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Sickest patients could benefit from revamped liver distribution system

Ben Schmitt
| Tuesday, Dec. 5, 2017, 6:18 p.m.
Surgeons perform a liver transplant (Tribune-Review file photo)
Tribune-Review
Surgeons perform a liver transplant (Tribune-Review file photo)

The organization overseeing how livers for transplant are distributed across the country made policy changes last week they say should benefit the sickest patients waiting for a new organ.

The Northeast, including Pennsylvania, has a relatively large number of people awaiting liver transplants compared with livers available.

Under the newest proposal, transplant candidates at increased medical urgency, who are at hospitals within 173 miles of a donor hospital, could receive a liver from a donor even if they are in different transplant regions, based on an amended scoring system.

The policy was approved by the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS).

“I think it's a small change, nothing dramatic, but it's a step in the right direction,” said Dr. Ngoc Thai, director of abdominal transplantation for Allegheny Health Network. “This whole reallocation is about taking care of the sickest patients first. I think that is the appropriate goal.”

Several models for distributing organs have been considered and rejected over the past five years, including one in 2016 that would have reduced transplant regions from 11 to 8.

Geographic disparity in liver allocation has been talked about for many years, said Dr. Christopher Hughes, UPMC's surgical director of liver transplantation.

“The northeast United States and California are at a disadvantage due to a discrepancy between the number of people listed and the number of eligible donors locally,” he said. “Sharing over a larger area is necessary to make organ access more equitable for patients.”

The new policy uses a scoring system to connect the first available organ to the sickest person in the country. A scoring system called MELD, which stands for Model for End-Stage Liver Disease, ranks liver transplant candidates on a scale ranging from 6 for the least ill to 40 for those at greater risk of death. Those with the highest MELD score go to the top of each region's list.

Now, high-priority patients with MELD score of at least 32 will be able to cross transplant region borders for livers. Previously, potential liver recipients needed a MELD score of 35 to cross those border.

“For many years, there have been considerable differences from one area of the country to another in terms of how sick most liver candidates need to be before they are likely to get a transplant,” Dr. Yolanda Becker, president of the OPTN/UNOS Board of Directors, said in a news release. “The revised policy reduces the effect of geography on transplant access and puts more appropriate emphasis on medical criteria that save and lengthen lives.”

Hughes said UNOS is consistently challenged in trying to balance the positive side of equity in organ sharing with the negative side of added travel time to obtain organs, costs of larger distribution, and safety risks to transplant teams flying in small planes and helicopters.

There are more than 14,000 people on the waiting list for a liver transplant, according to UNOS. Last year, 7,496 Americans received liver transplants from deceased donors.

As a result of this organ shortage some transplant centers, such as UPMC, are offering more living-donor liver transplantation to people on wait lists, “where a portion of a living person's liver is transplanted into the patient in need.”

“This is only done by the most experienced centers,” he said. “UPMC is increasingly using this method to save lives of people who may have otherwise died.”

Ben Schmitt is a Tribune-Review staff writer. Reach him at 412-320-7991, bschmitt@tribweb.com or via Twitter at @Bencschmitt.

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