Best use of lifesavers
A good step for fairness in liver transplants
For five years, some of the best medical minds in America have pondered the question of how best to allocate the livers made available for transplants. Changes approved Dec. 4 are not perfect, but they are a potential improvement. While there will continue to be disparities in access to livers, the extensive debate leading to the revised policy shows how seriously the transplant community takes its charge to make the best use of the organs passing through its hands.
About 14,100 people are waiting for liver transplants across the country. That includes 60 people on the waiting list at Allegheny Health Network, 110 at UPMC and 63 at the separately counted Children’s Hospital of Pittsburgh of UPMC. Through Oct. 31 this year, there were nearly 7,000 liver transplants nationwide, including 140 locally.
While those figures show the stark shortage of livers, they mask geographic disparities that put some transplant candidates at increased risk of dying before a liver becomes available. Some areas, including the Northeast and West Coast, have lower organ donation rates but more transplant candidates than other parts of the country, meaning patients tend to be sicker when they finally get transplants and have a greater chance of dying on the waiting list than patients elsewhere.
Livers traditionally have been allocated locally and regionally before being offered to candidates nationwide, so the transplant community began to consider the possibility of broader sharing of organs to ease geographic disparities and cut waiting list deaths. A proposal made in 2014 would have collapsed 11 transplant regions into four or eight districts. That drew protests from transplant centers in the South, Midwest and Pacific Northwest loath to see an exodus of organs from their areas.
The revised policy is a compromise. Among other changes, it gives additional priority to certain candidates within 150 nautical miles of the hospital where a liver is harvested. The United Network for Organ Sharing, the nonprofit that operates the transplant system for the federal government, predicted an overall decrease in waiting list deaths and improved access for children who are waiting for livers. For Pittsburgh, UNOS said, the revised policy likely will mean no significant changes in the number of transplants, a small increase in the number of non-local livers used and a slight decrease in waiting list deaths.
Christopher Hughes, surgical director for liver transplantation at UPMC, said “bigger steps” are needed to address unequal access to livers. He’s right, but this is a start. UNOS has pledged to monitor the policy’s effects, and the transplant community is bound to revisit the issue in coming years. Doctors also are working to reduce the need for livers from deceased donors; for example, 49 of 93 transplants at UPMC and 11 of 28 at Children’s Hospital this year have involved living donors.
Nationwide, there are shortages of many organs besides livers and debates over how best to allocate them, too. The tug-of-war is a reminder of the need for higher rates of organ donation in all parts of the country.