title: Age and equity in liver transplantation: An organ allocation model.
abstract: 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.
authors.affiliation: Department of Medical and Surgical Sciences, Policlinico Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Cucchetti
authors.affiliation: Departments of Pediatrics, University of Chicago, Chicago, IL.|Departments of Surgery, University of Chicago, Chicago, IL.|MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL.
authors.forename: Lainie Friedman
authors.initials: LF
authors.lastname: Ross
authors.affiliation: Departments of Surgery, University of Chicago, Chicago, IL.|MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL.
authors.forename: J Richard
authors.initials: JR
authors.lastname: Thistlethwaite
authors.affiliation: Departments of General Surgery and Organ Transplantation, Hepatobiliary Surgery and Liver Transplant Unit, University of Padua, Padua, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Vitale
authors.affiliation: Department of Medical and Surgical Sciences, Policlinico Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Ravaioli
authors.affiliation: Department of Medical and Surgical Sciences, Policlinico Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Cescon
authors.affiliation: Department of Medical and Surgical Sciences, Policlinico Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Ercolani
authors.affiliation: Departments of Surgery, Oncology, and Gastroenterology, Multivisceral Transplant Unit, University of Padua, Padua, Italy.
authors.forename: Patrizia
authors.initials: P
authors.lastname: Burra
authors.affiliation: Departments of General Surgery and Organ Transplantation, Hepatobiliary Surgery and Liver Transplant Unit, University of Padua, Padua, Italy.
authors.forename: Umberto
authors.initials: U
authors.lastname: Cillo
authors.affiliation: Department of Medical and Surgical Sciences, Policlinico Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Antonio Daniele
authors.initials: AD
authors.lastname: Pinna
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D003661:Decision Support Techniques; D005260:Female; D000069576:Health Equity / Q000458:organization & administration*; D006297:Health Services Accessibility / Q000458:organization & administration*; D054625:Healthcare Disparities; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D008017:Life Expectancy; D016031:Liver Transplantation / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011050:Policy Making; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014019:Tissue Donors / Q000600:supply & distribution*; D009927:Tissue and Organ Procurement / Q000458:organization & administration*; D016896:Treatment Outcome; D055815:Young Adult