Surgeons Seek Reform of Liver Allocations

By Andrew Conte; Luis Fabregas | Tribune-Review/Pittsburgh Tribune-Review, March 14, 2008 | Go to article overview

Surgeons Seek Reform of Liver Allocations


Andrew Conte; Luis Fabregas, Tribune-Review/Pittsburgh Tribune-Review


The nation's liver allocation policies must be overhauled to stop transplant centers from doing surgeries on patients who don't need them, some of the nation's top transplant surgeons said.

Hundreds of people each year undergo these transplants, and one in 10 dies when they could have lived longer without the surgery, the Tribune-Review reported this week in a three-day series.

Potential changes include limiting the liver transplant waiting lists to people who have reached a certain level of sickness and revising how those patients move up the list.

"This practice of using marginal organs in not very sick people is not benefiting patients for the most part and is hurting the people who really need them," said Dr. Richard B. Freeman Jr., transplant surgeon at Tufts-New England Medical Center in Boston.

Whatever changes are made must start with doctors, and then they can be enforced with federal regulations, said the nation's top health administrator, U.S. Health and Human Services Secretary Mike Leavitt.

"We need to listen to them," Leavitt said during a visit to Pittsburgh this week. "Organ transplantation is a new enough discipline that we're all learning. There are probably places where we're not perfect in our execution as a society."

UNOS may revise rules

Leavitt said an overall system is in place to consider possible changes. That includes the United Network for Organ Sharing, or UNOS, which sets organ allocation rules under contract with the federal government.

A top UNOS leader said any changes cannot interfere with the medical judgment of a doctor, a sentiment echoed by surgeons.

Dr. Ken Washburn, vice chair of the UNOS liver and intestinal organ transplantation committee, said it isn't right for surgeons to transplant livers into people who are better off waiting. However, he stopped short of saying that what they're doing can be avoided.

"We can't dictate to someone whether you can or cannot get a transplant," said Washburn, who is head of the liver transplant division at the University of Texas Health Science Center in San Antonio. "We can make it harder for those less ill patients, but we can't say you can't get one."

Washburn cited a 2005 UNOS rule called Share 15 as an example of how the agency has tried to curb transplants on the less ill. Although the rule has led to an overall drop in low-MELD transplants, some centers continue to do them. Patients on the waiting list are ranked by a scoring system called MELD, for Model for End-stage Liver Disease.

Detailing reforms

The Trib's investigation found four centers have done half of the 846 low-MELD transplants since 2005: in order by volume, Clarian Health in Indianapolis, the University of Pittsburgh Medical Center, Mayo Clinic/St. Luke's Hospital in Jacksonville and Strong Memorial Hospital in Rochester, N.Y. About a third of the transplants at Clarian in that period were in patients with low-MELD scores.

"I think it's hard for us to legislate to individual centers on what you can and cannot do," Washburn said.

Among the suggested changes in response to the Trib's stories, doctors called for:

Increasing organ sharing among more of the sickest patients before the livers move down the list of those who are less ill. …

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