Success of Pittsburgh VA Healthcare System liver transplant program reveals faults in system
The success of a liver transplant program at the Pittsburgh VA Healthcare System is boosting the demand for livers here and highlighting the flaws of an organ allocation system in which the risk of dying can depend upon where you live.
The Pittsburgh VA performed 48 transplants last year. According to government reports, that's more than twice as many as the VA's two other liver transplant centers — in Portland, Ore., and Houston — combined.
As of this month, 186 people awaited liver transplants at the VA facility here. Coupled with 207 people on a waiting list at UPMC and 80 people at Allegheny General Hospital, that leaves nearly 500 individuals waiting for livers.
The United Network for Organ Sharing (UNOS) allocates organs by geographic region, and the number available hasn't increased dramatically. A shortage of livers for transplant exists, and about 1,500 people die each year awaiting a transplant.
Dr. Abhinav Humar, chief of transplantation at UPMC, said those factors mean that people needing transplants in regions with greatest demand might be much sicker by the time an organ is available.
“VA patients come from all over the country to Pittsburgh, and the reason they do is because they've got a great team of doctors and nurses. But the organs don't come with them,” Humar said,
UNOS is considering a new mathematical formula to make organ allocation more equitable by redrawing the nation's 11 transplant regions based on distribution and demand for donated organs.
“This is gerrymandering for the public good. We have applied to transplantation the same math used for political redistricting, school assignments, wildlife preservation and zoning issues,” said Dr. Dorry L. Segev, a transplant surgeon and associate professor of surgery and epidemiology at Johns Hopkins University who led the team that developed the proposed reallocation formula.
Doctors evaluate candidates for a liver transplant according to the Model for End-Stage Liver Disease, or MELD, scale, which scores each person based on how urgently he or she needs a transplant within the next three months. Those with the highest MELD score go to the top of each region's list.
Humar said the average MELD score at transplantation at the Pittsburgh transplant centers, which was once 26 or 27, climbed to 32 or 33. The average score at transplantation in Indiana and Ohio is 22.
The transplant network's liver committee is considering different map options as it debates how to improve fairness without having to fly organs too far around the country.
“Details of this proposal and its potential local impact has not been fully assessed. We look forward to discussing improved access to transplant care for all those in need,” VA spokeswoman Ndidi Mojay said.
Turf wars might challenge any change, because transplant centers with shorter waits understandably don't want them to lengthen, said committee chairman Dr. David Mulligan of the Mayo Clinic in Phoenix.
Dr. Ngoc Thai, a liver transplant surgeon and director of the Center for Abdominal Transplantation at Allegheny General Hospital, said the issue that merits great scrutiny.
“I wouldn't immediately jump into changing the geography before I looked at (organ donation and procurement) performance. I think that needs to be a greater initiative,” he said, noting that this region has a better organ donation rate than many.
The Associated Press contributed to this report. Debra Erdley is a staff writer for Trib Total Media. She can be reached at 412-320-7996 or firstname.lastname@example.org.
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