status and 1-year post-transplant survival. Results Of 8,015 patients listed for HTx, 31.8% were women. In the pre-policy change era, 290 of 4,027 (7.2%) were listed with tMCS vs 649 of 3,988 (16.3%) in the post change era (p Conclusion In the current and previous heart allocation policy era, the rate of Women listed for HTx with tMCS appears to be lower compared to Men. The reasons for these inequities of care needs to be further determined. In patients who were listed with tMCS, we did not identify sex differences in waitlist mortality, transplant rates, or survival after transplant.

Purpose Adults with congenital heart disease (ACHD) are more likely to die or be delisted while awaiting heart transplant, less likely to receive a heart transplant and more likely to die in the early (30-day) post-transplant period compared to non-ACHD patients. On October 18, 2018; the UNOS heart allocation system was redesigned providing unique listing status for ACHD patients. The impact of this change on outcomes is unstudied. Methods Using the Scientific Registry of Transplant Recipients we compared ACHD patients listed for the first-time for heart transplant from 2 eras of equal duration (new era: October 18, 2018 to June 2, 2020 and prior era: March 3, 2017 to October 17, 2020). Patients with transplants occurring in the new era who were initially listed in the prior era were excluded. We compared baseline characteristics, Kaplan Meier curves and log-rank tests to assess differences in early post-transplant mortality and the composite of waitlist mortality or delisting due to clinical worsening among those with CHD between both eras. Results Out of 535 ACHD patients listed, 293 were in the new era (4.7% of total listings) and 242 were in the prior era (3.7%). Age, sex, racial distribution, renal function, hemodynamics and need for ECMO were identical between the two groups. 163 (56%) ACHD patients in the new era versus 150 (62%) in the prior era were transplanted; 11 (3.8%) versus 15 (6.2%) died on the waitlist; 32 (11%) versus 35 (14%) were delisted and 15 (9.2%) versus 19 (12.7%) died within 30 days of transplant respectively. In the new era, ACHD patients were significantly less likely to experience waitlist mortality or delisting due to clinical worsening but had similar early post-transplant mortality compared to the prior era. Conclusion The new UNOS heart transplant allocation system improved waitlist outcomes among ACHD patients listed for heart transplant.

Objectives This study sought to assess the impact of implantable cardioverter-defibrillators (ICDs) on waitlist mortality in patients listed for heart transplantation (HT). Background The impact of ICDs on preventing sudden cardiac death in patients awaiting HT has not been studied in large multicenter cohorts. Furthermore, whether ICDs benefit patients with a left ventricular assist device (LVAD) is unknown. Methods Adults (age ≥18 years) listed for first-time HT in the United States between January 1, 1999, and September 30, 2014, were retrospectively identified from the United Network for Organ Sharing registry. The primary predictor variable was the presence of an ICD at the time of listing. Primary outcome variable was all-cause waitlist mortality. Results Data on 32,599 patients (mean age 53 ± 12 years, 77% male, 70% Caucasian) were analyzed. During median follow-up of 154 days, 3,638 patients (11%) died on the waitlist (9% in ICD group vs. 15% in no-ICD group; p Conclusions ICD use was associated with improved survival on the HT waitlist in patients with or without LVADs. These findings strengthen the current guideline recommendations of using ICDs in nonhospitalized patients awaiting HT and provide new insight into the effectiveness of ICDs on survival in LVAD-supported patients.

Summary Pediatric lung transplantation is a lifesaving option for patients with end stage lung disease, although the scarcity of suitable donor organs results in long wait times and increased waitlist mortality. Many pediatric centers consider mechanical ventilatory support, such as long-term invasive ventilation and ECMO, a contraindication to lung transplantation. We hypothesized that current survival rates and outcomes for patients on mechanical ventilatory support in the pre-transplant period were not remarkably different. In our retrospective analysis we included patients between the ages of 0–21 years listed for lung transplantation from deceased donors between 2007 and 2014 at our institution. One-year survival outcomes were compared between three groups of patients: (i) patients bridged to transplant on ECMO (n = 6, 1-year survival = 67%); (ii) patients needing mechanical ventilation (either through endotracheal intubation or tracheostomy) but not ECMO (n = 12, 1-year survival = 75%); and (iii) patients who did not need endotracheal ventilation, tracheostomy, or ECMO (n = 25, 1-year survival = 88%). Comparison of outcomes of transplanted patients between these three groups were not statistically different in terms of successful hospital discharge and 1-year survival rates (P > 0.05). We believe that “bridging” the end-stage lung disease patient with long-term mechanical ventilation and/or ECMO support is a reasonable option in selected patients until suitable donors become available. Pediatr Pulmonol. 2016; 9999:XX–XX. © 2016 Wiley Periodicals, Inc.

