Transplant Network Tries New Rules For Allocating Livers

By Rachel Smolkin

Post-Gazette National Bureau

WASHINGTON -- The nation's organ transplant network yesterday approved new rules designed to funnel rare livers to the sickest patients.

The new system will emphasize severity of illness rather than time spent on a transplant waiting list, a key factor under the current distribution system. It uses a scoring system based on a battery of blood tests to determine which patients most urgently need a liver transplant to survive.

Distributing livers fairly is of utmost importance because demand for the scarce organs far outweighs supply: More than 16,000 patients are waiting for liver transplants, but only 4,700 transplant operations were performed last year.

"This is a very dramatic change from what we've done in the past," said Todd Howard of the United Network for Organ Sharing, or UNOS.

The new rules do not address whether to change the geographic distribution of livers, a thorny issue that has pitted large urban hospitals, such as UPMC in Pittsburgh, against small transplant centers in rural areas.

The current distribution system keeps most organs within the communities where they are donated rather than sending them to faraway patients in need. UPMC and other large institutions argue that they serve more patients and therefore should receive more organs to help those patients, even if the organs were donated elsewhere.

U.S. Health and Human Services Secretary Donna Shalala has directed UNOS, the private contractor that operates the organ distribution system, to break down geographic barriers.

But a UNOS committee determined that downplaying waiting-list time would do more to help patients than shifting geographic boundaries.

The committee studied 17 proposals for altered geographic distribution but concluded that broader geographic sharing did not significantly boost patient survival or the number of patients receiving transplants.

UNOS' decision alarmed some large medical institutions and patient-advocacy groups.

"This has nothing to do with allocation," said John Fung, director of transplantation at UPMC. "We're approaching almost one year after the implementation of the regulations. We'll be two years into the system before we can hope to see any changes. It's a delay tactic as far as I'm concerned."

Craig Irwin, president of the National Transplant Action Committee, said UNOS was "skirting around the issues we've been fighting for for eight years. They're not complying with the federal regulations."

The new rules will not immediately affect liver distribution. UNOS must submit its plan to the U.S. Department of Health and Human Services for final approval. The network also will spend the next several months collecting information from patients on waiting lists nationwide and running computer tests to compare results from the new system with those of the current system.

Jon Nelson, director of the organ transplantation program for HHS, said UNOS' action is a "significant and important change, and it's also consistent with the regulations." Nelson said his agency will study the results from the UNOS computer tests and then consider whether broader geographic sharing could further aid the sickest patients.

"The most important thing is that the system functions fairly," Nelson said. "It's not broader sharing per se that we're trying to pursue; it's a fairer system."

The new system uses three blood tests to determine the severity of a patient's illness, analyzing whether the liver is properly producing blood-clotting factors, getting rid of toxins that could harm the kidneys and transforming material that causes jaundice. Waiting time will still be used to break ties in patient scores.

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This article posted January 26, 2001.