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Donor Management Goals: A Transplant Center Perspective

UNIVERSITY OF UTAH SCHOOL OF MEDICINE. Donor Management Goals: A Transplant Center Perspective (as viewed by a practicing nephrologist & researcher). Isaac E. Hall, MD, MS Assistant Professor of Medicine University of Utah School of Medicine Department of Internal Medicine

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Donor Management Goals: A Transplant Center Perspective

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  1. UNIVERSITY OF UTAH SCHOOL OF MEDICINE Donor Management Goals: A Transplant Center Perspective (as viewed by a practicing nephrologist & researcher) Isaac E. Hall, MD, MSAssistant Professor of MedicineUniversity of Utah School of MedicineDepartment of Internal Medicine Division of Nephrology & Hypertension

  2. Should transplant centers care about DMGs? • More DMGs met associates with: • more organs procured from those donors (including “expanded criteria donors”)1-3 • less delayed graft function (DGF) in kidney transplants4 • Increased utilization of livers5 1. Malinoski et al. J Trauma. 2011;71: 990-6 2. Malinoski et al. Crit Care Med. 2012; 40:2773–2780 3. Patel et al. JAMA Surg. 2014; 149:969-75 4. Malinoski et al. Am J Transplant. 2013; 13:993-1000 5. Bloom et al. J Am Coll Surg. 2015; 220:38-47

  3. There are potential challenges/concerns about transplant centers using DMGs. • “Not meeting DMGs” could be a new reason to decline offers • “# of DMGs met” at a defined time-point or even “change in # met between time-points” may just represent underlying donor characteristics (i.e., not modifiable) • A cause-and-effect relationship between DMGs and allograft outcomes is difficult to prove using observational data

  4. How might the field benefit as a whole? • If improvements can be made in meeting DMGs: • It might increase the organ pool and number of lives saved by transplant • It might prolong allograft survival and reduce the need for re-transplantation

  5. DMG data are available for use by centers • Centers can consider ongoing review of recent DMG data during regular quality assurance / process improvement (QAPI) meetings • For turned-down offers accepted elsewhere, would we have reconsidered if we knew the # of DMGs met had been increasing? • It may be premature to use DMG data in real-time to make yes/no decisions about organ offers now

  6. Centers might want to consider DMGs when deciding about early treatments • Adjusted odds ratio of DGF when “DMGs met” (≥7 out of 9 DMGs achieved) was about 0.51 • Alternatively, can consider the inverse...if at least 7 DMGs not met, DGF was twice as likely • If DGF is likely, may be reason to: • Therapeutically pump kidney • Shorten cold ischemia time • Augment induction regimen • Delay intro of CNIs • More aggressively support BP • Preemptively dialyze post-op • Consider other novel therapies 1. Malinoski et al. Am J Transplant. 2013; 13:993-1000

  7. Summary – what should centers do with DMGs? • DMGs might be most enlightening during QAPI review • Determining how to use new data clinically once we’ve decided we probably should can still be difficult • Additional studies are needed to see if “DMGs met” is a reliable surrogate marker for hard transplant outcomes

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