Liver access crucial, experts say

[Clark]

http://triblive.com/news/healthnews/6319633-74/transplant-meld-scores#axzz36mzqgj4i

Liver access crucial, experts say
By Luis Fábregas

Too many people die while waiting for liver transplants because of geographic disparity in the allocation of organs, says a committee of the United Network for Organ Sharing, the nonprofit that coordinates the nation's organ transplant policies.

The committee is asking organ transplant organizations to consider offering available livers to people within larger geographic boundaries in order to reduce the number of wait-list deaths, said Dr. David C. Mulligan, committee chair and a professor of surgery at Yale School of Medicine.

The UNOS committee favors four to eight districts with no fewer than six transplant centers in each. Officials said this will give sicker patients equal access to organs.

“Unfortunately, there are many people that are dying every week around the country because they can't get access to lifesaving livers,” Mulligan said.

Under the allocation system, donated livers first are offered to patients within defined local regions. If a transplant center rejects an organ, it is offered to patients within a region that might cover more than one state, and finally to all those waiting nationwide.

The donation needs to happen within hours because organ function can deteriorate.

Federal officials prioritize transplant candidates based on a scoring system called MELD, or Model for End-stage Liver Disease. It ranges from 6 for the least ill to 40 for those at greater risk of death.

People with higher MELD scores die more often while on the waiting list, Mulligan said, because some parts of the country have lower organ donation rates. He said donation rates match death rates, which vary because people tend to live longer in some parts of the country. Different lifestyles lead to different ages at death, which lead to differences in medically eligible potential donors.

Transplant recipients in New England and California get organs at the highest MELD scores — above 28. In Pittsburgh, people on average get transplants when they have MELD scores between 26 and 28.

“There's a huge disparity on how sick people are, depending on where they live, to have access to a lifesaving transplant,” Mulligan said.

People with MELD scores higher than 35 have a 33 percent chance of dying while awaiting a transplant, according to a UNOS analysis of 28,000 candidates added to wait lists between 2007 and 2010. By contrast, patients with MELD scores lower than 15 have an 8 percent chance of dying while waiting.

“More people, year by year, continue to die on the wait list ... and this is an ongoing problem and certainly something that we have to do something about,” Mulligan said.

Statistical modeling suggests that using fewer geographical allocation districts would reduce wait-list deaths, Mulligan said UNOS found.

A redistribution plan with eight districts would result in 342 fewer deaths; a plan with four districts would result in 581 fewer deaths, according to the analysis.

Officials for years have talked about establishing a broader sharing process because of a limited supply of organs. More than 16,000 people nationwide are awaiting livers; doctors perform only about 6,400 liver transplants every year, according to UNOS.

The timing to change the system has not been right, said Dr. Ngoc Thai, director of transplantation at Allegheny Health Network, because transplant centers with sicker patients would dominate the landscape.

“We would have the entire country dominated by a few transplant centers,” Thai said. “Now you have transplant centers everywhere, so it makes more sense.”

A 2008 Tribune-Review investigation found hundreds of patients each year underwent liver transplants when they didn't need them. Some received organs when their MELD scores were 14 or lower, despite research showing they had better odds of surviving by waiting until they became sicker.

UPMC was one of four transplant centers that, combined, performed half of the low-MELD transplants between 2005 and 2007.

Dr. Christopher Hughes, UPMC's surgical director of liver transplantation, said UPMC sees much sicker patients than before. Though the region that includes Western Pennsylvania is constrained by a lack of donors, other parts of the country have higher donor rates and organs go to people with lower MELD scores, Hughes said.

“Something has to change to be able to make it a little more even,” Hughes said.

Changing the system would result in fewer transplants on people with MELD scores lower than 15, according to UNOS.

Hughes said some transplant centers struggle to perform transplants on sicker patients because donated organs are not in the best shape. Organs from older donors or people with chronic diseases are not suitable for people with higher MELD scores, he said.

“When you start adding marginal donor with a very sick recipient, your outcomes are poor,” he said.

UNOS said a proposal might not be ready for public review until spring.