Strong Memorial puts extra caution in liver transplants

Number of surgeries declines

Staff writer

November 30, 2004

JAMIE GERMANO staff photographer

Dr. Adel Bozorgzadeh, director of Strong Memorial Hospital's liver transplant program, performs a transplant. Strong is being more careful with using marginal organs, and transplant numbers have decreased there.

What's at stake

Strong Memorial Hospital is a leader in liver transplantation nationwide, even though its volume has decreased since 2002. It's the only liver transplant center in New York north of Westchester County and one of the Northeast's largest.

As soon as Greece native Michelle Alves, 30, heard that doctors can take part of a person's liver and give it to someone else, she was convinced.

She was going to donate part of her liver to her father, Bob, 59, who was slowly dying from liver disease.

The 12-hour operation at Strong Memorial Hospital in June was successful -- one of 20 live-donor liver transplants there so far this year.

But patients such as Bob Alves are more of a rarity than in years past. Liver transplants have decreased at Strong -- at a time when the number of people who need livers increases every year. Strong's national ranking for volume dropped from fifth in 2002 to 13th in August; from 2002 to 2003, its volume declined 33 percent.

As of last week, Strong has done 106 liver transplants this year.

Live liver transplantation is down nationwide amid concerns about keeping donors alive and healthy. And so transplant centers, to stretch the organ supply, are increasingly turning to marginal organs -- those that could come from the elderly or former drug users.

Strong, however, is being more careful with the use of marginal organs. The state Health Department cited the hospital earlier this year for not documenting why some of these high-risk surgeries were being done or whether the risks were fully explained to the patients. The state recently approved the hospital's plan of correction and will watch Strong into next year.

But hospital officials say they began proceeding cautiously with marginal organs even before the violations were cited in April, amid a call by some health officials for closer scrutiny. The state Health Department, for example, has convened a task force to assess the risks of using marginal organs.

"(Hospitals) are starting to accept organs that aren't the best," said Arthur Caplan, chairman of the department of medical ethics at the University of Pennsylvania. "It's a challenge for programs to maintain good outcomes."

For now at least, live donors such as Michelle Alves may be the best hope for some patients dying of liver disease.

Being conservative

At Strong this past spring, Michelle went through a three-day round of testing -- lab work, liver biopsy, CAT and MRI scans -- to make sure her liver would work inside her father, an Eastman Kodak Co. retiree. She also had to undergo interviews by a financial counselor, a psychologist and the transplant surgeon to ensure she was mentally prepared for what she was about to do.

"They really kind of drill you," said Michelle, a 1992 Greece Olympia graduate who is now a dolphin trainer in Orlando, Fla.

Welcome to Strong's live-donor liver transplant program.

In Michelle and Bob Alves' case, a state mandate has required New York hospitals to critically examine all live liver transplant cases to make sure that both the donor and the recipient are right for the procedure. The death of a live donor at Mount Sinai Hospital in New York City in early 2002 prompted the closer scrutiny -- and much of that has also been adopted nationally by the United Network for Organ Sharing (UNOS), said Dr. Lewis Teperman, director of transplantation at New York University and president of the New York Center for Liver Transplantation.

Dr. Adel Bozorgzadeh, who took over Strong's liver transplant program in late 2002, said Strong is also more critical of what kind of deceased donor organs it uses. That likely caused some of the decrease in total liver transplants, from 155 in 2002 to 104 in 2003.

"We looked at (the liver transplant program) very, very carefully. And our conclusion was it was on the aggressive end of a reasonable system of care," said Dr. Robert Panzer, chief quality officer at Strong.

All hospitals now use what are called "extended criteria," or marginal, organs. Marginal organs are used because the number of people who need a transplant increases every year -- while the number of deceased donor organs stays flat.

As of August, 3,896 livers from deceased donors were used for transplants nationally; 17,517 people are currently on waiting lists, according to UNOS. In Strong's program, 313 people are waiting for a liver.

Marginal organs can be used more often now because of advances in surgical techniques and anti-rejection drugs, but how many marginal organs are used is up to individual transplant centers.

"Some places may be aggressive, some places may be conservative. It doesn't mean one place is right or wrong," said Dr. Philip Rosenthal, medical director of the pediatric liver transplant program at the University of California, San Francisco.

Leader leaves

There might be other reasons why Strong does fewer transplants now than it did before.

In the summer of 2000, Strong hired a new head of liver transplantation, Dr. Amadeo Marcos of the Medical College of Virginia. Marcos was known internationally for his work in liver transplants using live donors rather than organs from cadavers. More than a third of the transplants done at Strong in 2001, 56 of them, were "live liver" transplants. Strong did the most live liver transplants of any hospital in the nation that year.

Marcos left Strong for the University of Pittsburgh Medical Center in August 2002. And although live liver transplants have decreased nationwide, Strong's total liver transplants may have decreased because patients followed Marcos to Pittsburgh, Panzer said.

Marcos has done for Pittsburgh what he did for Strong. Pittsburgh is now tops in the nation for liver transplant volume, going from 179 transplants in 2002 to 276 transplants in 2003.

Marcos declined to comment for this story.

More important than sheer volume, Bozorgzadeh said, is if you're doing a good number of transplants and keeping waiting-list mortality and retransplantation low -- while keeping patient and organ survival high.

"High volume isn't always a bad thing. The problem is if it's the only view you use to look at the program," said Dr. John Fung, chairman of general surgery at the Cleveland Clinic. Fung headed the University of Pittsburgh Medical Center's transplant program before Marcos took it over.

"If you don't look at quality outcomes, that's not good," Fung said. "If you're being a factory, you're turning patients out without looking at the quality of life ... you may not be giving them the best care either."

Is quality up?

The quality of Strong's liver transplant program was brought into question when the state Health Department cited Strong for 10 violations based on patient cases between 2000 and 2003. While not critical of the program's clinical practices, the state said there was no documentation explaining why two Strong patients received less-than-ideal livers and then needed multiple liver transplants. Strong wrote a plan of correction to address the problem, and the state will monitor the program into next year.

Although Strong's doctors trumpet the program's new critical eye, some of the data coming out of the program since 2001 wasn't so bad.

About 88 percent of people who received a transplant between January 2001 and June 2003 survived one year after their first transplant, slightly higher than the national average of 86 percent. These statistics are from the Scientific Registry of Transplant Recipients, which tracks organ transplant data.

And the number of people who have needed a second transplant has decreased. Of transplants at Strong in 2002, 17.4 percent were the second, or even third, liver a patient had received. As of August this year, that number had dropped to 7.5 percent for 2004.

Experts say a program is likely of better quality if it only has to do a transplant once. However, these statistics don't reflect the date of a patient's first transplant. A patient could have gotten a second transplant in 2002, but he might have gotten his first 10 years earlier.

Bozorgzadeh said the program's outcomes, such as mortality rates, would be even better in 2004. Data on that won't be released until later next year.

LSTANFOR@DemocratandChronicle.com