Heart transplantation equitable distribution of donor hearts: Difference between revisions
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{{Heart transplantation}} | {{Heart transplantation}} | ||
'''Editor(s)-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]]; '''Associate Editor-In-Chief:''' {{CZ}} | '''Editor(s)-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]]; '''Associate Editor-In-Chief:''' {{CZ}}{{IF}} | ||
==Equitable Distribution of Donor Hearts to those Awaiting Transplantation and the Process of Being Listed for a Transplant== | ==Equitable Distribution of Donor Hearts to those Awaiting Transplantation and the Process of Being Listed for a Transplant== | ||
In order to assure that access to donor hearts is equitably distributed, the United Network for Organ Sharing (UNOS), was created. In general, patients who are hospitalized and require ongoing administration of parenteral [[inotropic]] agents are at highest risk of death, and are placed at the highest priority on the list of potential recipients. | *In order to assure that access to donor hearts is equitably distributed, the '''''[https://unos.org/ United Network for Organ Sharing] (UNOS)''''', was created. In general, patients who are hospitalized and require ongoing administration of parenteral [[inotropic]] agents are at highest risk of death, and are placed at the highest priority on the list of potential recipients. | ||
*The following factors are used in '''''assigning the priority''''' for transplantation: | |||
:*The level of acuity of the patient's condition (sicker patients are higher on the list) | |||
:*The time the patient has waited on the list (patients who have waited longer are higher on the list) | |||
:*Duration of ischemic time anticipated when a donor heart does become available (assessed in increments of 500 miles between donor and recipient hospitals)(patients who are located closer to the donor heart are higher on the list) <ref name="pmid3539399">{{cite journal| author=Robertson JA| title=Supply and distribution of hearts for transplantation: legal, ethical, and policy issues. | journal=Circulation | year= 1987 | volume= 75 | issue= 1 | pages= 77-87 | pmid=3539399 | doi=10.1161/01.cir.75.1.77 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3539399 }} </ref> | |||
Later, UNOS adopted a policy known as the "final rule" ({{cite web |url=https://optn.transplant.hrsa.gov/governance/public-comment/frameworks-for-organ-distribution/ |title=Frameworks for Organ Distribution - OPTN |format= |work= |accessdate=}}) mandating that organ donors should be allocated to the sickest candidates such that acuity of care takes precedence over geographic factors. <ref name="pmid30311153">{{cite journal| author=Khalili M, Wong RJ| title=Underserved Does Not Mean Undeserved: Unfurling the HCV Care in the Safety Net. | journal=Dig Dis Sci | year= 2018 | volume= 63 | issue= 12 | pages= 3250-3252 | pmid=30311153 | doi=10.1007/s10620-018-5316-9 | pmc=6436636 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30311153 }} </ref> | |||
The | *Some patients may be moved down the list or they may be taken off of the list ('''''delisted'''''). About 5% of patients are delisted because they improve with medical therapy. | ||
The prognosis of patients who have been delisted is controversial. The largest study to date of 100 patients indicates that delisted patients may have a slightly poorer long-term prognosis than those patients who are transplanted. While early survival was better among those patients who were delisted, survival after 30 months tended to be better among patients who were transplanted. Although data is lacking, it has been hypothesized that survival could be further improved among delisted patients to 45% at 10 years if a [[defibrillator]] or [[AICD]] was implanted. <ref name="pmid18455599">{{cite journal |author=Hoercher KJ, Nowicki ER, Blackstone EH, Singh G, Alster JM, Gonzalez-Stawinski GV, Starling RC, Young JB, Smedira NG |title=Prognosis of patients removed from a transplant waiting list for medical improvement: implications for organ allocation and transplantation for status 2 patients |journal=[[The Journal of Thoracic and Cardiovascular Surgery]] |volume=135 |issue=5 |pages=1159–66 |year=2008 |month=May |pmid=18455599 |doi=10.1016/j.jtcvs.2008.01.017 |url=http://linkinghub.elsevier.com/retrieve/pii/S0022-5223(08)00168-2 |issn=}}</ref> | |||
* Survival of patient's on the transplant list has significantly improved. Urgent cardiac transplant is still an important factor for the survival of UNOS status 1 cadidates. | |||
* Some factors that predict death in the first two months of being placed on a transplant list include- <ref name="pmid17888847">{{cite journal| author=Lietz K, Miller LW| title=Improved survival of patients with end-stage heart failure listed for heart transplantation: analysis of organ procurement and transplantation network/U.S. United Network of Organ Sharing data, 1990 to 2005. | journal=J Am Coll Cardiol | year= 2007 | volume= 50 | issue= 13 | pages= 1282-90 | pmid=17888847 | doi=10.1016/j.jacc.2007.04.099 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17888847 }} </ref> <ref name="pmid29664407">{{cite journal| author=Sridharan L, Wayda B, Truby LK, Latif F, Restaino S, Takeda K | display-authors=etal| title=Mechanical Circulatory Support Device Utilization and Heart Transplant Waitlist Outcomes in Patients With Restrictive and Hypertrophic Cardiomyopathy. | journal=Circ Heart Fail | year= 2018 | volume= 11 | issue= 3 | pages= e004665 | pmid=29664407 | doi=10.1161/CIRCHEARTFAILURE.117.004665 | pmc=5905429 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29664407 }} </ref> | |||
**[[Inotropic]] and [[intra-aortic balloon pump]] support | |||
**[[Pulmonary capillary wedge pressure]] greater than 20 mm Hg | |||
** UNOS status 1A | |||
** Patient on [[Mechanical ventilation]] | |||
** Raised serum [[creatinine]] >1.5 mg/dl | |||
** Failure of [[cardiac transplant]] | |||
** Valvular [[cardiomyopathy]] | |||
** Age >60 years | |||
** Caucasian ethnicity | |||
** Weight ≤70 kg | |||
** Lack of an [[AICD]] on the day of listing | |||
==References== | ==References== | ||
Latest revision as of 17:54, 21 July 2020
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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [1]Ifrah Fatima, M.B.B.S[2]
Equitable Distribution of Donor Hearts to those Awaiting Transplantation and the Process of Being Listed for a Transplant
- In order to assure that access to donor hearts is equitably distributed, the United Network for Organ Sharing (UNOS), was created. In general, patients who are hospitalized and require ongoing administration of parenteral inotropic agents are at highest risk of death, and are placed at the highest priority on the list of potential recipients.
