A typical patient of mine will have a better outcome if his or her liver transplant is performed at a higher volume program. That fact has been known for a number of years, and it seems to make sense to most people. After all, practice makes perfect, right? Unfortunately, it is not so simple in the real world. Not all patients are typical, very few donor organs are truly average in quality, and the performance of all transplant programs with a certain volume of activity is not uniform.
Donor quality, an elusive concept, is partially quantified by the donor risk index (DRI) for livers recovered from deceased donors. 1 The DRI is a composite measure that considers the following: the donor's age, race/ethnicity, and height; the cause and type of death (eg, donation after cardiac death); the type of graft (whole versus partial); the donor's location with respect to the local organ procurement organization service area; and the cold ischemia time. On average, for the typical patient, and at the typical liver transplant program, a higher DRI is associated with worse outcomes, and a lower DRI is associated with better outcomes.
Lately, we have been experiencing a form of Lake Wobegon syndrome: all donated organs seem to be worse than average. Of course, this is not mathematically possible. However, the reverse is true: the average organ is getting worse, at least according to DRI measurements. This is not surprising because donor age is a prominent DRI component, and the donor population is aging along with the rest of us.
How well are we doing with these higher DRI organs, and are higher volume programs particularly