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Day 2: 'The sicker they are ... you see a miracle'

| Monday, March 10, 2008
Surgeons perform a liver transplant (Tribune-Review file photo)
Surgeons perform a liver transplant (Tribune-Review file photo)

MIAMI -- Dr. Andreas Tzakis cuts open the woman's belly to reveal her sick liver.

Its surface is bumpy and dark pink.

"It's supposed to be smooth and light pink," Tzakis said, his mouth covered with a green surgical mask.

In the next three hours, Tzakis and his surgical team at Jackson Memorial Hospital will disconnect the sick liver and replace it with a new one. It is a surgery he's done thousands of times and it gratifies him.

"It's a reward for us," he said. "To help those who need us the most. The sicker they are and the better they do ... you see a miracle."

Such philosophy emanated from Tzakis' mentor at the University of Pittsburgh, Dr. Thomas E. Starzl. The father of transplantation taught Tzakis and hundreds of other students to always transplant the sickest.

"My upbringing was to try to help the people who need me the most," said Tzakis, 56, who completed a two-year fellowship under Starzl and moved on to head one of the most successful transplant programs in the country. He is the director at the Transplant Institute at the University of Miami/Jackson Medical Center. "I like to do the high-MELD patients because it's where I get more satisfaction."

At Jackson Memorial, the third largest public hospital in the nation, the vast majority of its 200 liver transplants every year -- 95 percent -- are done on critically ill patients, those who are MELD 15 or above and thus favored on the waiting list.

Tzakis, who by his own count has performed more than 3,000 transplants, said he is following the rules established by the United Network for Organ Research. The agency has implemented rules to ensure the first available livers go to patients with MELD scores above 15.

"Since we always have patients who have a high-MELD score and since we have a limited number of organs, we use it on the high-MELD score," Tzakis said.

Like Tzakis, many of Starzl's disciples practice under the same philosophy.

Dr. John Fung worked for 13 years as UPMC's chief of transplantation and collaborated with Tzakis in 1992 on the world's first human transplant using a baboon liver. He said the lowest-risk patients shouldn't be transplanted.

His argument: Even with a perfect liver, transplant recipients already have a 10 percent chance of dying in the first year -- exceeding the risk of just waiting to get sicker.

"There is a point where, and we've argued this for years, the lowest-risk patients shouldn't be transplanted because they don't need it," said Fung, who in 2004 left Pittsburgh to become chairman of surgery at The Cleveland Clinic. "Their risk of dying on the waiting list is low, and they are better off just waiting."

With rare exceptions, that's the philosophy at Cleveland, where only 3 percent of transplants in the past two years were performed on patients with MELDs lower than 15.

The practice of transplanting into the less ill emanates from internal hospital pressures, Tzakis said.

"The futility factor comes into play," he said. "When is it too late to transplant someone? Sicker patients require a lot more resources."

That includes more doctor time, additional drugs and longer stays in intensive care units, which are notoriously costly and often scarce at a time when more chronically ill patients require hospitalization.

"The hospital doesn't like it, the insurance company doesn't like it, the doctors don't like it because it requires a lot of work," he said. "If you put all those things together, there's a lot of pressure to do patients with low-MELD scores."

The patients with low-MELD scores wind up getting organs that have been rejected by surgeons across the country, but Tzakis doesn't mind using those organs on sicker patients with higher scores.

"If it's a good enough liver, you can place it in anybody on the list," Tzakis said.

Luis Fábregas can be reached at or 412-320-7998. Andrew Conte can be reached at or 412-320-7835.

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Day 2: Treat sickest first, or give livers to the less ill?
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About the data
• Despite a federal rule designed to limit the number of liver transplants in patients who aren't critically ill, four of the nation's 127 programs ...
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