In the April Annals (partially excerpted herein) Russo et al propose to determine the clinical outcomes associated with alternate listing transplantation, which utilizes "marginal" donor organs by transplanting them into high-risk recipients who fail to meet the standard criteria for transplantation.  Employing UNOS data, their analysis included 13,024 patients.  High risk criteria included: age more than 65 years, retransplantation, hepatitis C-positive, HIV-positive, creatinine clearance less than 30 mL/min, diabetes mellitus with peripheral vascular disease, and diabetes with creatinine clearance less than 40 mL/min. Marginal donor criteria included age more than 55 years, diabetes mellitus, hepatitis C-positive, HIV-positive, ejection fraction less than 45%, and donor/recipient weight ratio < 0.7.

Survival in the nominal risk transplant group, with nonmarginal organs, was better than in all other groups (p < 0.001). Alternate listing transplantation patients had the worst survival (p < 0.001). The 5-year survival for the alternate listing transplantation group was 51.4% vs. 75.1% in the standard transplant group.  Standard transplant patients had the lowest incidence of in-hospital infection (21.1%) and dialysis (7.1%), and the best transplant hospitalization outcome (p < 0.001). In contrast, alternate listing transplantation patients had the highest incidence of in-hospital infection (35.4%; p < 0.001). Length of stay during transplant hospitalization was also shortest in the standard transplant group (18.8 days; p < 0.001).

The authors concluded that alternate listing transplantation is associated with greater morbidity and resource utilization compared with standard transplantation, but offers a median survival of 5.2 years to patients who would otherwise be expected to live 1 year, and therefore, may be reasonably applied. Further studies examining the costs and quality of life related to this approach are needed.
Please read the article at http://ats.ctsnetjournals.org/cgi/content/full/87/4/1066 and add your comments regarding this interesting and controversial paper in the Dilemmas in Adult Cardiac Surgery discussion forum.