- The following factors are used in assigning the priority for transplantation:
- The level of acuity of the patient's condition (sicker patients are higher on the list)
- The time the patient has waited on the list (patients who have waited longer are higher on the list)
- Duration of ischemic time anticipated when a donor heart does become available (assessed in increments of 500 miles between donor and recipient hospitals)(patients who are located closer to the donor heart are higher on the list) [1]
Later, UNOS adopted a policy known as the "final rule" ("Frameworks for Organ Distribution - OPTN".) mandating that organ donors should be allocated to the sickest candidates such that acuity of care takes precedence over geographic factors. [2]
- Some patients may be moved down the list or they may be taken off of the list (delisted). About 5% of patients are delisted because they improve with medical therapy.
The prognosis of patients who have been delisted is controversial. The largest study to date of 100 patients indicates that delisted patients may have a slightly poorer long-term prognosis than those patients who are transplanted. While early survival was better among those patients who were delisted, survival after 30 months tended to be better among patients who were transplanted. Although data is lacking, it has been hypothesized that survival could be further improved among delisted patients to 45% at 10 years if a defibrillator or AICD was implanted. [3]
- Survival of patient's on the transplant list has significantly improved. Urgent cardiac transplant is still an important factor for the survival of UNOS status 1 cadidates.
- Some factors that predict death in the first two months of being placed on a transplant list include- [4] [5]
- Inotropic and intra-aortic balloon pump support
- Pulmonary capillary wedge pressure greater than 20 mm Hg
- UNOS status 1A
- Patient on Mechanical ventilation
- Raised serum creatinine >1.5 mg/dl
- Failure of cardiac transplant
- Valvular cardiomyopathy
- Age >60 years
- Caucasian ethnicity
- Weight ≤70 kg
- Lack of an AICD on the day of listing
References
- ↑ Robertson JA (1987). "Supply and distribution of hearts for transplantation: legal, ethical, and policy issues". Circulation. 75 (1): 77–87. doi:10.1161/01.cir.75.1.77. PMID 3539399.
- ↑ Khalili M, Wong RJ (2018). "Underserved Does Not Mean Undeserved: Unfurling the HCV Care in the Safety Net". Dig Dis Sci. 63 (12): 3250–3252. doi:10.1007/s10620-018-5316-9. PMC 6436636. PMID 30311153.
- ↑ Hoercher KJ, Nowicki ER, Blackstone EH, Singh G, Alster JM, Gonzalez-Stawinski GV, Starling RC, Young JB, Smedira NG (2008). "Prognosis of patients removed from a transplant waiting list for medical improvement: implications for organ allocation and transplantation for status 2 patients". The Journal of Thoracic and Cardiovascular Surgery. 135 (5): 1159–66. doi:10.1016/j.jtcvs.2008.01.017. PMID 18455599. Unknown parameter
|month=ignored (help) - ↑ Lietz K, Miller LW (2007). "Improved survival of patients with end-stage heart failure listed for heart transplantation: analysis of organ procurement and transplantation network/U.S. United Network of Organ Sharing data, 1990 to 2005". J Am Coll Cardiol. 50 (13): 1282–90. doi:10.1016/j.jacc.2007.04.099. PMID 17888847.
- ↑ Sridharan L, Wayda B, Truby LK, Latif F, Restaino S, Takeda K; et al. (2018). "Mechanical Circulatory Support Device Utilization and Heart Transplant Waitlist Outcomes in Patients With Restrictive and Hypertrophic Cardiomyopathy". Circ Heart Fail. 11 (3): e004665. doi:10.1161/CIRCHEARTFAILURE.117.004665. PMC 5905429. PMID 29664407.