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Report: UPMC needs to up transplant survival rate

Luis Fábregas
| Sunday, July 17, 2011

UPMC's live-donor liver and kidney transplant programs are back in operation after a more than nine-week shutdown, but a new national report indicates the world-renowned facility needs to improve the survival rate of its liver transplant patients and transplanted livers following surgery.

The one-year survival rate for adult liver transplant patients — a key measure of performance — was 82 percent at UPMC's Thomas E. Starzl Transplantation Institute compared with an expected survival rate of 87.3 percent, according to the report published last week by the Scientific Registry of Transplant Recipients.

On average, nearly 89 percent of liver transplant patients nationwide were alive a year after the surgery, according to the report, which measured outcomes in liver transplants performed between January 2008 and June 2010 against expected rates. The report also showed 78.5 percent of transplanted livers at UPMC were functioning a year after surgery, compared with an expected 83 percent rate.

The UPMC data showed that of the 254 liver patients who received liver transplants during the period in the report, 43 died within a year, compared with the expected 29.

UPMC officials agree more work needs to be done on transplant outcomes.

"We take outcomes very seriously," Dr. Abhi Humar, UPMC chief of transplantation, told the Tribune-Review.

UPMC recently hired a surgeon dedicated to looking at quality control issues such as outcomes and compliance for all the transplant programs, he said. The region's largest health care system also hired a coordinator who will work with state and federal oversight agencies to monitor quality.

Jim Kaufmann, publications director of the Minneapolis-based scientific registry, said a lower-than-expected survival rate can indicate that further investigation of a transplant center may be warranted. Patients should not automatically be concerned because a lower rate may simply reflect random variation, or chance, he said. It also could mean that the statistical methods used to generate the survival rating are not capturing something significant that is happening at a particular center, he said.

The registry issued its report on Wednesday, the day before UPMC reopened of its live-donor liver and kidney programs, which temporarily closed in early May. Hospital officials shut down the programs after discovering that a male kidney transplant patient received a kidney from a donor who was infected with the hepatitis C virus. The live-donor kidney program at Children's Hospital, which relies largely on adult donors, also was temporarily shuttered until its reopening last week.

UPMC officials reopened the transplant programs after receiving clearance from United Network for Organ Sharing, the federally funded transplant monitoring agency.

Lots of variables

UPMC's Humar cautioned that patient and liver graft survival rates change over time and fluctuate.

"You have to be careful just looking at one single snapshot," Humar said, noting that UPMC's one-month and three-year survival rates fell within expected ranges.

Humar attributed the decline in one-year outcomes to operating on patients who are sicker, or who come to UPMC after being turned down by other centers in the country. UPMC surgeons also do more retransplants on patients who may have had a transplant more than 10 years before, and those cases are tougher to do, he said.

Survival rates are adjusted for each facility in the registry's reports based on the hospital system's experiences, the condition of the patients they accept and other factors.

"While the (registry's) data is risk-adjusted, it cannot account for all the variables, both donor and recipient, that can impact on patient and graft survival," Humar said. "It is a good system, but not perfect."

The one-year survival measure is an important milestone after a liver transplant because most complications tend to occur before that, organ transplant experts said.

"If you get to the one-year mark, you have a chance of getting to the five-year and 10-year mark," said Dr. John Fung, chairman of surgery at the Cleveland Clinic and chief of transplantation at UPMC through 2004.

Dr. Goran Klintmalm, chief of the Baylor Regional Transplant Institute in Dallas and past president of the American Society of Transplant Surgeons, cautioned against using patient or graft survival as the sole metric of a program's quality. Patients should select a transplant center based on its volume, its infrastructure and the experience of the staff, he said.

"You want to have surgeons who are experienced. That's more important than anything," Klintmalm said. He cited a New England Journal of Medicine study that showed patients who experience complications are more likely to survive at a high-volume hospital.

Rival's surgical success

At UPMC rival Allegheny General Hospital, its liver transplant program posted a one-year patient survival rate of 89 percent compared with an expected 83.5 percent.

Allegheny General surgeons performed 28 transplants in the same data period and 50 since the liver program opened in 2007. The center's transplants climbed to 16 in 2010 from nine in 2009.

"The referrals are coming in steady," said Dr. Ngoc Thai, director of abdominal transplantation at AGH. "We're definitely on the up slope."

Thai credited the success of the AGH program to the influence of Starzl, the now-retired pioneer surgeon who performed the world's first successful liver transplant. All liver transplant surgeons at AGH completed fellowships at UPMC under Starzl and Fung.

"It gave us exposure and experience into things we wouldn't have seen in other places," Thai said. The other surgeons are Drs. Kusum Tom and Akhtar Khan.

Starzl, 85, would not talk about the difference in outcomes at UPMC and AGH when contacted by the Trib, but praised the AGH surgeons.

"I'm proud of them," Starzl said. "Anyone who went through that program has succeeded. I have vicarious pride."

Liver transplant volume at UPMC was nearly flat last year with 125 transplants, down from 126 in 2009. Officials could not say how the temporary shutdown will impact this year's volume.

A recent inspection of the kidney transplant program at Children's Hospital, which operates in collaboration with UPMC's program, found kidneys there failed at a higher-than-expected rate during a six-year period.

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