Background Longer wait time and poor outcomes after heart transplant (HT) have been reported among blacks and minor ethnic groups. Whether racial disparity exists in the utilization of mechanical circulatory support, waitlist mortality, and HT rates is unknown. Methods We identified the adult patients listed for HT between 2000 and 2018 in the Scientific Registry of Transplant Recipients. Recipient characteristics, including hemodynamic and biochemical variables, are compared between racial groups-blacks, Asians, and others. The patients were followed until death, transplant, or end of data availability. Waitlist mortality and successful HT were compared between racial groups using a Fine and Gray competing risk regression model adjusted for known risk factors. Results Of the 57,285 listings; 43,485 (75.9%) were whites; 11,640 (20.3%) were blacks; 1,547 (2.7%) were Asians and 613 (1.1%) were listed as others. Blacks were significantly younger, had higher BMI, non-ischemic cardiomyopathy, hypertension, renal dysfunction, and dialysis (Table). Although more blacks were listed with LVAD bridge vs. whites, ECMO utilization was significantly lower. In the 37,164 patients who received a successful HT, the median wait time to transplant was lower (p Conclusions Overall, waitlist mortality and successful transplantation rates were similar across racial groups. Black HT candidates were less likely to be bridged with ECMO compared with Whites. Asians had higher transplantation rates while supported on ECMO or IABP.

Background The patients in cardiogenic shock supported with Extracorporeal Membrane oxygenation (ECMO) or non-dischargeable biventricular mechanical support (BiVAD) are more likely to receive heart transplantation (HT) since the donor allocation system was revamped in 2018, to favor sick patients and reduce waitlist mortality. However, the patients' characteristics and outcomes bridged with BiVAD or ECMO and listed for HT in the contemporary era before the policy changed are not explored. Methods We queried the Scientific Registry of Transplant Recipients database for adults listed for HT with BiVAD or ECMO between 2000 and 2018. Recipient characteristics, including hemodynamic and biochemical variables, are compared between groups. The patients were followed until death, transplant, or end of data availability. Waitlist mortality and successful HT were compared using a Fine and Gray competing risk regression model adjusted for known risk factors. Results Of the 1495 patients identified, 868 (58.1%) and 627 (41.9%) were bridged with BiVAD or ECMO. Since 2004, a more significant proportion of patients were on BiVAD, but that trend reversed over the past 5 years with more candidates on ECMO (pTrend Conclusions In recent years, there has been a rise in patients bridged to HT with ECMO. However, patients on ECMO suffered higher waitlist mortality and lower transplantation rates. This could, in part, be explained by the sicker profile of patients on ECMO.

Introduction The 2018 revised United Network of Organ Sharing (UNOS) heart transplant (HTx) donor allocation system, initiated on October 18, 2018, aimed to minimize waitlist mortality by prioritizing the transplant of more unstable candidates. However, this prioritization could potentially trade lower waitlist mortality for higher post-transplant morbidity and mortality. The purpose of this study was to examine the impact of the revised HTx allocation system on the clinical characteristics and outcomes of HTx recipients from a high-volume transplant center. Methods We identified 169 adult patients undergoing first-time single-organ HTx between October 2017 and October 2019. The cohort was divided into Era 1 (79 patients; 10/18/17-10/17/18) and Era 2 (90 patients; 10/18/18-10/17/19). Demographic and clinical characteristics, waitlist characteristics, and post-transplant morbidity and mortality were compared between eras. Results Patients in Era 2 were younger (55 v. 61 years, p=0.004), were twice as likely to be transplanted on temporary mechanical circulatory support (44% v. 20%, p Conclusion In a high-volume center, the revised HTx allocation system has shortened HTx waitlist time with transplantation of more unstable patients on temporary mechanical support with no impact on post-transplant outcomes. This suggests that, with careful patient selection, the revised allocation system may optimize both waitlist and post-transplant outcomes.

Background The Public Health Service Increased Risk designation identified organ donors at increased risk of transmitting hepatitis B, hepatitis C, and human immunodeficiency virus. Despite clear data demonstrating a low absolute risk of disease transmission from these donors, patients are hesitant to consent to receiving organs from these donors. We hypothesize that patients who consent to receiving offers from these donors have decreased time to transplant and decreased waitlist mortality. Methods We performed a single-center retrospective review of all-comers waitlisted for liver transplant from 2013 to 2019. The three competing risk events (transplant, death, and removal from transplant list) were analyzed. 1603 patients were included, of which 1244 (77.6%) consented to offers from increased risk donors. Results Compared to those who did not consent, those who did had 2.3 times the rate of transplant (SHR 2.29, 95% CI 1.88–2.79, p p p Conclusions The findings of decreased rates of transplantation and increased risk of death on the waiting list by patients who were unwilling to accept risks of viral transmission of 1/300–1/1000 in the worst case scenarios suggests that this consent process may be harmful especially when involving “trigger” words such as HIV. The rigor of the consent process for the use of these organs was recently changed but a broader discussion about informed consent in similar situations is important.