‘Acuity Circles’ Policy Tied to Delays in Liver Procurement for Transplant

Implementation of the acuity circles (AC) allocation policy led to more delays in organ procurement, a retrospective study found.

The average pre-procurement time grew from 47.6 hours prior to the AC allocation policy to 50.3 hours afterward, with multivariable regression showing the policy to be associated with significant delays (β coefficient 3.59, 95% CI 2.99-4.18, P<0.001), reported David Seth Goldberg, MD, MSCE, of the University of Miami, and colleagues in a JAMA Surgery research letter.

While the AC policy is aimed at facilitating broader sharing of donor livers, the “consequences of broader sharing are increased numbers of local centers, travel for donor procurements, and complexity for organ procurement organizations,” the researchers noted. “We hypothesized that the AC policy has been associated with pre-procurement delays (i.e., time from brain death to cross-clamp).”

In the study, longer pre-procurement times were observed in donors who had and did not have concurrent thoracic organ placement.

“On transplant message boards, I read transplant physicians asking their colleagues whether they have experienced delays in donor procurement, with a few even reporting that cases got canceled because the delays led to families withdrawing donor authorization,” Goldberg told MedPage Today. “Based on this, we wanted to study whether this was an isolated phenomenon or was more widespread.”

The group retrospectively examined Organ Procurement and Transplantation Network data on liver donation after brain death from April 2019 through June 2021, with 6,230 organs donated before the AC policy and 10,749 donated after the policy was implemented on Feb. 4, 2021. Multivariable regression models were stratified by concurrent thoracic organ placement. Most donors were men (60-65%) with a mean age of 40 years.

“Although the average increase in pre-procurement time was two to four hours, there were outliers with increases of 48 hours or longer in most regions,” Goldberg said in a statement. “Future studies are needed to better understand the impact of pre-procurement delays on families, ICU strains, and financial consequences for donor hospitals.”

No differences were observed between the study periods for primary non-function or early graft failure at 14 and 30 days after transplantation.

Concurrent thoracic organ procurement was similar during both the pre-AC and AC periods (54% vs 53%), and the average time of day for donor cross-clamp between the two periods was similar for donors who had (12:40 p.m. vs 1:06 p.m.) and did not have concurrent thoracic placement (12:10 p.m. vs 12:36 p.m.).

Adjusted multivariable regression analysis also showed other donor variables to be associated with pre-procurement time:

• Thoracic donor: β coefficient 7.78 (95% CI 7.09-8.47)
• Body mass index: β coefficient 0.73 (95% CI 0.56-0.91)
• Height: β coefficient 0.20 (95% CI 0.16-0.25)
• Weight: β coefficient -0.22 (95% CI -0.29 to -0.16)
• Age: β coefficient -0.17 (95% CI -0.19 to -0.15)

“The magnitude of the difference in the time from brain death declaration to procurement between donors who donated a thoracic (lung and/or heart) versus those who didn’t was much larger than I expected,” Goldberg said.

While the study overlapped with the pandemic, the researchers found that COVID-19 was not responsible for the delays observed. Study limitations included the inability to identify specific causes of the pre-procurement delays.