ABSTRACT
Background: Liver transplant is an important curative option for select patients with hepatocellular carcinoma (HCC). The acuity circles-based allocation in February 2021 and a change setting model for end stage liver disease (MELD) exception points for HCC to the regional median MELD minus three, have the potential to create a difference in transplant opportunity for HCC patients despite having the same disease. We analyzed the effect of allocation changes on deceased donor liver transplant (DDLTs) for HCC in various regions of the US. Methods: Characteristics of HCC and non-HCC DDLTs in the year before (2/4/2019-2/3/2020) and after (2/4/2020-2/4/2021) introduction of the acuity circle policy were assessed using the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) database. Based on the median national MELD at transplant of 28, OPTN regions were stratified into low (≤28) and high (>28) MELD regions. We performed chi-squared proportional testing to compare differences in transplant volumes in both eras. Results: In the pre-acuity circle era there were 6699 DDLTs performed compared to 6660 DDLTs in the post-acuity circle area era (-0.6%). The 0.6% decrease in the number of DDLTs was driven entirely by a decrease in DDLTs for HCC (1529 to 1351;-11.6%) (Figure 1). There was a reduction in the absolute numbers of HCC transplants performed in most regions. There were statistically significant decreases in regions 2 (-37.8%, p<0.001) and 4 (-28.3%, p=0.001) and a numerical decrease in region 11 (-20.3% p=0.088), all low MELD regions. Conversely, there were absolute increases in DDLTs for HCC in region 9 (+17.6%, p=0.388), region 1 (+3.0%, p=0.875), and region 5 (+1.6%, p=0.811), all high MELD regions. To assess if the reduction in HCC transplants was attributable to the COVID-19 pandemic, we examined changes in the proportion of all DDLT being performed for HCC. Similar to the changes in the absolute number of DDLTs, the overall percentage of DDLTs performed for HCC decreased after the new allocation system nationally (22.8% to 20.3%) with statistically significant decreases in regions 2 (26.5% to 18.3%, p<0.001) and 4 (27.8% to 20.5%, p=0.001). Conclusion: After introduction of new organ allocation policies in early 2020, there were large shifts in regional sharing of organs and statistically significant decreases in DDLT for HCC both nationally and in low MELD regions. The COVID-19 pandemic-related changes are unlikely to account for disproportionate decreases in HCC transplants. Ongoing investigation of these trends are needed to ensure that HCC patients are not unfairly disadvantaged because of geographic differences in score allocation for the same disease.
ABSTRACT
Background: Smartphone applications are on the rise;yet it is unclear whether liver transplant (LT) recipients would use or benefit from this technology. We aimed to understand baseline smartphone practices and identify preferences for an app-based intervention to guide the development of the LiveRightTM Transplant app among LT recipients Methods: Twenty in-depth, in-person interviews were conducted from 2019-2020 among adults 3 to 6 months after LT at the University of North Carolina We evaluated baseline use of smartphone technology, as well as acceptability of and preferences for a LT app Interviews were conducted by trained qualitative experts and analyzed in an iterative fashion using a thematic content approach to identify relevant themes Coded transcripts were analyzed using Dedoose qualitative software Results: Among 20 LT recipients, median age was 61 years (range 28-68);65% were male;60% Caucasian;40% underwent LT for non-alcoholic fatty liver disease, 20% for viral hepatitis, and 10% for alcohol-associated liver disease Patients lived 76 miles (range 14-270) from the hospital A majority (90%) of patients owned smartphones In addition to calls, text, and email, smartphone users engaged in social media including Facebook (55%), sought information through search engines (50%), and played games or watched videos (30%) on their phones Most (65%) used EPIC MyChart to communicate with the transplant team and set phone alarms for medication reminders A majority (80%) were interested in a LT app that enabled: 1) anonymous and secure ways to connect with other LT recipients, 2) logging biometric data, 3) medication reminders including real time updates of dosages, 4) virtual communication with the medical team (after hours or early in post-LT recovery when difficult to travel to clinic), and 5) vetted educational materials especially on medication side effects/symptoms, diet, and physical activity (Figure 1) Conclusion: LT recipients want a smartphone app to aid in their recovery Most important to them is connecting with other LT recipients for peer support, educational resources related to expectations, symptoms and medication side effects, and easy options to log biometric data to be shared with their transplant team With the advent of COVID-19, using smartphone interventions will be critical to improving transplant outcomes These data informed the development of the LiveRightTM app with pilot testing underway. (Table Presented).