Salvaging discarded livers with normothermic machine perfusion: Is it worth the cost?
Reinier de Vries1,2, Siavash Raigani1, Cailah Carroll1, Ya-Wen Chen 1, David C. Chang1, James F. Markmann1, Korkut Uygun1, Heidi Yeh1.
1Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; 2Surgery, Amsterdam University Medical Center - AMC, Amsterdam, Netherlands
Introduction: Normothermic machine perfusion (NMP) enables transplantation of discarded grafts with excellent outcomes in clinical trials. The cost of deploying NMP is often cited as the biggest barrier to widespread implementation, especially since large clinical studies do not show clear clinical improvements or overall cost savings for standard criteria donor livers graft. However, the cost-benefit analysis of NMP for salvage of discarded grafts for transplantation has yet to be evaluated.
Methods: We tested 20 discarded donor livers for viability with NMP to predict the potential salvage rate in a United States sample cohort. The minimum, median and maximum perfusion costs per graft in a back-to-base setting were subsequently calculated, accounting for the price range of perfusion systems, materials and reagents, personnel and facility costs, and for different operative and perfusion durations. Next, we modeled the costs to convert one discarded liver for transplantation as a function of these perfusion costs, and the percentage of livers that met transplantable viability criteria during NMP.
Results: 55% of the tested discarded livers met the transplantable viability criteria used in clinical trials. The median NMP cost per graft was $15,406, of which 91% were fixed and 9% variable with perfusion duration. Imputing these parameters in our model, the median costs to yield one discarded liver for transplantation with NMP was $28,011. Including additional procurement costs to recover grafts that are currently not recovered for transplant raised these costs to $44,869.
Conclusion: The median costs to convert one discarded graft for transplantation with NMP are low in perspective to the average $577,100 USD cost of a liver transplant and the monthly $22,675 cost of care for a high MELD-score waitlist patient. Therefore, the costs of NMP should not limit its clinical implementation in efforts to alleviate the donor organ shortage.
National Institute of Health. The Executive Committee on Research (ECOR) of Massachusetts General Hospital .
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