Donation after circulatory death liver transplants are higher and unevenly distributed in the United States after the implementation of the acuity circle allocation policy

ABSTRACT

Background: This study aimed to assess the impact of the recently (02/2020) implemented Acuity Circles (AC) liver allograft allocation policy on MELD at transplant and Donation after Circulatory Death (DCD) rates. Methods: Study period 01/2016- 08/2021. Data retrieved from SRTR database. Inclusion criteria All DCD liver transplants (LT). The cohort was dichotomized into a pre- and post-AC era. DCD rate (defined as DCD/ 50k population/year) was calculated for each State. The change (Δ) on the DCD rate (ΔDCD) and the MELD (ΔMELD) between the two periods was also calculated. Results: 1. Total LT increased in the post-AC era (26%/50k vs. 15%/50k, p=0.0567). 2. DCD LT increased in the post-AC era (15%/50k vs.10%/50k, p=0.0885). 3. MELD increased in the post-AC era in nearly all States (ΔMELD, fig.1, 2 & 3). 4. Uneven distribution of pre- & post-AC DCD activity, with a few States driving DCD LT in the US (fig.4 & 5). 5. Arizona and Louisiana had the highest pre-AC DCD rates (58%/50k & 31%/50k, respectively;fig.3). 6. The top post-AC DCD rate was reached in Arizona (78%/50k, fig.5). 7. Top post-AC ΔDCD was noted in Arkansas & Arizona (fig.6). 8. The highest ΔMELD was noted in low DCD/ negative ΔDCD areas (fig.7). 9. The lowest ΔMELD was noted in areas with the highest DCD rate (fig.7) 10. The State with the highest DCD rates pre-AC had the highest ΔDCD (fig.5). 11. 10/11 States with negative ΔDCD were located North of the 35o. Conclusions: AC implementation coincided with an increase in the overall LT & DCD LT activity. However, causation remains to be clarified, given the concurrent opioid crisis and SARS-CoV-2 pandemic. There was remarkable DCD rate variation. States with high DCD rates/ΔDCD demonstrated greater adaptability in the allocation change, maintaining low ΔMELD across eras. (Figure Presented).