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Organ Allocation
Allocation Process
What principles should be followed during allocation of organs?
3 minute “fast think” brainstorm
Allocation Principles
JusticeJustice
EquityEquity
EfficacyEfficacy
Best outcome
Best outcome
PracticalPractical
LocalLocal
TechnicalTechnical
TimingTiming
Allocation Principles
EqualityEquality
Prioritarism(sickest =
1st)
Prioritarism(sickest =
1st)Utilitarianism
(most benefit)
Utilitarianism(most
benefit)
Social usefulness
Social usefulness
Allocation Strategies
CentreCentre PatientPatient
Organ assigned to transplant centre Organ assigned to a patient
*Mixed**Mixed*
Most common
Advantages/Disadvantages of center, patient, and mixed allocation strategies
3 minute “fast think” brainstorm
Considerations
• “Priority status” (eg. kids, fulminant, etc.)• When equal, longer time on list• Distance of travel (cold ischemic time)• Maximize potential (split liver where can, etc)
• Larger geographic sharing for fulminant “high” or “urgent” status
• ABO• HLA• Mismatch probability• Urgency (eg vasc access failure)• Age• Matching• Time on dialysis• Outcome probability24-48 hr cold ischemic time
• ABO• Morphological match• MELD (Na-MELD)• Time on waiting list• Age
12-16 hrs cold ischemia
• ABO• Morphological match• Urgency
4-6 hrs cold ischemic time6-8 hrs cold ischemic time
Allocation exercise
Four groups split equally to allocate the liver – 5 minutes to allocate.We will then compare the answers.
Note: These slides will not be shown but rather printed and distributed to participants so they can see the “case files” and post them on the wall in order of allocation.
• All matched by ABO identical• Donor dead by neurological criteria with
normal liver function and enzymes, negative serology. Medically suitable.
• Donor is stable.• Baby Joe lives 4 hours from transplant
centre. All others live in the same city as the transplant centre and the donor.
A liver to allocateA liver to allocate
Mrs Curly
Age / Sex 54 F
Listing Condition
EtOHic cirrhosisEtOH free for 12 mos prior to listing
MELD Score 26
Specific Priority
None
Time on the List
46 months
Mr Ball
Age / Sex 19 M
Listing Condition
Fulminant liver failureTylenol ingestionExpect to live <24 h
MELD Score N/A
Specific Priority
Fulminant (“4F”)
Time on the List
2 days
Baby Joe
Age / Sex 2 M
Listing Condition
Biliary atresia, failed Kasai procedure.
MELD Score 22
Specific Priority
Pediatric
Time on the List
3 months
Mrs Smith
Age / Sex 29 F
Listing Condition
Primary sclerosing cholangitis, hx of IV drug use 1 year ago
MELD Score 26
Specific Priority
None
Time on the List
12 months
Critical Take Home Points
Fair, equitable, transparent
Fair, equitable, transparent
Sickest then longest waiting
Sickest then longest waiting
Centre, Patient, or Combined
Centre, Patient, or Combined
Geography, practical considerations
Geography, practical considerations
