Earlier this month, the Division of Transplant Surgery in the University of Colorado Department of Surgery hosted its annual Controversies in Transplantation conference (CIT), which gathered the finest minds in transplantation science from around the country in Colorado. For more than two decades, this conference has served as a platform for groundbreaking ideas and discussions within the transplant community.
“Controversies in Transplantation has been the birthplace of some of the most monumental innovations that have occurred in transplantation,” said Elizabeth Pomfret, MD, PhD, chief of the Division of Transplant Surgery.
“Past conferences have led to the MELD score that determines how urgently a liver transplant candidate needs the surgery, as well as adult-to-adult living donor transplantation in the U.S. Most of the allocation changes made in the U.S. were vetted in these meetings before implementation.”
“Due to the free flow of dialogue, most newer therapeutics and diagnostics have also been vetted at CIT,” explains Pomfret. “The Young Investigator Forum (YIF) has also been an emerging board for many of the leaders in transplantation.”
This year, for the first time, the event was held in Vail, Colorado. Attendees enjoyed the ski-in location, which provided a perfect interlude between the thought-provoking talks that promised to revolutionize the field of transplantation forever.
Improving access to transplant care
Conference co-organizer Jesse Schold, PhD, director of transplant outcomes and policy within the Colorado Center for Transplantation Care, Research, and Education (CCTCARE) and associate vice chair of policy and outcomes for the CU Department of Surgery, has dedicated most of his career to researching transplant policies and how to ensure their outcomes are equitable.
During the conference, Schold presented a historical overview of regulatory oversight and metrics in transplantation and how they have changed. He also discussed the gaps in data around knowledge about and access to transplantation.
“Since there isn’t any oversight or data metrics for access to transplantation, comprehensive evaluation of key processes of care associated with referral and evaluation for transplant patients are lacking,” said Schold.
From a research perspective, Schold is trying to identify underserved populations and their barriers to care. “We are working to address these issues within transplant societies and academic collaborations, including access to novel data sources or interventions that provide objective criteria to identify eligible transplant populations.”
Transplant providers, including Schold, are also working to provide access to transplantation to all patients irrespective of their level of health literacy, resources, and historical inequalities in care. The Hispanic Transplant Clinic at the University of Colorado, he said, is a great example of using culturally sensitive care to bridge the gap.
“Efforts to inform national policy to address disparities in care and introduce metrics that incentivize best practices will be critically important for the field of transplantation,” said Schold.
Expanding the Donor Pool
Another discussion at the CIT conference looked at expanding the donor pool. Jordan Hoffman, MD, associate professor of cardiothoracic surgery and surgical director of lung transplant and chronic thromboembolic pulmonary hypertension (CTEPH) programs, presented his research on donation after cardiac death (DCD) heart transplantation. The talk focused on how using allografts from DCD donors is another option to increase the donor pool.
Though there historically has been some controversy around using DCD organs due to the definition and determination of death, widespread adoption of the process may increase overall heart transplant volume by as much as 30%, Hoffman said. These surgeries have been performed in Europe for several years. Hoffman also presented his research on the various techniques used for DCD and talked about how he was one of the surgeons that brought normothermic regional perfusion (NRP), a method used on DCD donors to recover organs with a shorter ischemic time, to the United States.
Hoffman added, “Our transplant colleagues in Europe have been using this technique in Europe for years, but we have been able to adopt and refine this technique here in the U.S.”
The biggest benefit of this technique is that it can help expand the donor pool. “It also helps improve outcomes in all organs. At the University of Colorado, so far, we have used NRP to recover about 15 organs, and we would not have been able to recover those organs had it not been for this technique.”
Challenging current perceptions on the timing of living donor liver transplant
Whitney Jackson, MD, assistant professor of gastroenterology and medical director of living donor liver transplantation, presented her team’s JAMA research on how living-donor liver transplant (LDLT) recipients gain an additional 13 to 17 life years following their transplant surgery compared with patients who remain on the donor waitlist.
Previously it was believed that patients who needed a liver transplant should have a Model for End-stage Liver Disease incorporating sodium levels (MELD-Na) score of at least 15 to be considered for a transplant. The MELD score is a prognostic scoring system based on laboratory parameters that predict 3-month mortality due to liver disease. However, analysis of the Scientific Registry of Transplant Recipients database of liver transplant candidates found that patients with MELD-Na scores as low as 11 who received a transplant had a 34% decrease in mortality compared with those who remained on the waitlist.
“Living donor liver transplantation remains an underused resource to help patients escape the risk of death on the waitlist, but patients continue to experience a lack of accurate and consistent guidance concerning the ideal timing of an LDLT,” explained Jackson. “I believe quantifying transplant benefits can be a future framework to guide individual risks/benefit discussions in LDLT.”
The findings of this study are significant considering the previous understanding that the survival benefit was not evident until a MELD of 15 or greater. “The study reveals that a proportion of patients previously thought to not benefit from transplants do, in fact, significantly benefit. We expect this will change practice around the country,” Jackson said.
Overall, despite their many debates on controversial topics in transplantation, all the participants can agree on one thing: CIT is a great place to learn more about the latest and greatest ideas in transplantation. The conference is set to return to Vail from March 1 to March 3, 2024.