Distribution of livers to those most in need not a simple matter

By Luis Fabregas, Pittsburgh Tribune-Review

April 11, 2010

Organ transplant policy makers are renewing efforts to change how livers are allocated, saying scarce livers should go to patients who need them the most.

The United Network for Organ Sharing will convene a forum in Atlanta on Monday, after a controversial attempt that last year failed to gain support from transplant centers.

"There's still people that are dying on the waiting list," said Dr. Ken Washburn, chair of the liver committee of UNOS, a nonprofit contracted by the federal government to run the nation's transplant system. "There's not really equity in terms of, 'Are patients being transplanted at similar disease stages across the country?' "

The agency began debating changes soon after the Tribune-Review published an investigation in March 2008 that showed hundreds of patients received liver transplants when they could have lived longer without the surgery. These patients are ranked by a scoring system called MELD, for Model End-stage Liver Disease, ranging from 6 for the east ill to 40 for those at greater risk of death.

The Trib's investigation found 846 cases, between 2005 and 2007, in which patients with scores of 14 or lower received a liver transplant. People with those scores face more danger from a transplant than from liver disease, according to a landmark study by surgeons at the Scientific Registry of Transplant Recipients.

In a proposal in spring 2009, UNOS suggested a broader geographic distribution of livers: Instead of organ sharing in small geographic areas, livers would be offered to larger regions. Its rationale was that such a system could prevent people from dying while awaiting surgery.

The plan, however, raised questions. UNOS received more than 1,800 letters offering feedback, far beyond what it receives during public comment phases. Among concerns:

• Donated organs would travel too far, increasing the time they spend outside the body and leading to potentially poor outcomes.
• An increase in air travel for workers procuring and retrieving livers.
• A decrease in volume at some transplant centers, which fear a negative financial impact.
• Organs leaving the local area would lessen people's interest in donating organs.

"There are far simpler things that can make or produce more organs," said Dr. A. Joseph Tector, transplant chief at Clarian Health in Indianapolis. "Just focusing on allocation, you won't come up with more organs."

Instead, Tector said, the system could be improved by increasing the number of organ donors. Fewer than 80 million Americans are enrolled in donor registries across the country, representing about 38 percent of licensed drivers, according to Donate Life America. The percentage of donors could be increased by taking a look at regions where there are more organ donors, Tector said.

"These places that are generating a lot of organs, what are they doing different?" he said. "That's an important question. Maybe we should be asking those people what to do."

Transplant surgeons have explored several ways to improve distribution of livers, which remain one of the least available organs for transplantation, along with kidneys. More than 6,000 people died last year waiting for liver transplants.

UNOS considered giving available organs to people with higher MELD scores, because it assumed this would reduce deaths on waiting lists.

That assumption was derailed by the University of Iowa's Larry Hunsicker, a surgeon who will present results of a study at this week's forum. Hunsicker examined the impact of a policy known as "Share 29" that was tested in a part of the United States designated by UNOS as Region 8 and included Colorado, Iowa, Kansas, Missouri, Nebraska and Wyoming.

The policy stipulated that livers be offered first in a donor's city to patients with MELD scores of 29 or higher, and then to those in a larger region with the same scores before they were offered to those with scores between 15 and 28.

"What we found was somewhat contrary to expectations," Hunsicker said. "Although it is clear that people with MELD scores higher than 29 were transplanted more rapidly ... there was no difference in the total number of deaths on the waiting list."

Copyright © 2010 Trib Total Media Inc.

This article posted April 26, 2010.