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Organ Acceptance Criteria

Organ Acceptance Criteria. Steven Colquhoun, M.D., FACS Director, Liver Transplantation Cedars-Sinai Medical Center. Organ Acceptance Criteria. Surgeon’s Brain?. Donor: Concerns Graft: Specifics Recipient: Matching Program: Survival Grafts & Recipients SRTR/UNOS/CMS

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Organ Acceptance Criteria

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  1. Organ Acceptance Criteria Steven Colquhoun, M.D., FACS Director, Liver Transplantation Cedars-Sinai Medical Center

  2. Organ Acceptance Criteria Surgeon’s Brain? • Donor: Concerns • Graft: Specifics • Recipient: Matching • Program: Survival • Grafts & Recipients • SRTR/UNOS/CMS • Payers (&LA Times)

  3. Concerns: • DGF & PNF • Biliary Issues: • Strictures & Casts • Likelihood Disease Recurrence • e.g., HCV v. Age v Genotype • Disease Transmission

  4. Donor Risk Index: Appealing • National Data • Quantitative Donor Risk Index • Seven Independent Donor characteristics • Predicted Risk of Graft Failure • Age • DCD & Splits • Race & Height • Cause of Death • Not: • Cold Time • Obesity • Elevated LFT’s Feng et al AJT 2006

  5. Donor Risk Index: Appeal • Feng et al 2006 • Liver Specific Deceased Donor Risk Indices (Wang et al Accepted) • Validation of DRI in Eurotransplant Region (Blok et al, Liver Transpl 2012) • Time to Graft Failure OLT: Transplant Risk Index (Stey et al Trans Proceed2013)

  6. Donor Risk Index: • Formulas Appealing • Retrospective • Only Utilized Organs • Numerator with no Denominator • Written about • Not Used (in actual practice)

  7. Donor Assessment: Still No Definition for Liver ECD* *Merion et al J of Hep 2006 • Age • Size • Hemodynamics • Pressors? • Co-morbidities • Duration of hospitalization

  8. Donor Assessment: • Enzymes • Start, Current, Trends • Sodium • Current, Peak, Time from Peak • Bilirubin • Start (only) • Serologies

  9. “Age Amortization” Likely to accept Things I don’t Like AGE

  10. Size Matters: (for Livers)

  11. Distance/Cold Time/Expense Travel More Likely with Share 35? NV UT SF CA LA NM AZ

  12. Fat – The “Big” Concern • Increasing Incidence • NAFL: “the new HCV” • PNF association • BMI, IDDM • Assessment? • Imaging v appearance • Goal: ≤ 30%

  13. Hepatic Steatosis: Surgeon v Path Yersiz et al Liver Trasnpl 2013 • Prospective • Blinded to Pathologist • “yellowness, scratch marks, round” • Prediction of ≥ 30% • 86.2% Judged by Texture • 75.5% Judged by Color

  14. Fat & Biopsy • Frozen section • Most All Studies • Practical Reasons: Still Common • Artifact = Fat • Permanents • Luxury of Time/Review • No Artifact

  15. Appearance Color Texture Experience Surprising how often we’re surprised

  16. Donor v. Recipient: Matching Donor Quality Recipient Condition Size Quality Condition Balance Required

  17. Recipients are Sick!

  18. Summary Age, History, BMI, Location Labs Size v Recipient Quality v Recipient Final Assessment: LOOK Role of biopsy?

  19. Surgeon’s Brain cars Sports OR Tantrum New gadgets Mumbling Sewing

  20. A Good Organ: *Justice Potter Stewart,  concurring opinion in Jacobellis v Ohio 1964 Is very similar to Pornography Difficult to define but.. “I know it when I see it”*

  21. When it all Comes Together

  22. end

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