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Title: Age and equity in liver transplantation: An organ allocation model
Authors: Cucchetti, Alessandro
Ross, Lainie Friedman
Thistlethwaite, J Richard
Vitale, Alessandro 
Ravaioli, Matteo
Cescon, Matteo
Ercolani, Giorgio
Burra, Patrizia 
Cillo, Umberto 
Pinna, Antonio Daniele
Mesh headings: Decision Support Techniques;Health Equity;Health Services Accessibility;Healthcare Disparities;Liver Transplantation;Tissue Donors;Tissue and Organ Procurement
Secondary Mesh headings: Adolescent;Adult;Age Factors;Aged;Aged, 80 and over;Algorithms;Female;Humans;Italy;Kaplan-Meier Estimate;Life Expectancy;Male;Middle Aged;Multivariate Analysis;Policy Making;Risk Assessment;Risk Factors;Time Factors;Treatment Outcome;Young Adult
Issue Date: Oct-2015
Publisher: WILEY
Journal: Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society 
A moral liver allocation policy must be fair. We considered a 2-step, 2-principle allocation system called "age mapping." Its first principle, equal opportunity, ensures that candidates of all ages have an equal chance of getting an organ. Its second principle, prudential lifespan equity, allocates younger donor grafts to younger candidates and older donors to older candidates in order to increase the likelihood that all recipients achieve a "full lifespan." Data from 2476 candidates and 1371 consecutive adult liver transplantations (from 1999 to 2012) were used to determine whether age mapping can reduce the gap in years of life lost (YLL) between younger and older recipients. A parametric Weibull prognostic model was developed to estimate total life expectancy after transplantation using survival of the general population matched by sex and age as a reference. Life expectancy from birth was calculated by adding age at transplant and total life expectancy after transplantation. In multivariate analysis, recipient age, hepatitis C virus status, Model for End-Stage Liver Disease score at transplant of >30, and donor age were significantly related to prognosis after surgery (P < 0.05). The mean (and standard deviation) number of years of life from birth, calculated from the current allocation model, for various age groups were: recipients 18-47 years (n = 340) = 65.2 (3.3); 48-55 years (n = 387) = 72.7 (2.1); 56-61 years (n = 372) = 74.7 (1.7) and for recipients >61 years (n = 272) = 77.4 (1.4). The total number of YLL equaled 523 years. Redistributing liver grafts, using an age mapping algorithm, reduces the lifespan gap between younger and older candidates by 33% (from 12.3% to 8.3%) and achieves a 14% overall reduction of YLL (73 years) compared to baseline liver distribution. In conclusion, deliberately incorporating age into an allocation algorithm promotes fairness and increases efficiency.
ISSN: 15276465
DOI: 10.1002/lt.24211
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