Liver transplant distribution changed after years of debate

By Lenny Bernstein-Washington Post
Published on December 4, 2017

After years of debate, the organization that oversees the allocation of livers for transplant took steps Monday to address a long-standing geographic disparity in supply of the scarce organs.

The policy approved by the Organ Procurement and Transplantation Network will make more livers available in some places — including cities such as New York and Chicago — where the shortage is more severe than it is in regions such as the southeastern United States.

“The essential thing to stress about this proposal is that it does move things in the direction we want to go, across the country,” said Julie Heimbach, chairwoman of the committee that developed the proposal after considering 63 alternatives over more than five years of often-heated debate.

Many speakers Monday described the approach as a compromise that most could adopt but that completely pleased few.

David S. Goldberg, a hepatologist at the University of Pennsylvania’s Perelman School of Medicine who has studied the liver disparity, said in an email that he has concerns about the policy because it does not consider liver donation rates, which vary sharply across the country.
But, Goldberg said, “in the spirit of compromise and maintaining the value of democratic debate and discussion within our transplant community and the broader public, I can support this proposal.”

Hanging over the vote was a demand made Friday by a severely ill patient at New York’s Mount Sinai Medical Center, who contended that the board should abandon its policy of first offering organs within each of the 58 districts where livers are procured, known as “donor service areas.”

An attorney for Tamiany de la Rosa, 25, said in a letter to Eric D. Hargan, the acting secretary of the U.S. Department of Health and Human Services, that arbitrary geographic boundaries violate the law, which emphasizes giving livers to the sickest patients first.

Last month, a court-ordered deadline in a New York lawsuit prompted an emergency change in policy that reduced the importance of geographic divisions in the allocation of lungs for transplant.

Under the plan approved Monday, the state of New York would become one very large district for the purposes of distributing livers.

The geographic disparity in available livers has plagued transplant patients for decades. The United Network for Organ Sharing, the nonprofit organization that coordinates organ transplantation, divides the country into 11 regions for the purposes of liver distribution.

In Region 9, for example, which includes New York, just 327 livers were donated in 2016, continuing a pattern of meager procurement that goes back ­decades. In Region 3, which includes the Deep South and Puerto Rico, 1,336 livers were obtained from deceased donors.

The United Network for Organ Sharing (UNOS) regional map showing how the country is currently divided into regions for liver distribution. (United Network for Organ Sharing)

That is partly because the Deep South is the center of the nation’s “stroke belt,” where higher rates of obesity, high blood pressure and diabetes lead to fatal strokes, leaving more donors with intact livers. Many Southern states also have above-average death rates from traffic accidents.

Overall, however, there are far too few livers available for the people who need them. Last year, 7,841 livers from deceased donors were transplanted in the United States, while 14,000 people remained on the national waiting list. More than a thousand people die on the waiting list every year.

Since 2002, people have been placed on waiting lists at the nation’s 143 liver transplant centers based on a score derived from blood tests that indicate the progress of their disease. The higher the score, the sicker the patient.

Using the scores, an organ is first offered within the local district and region where it was donated, before it can be distributed to other regions if there is no match between donor and recipient. People with means can register at multiple transplant centers, which is how the late Apple founder Steve Jobs, who lived in California, received a liver in Tennessee.

The complex new plan, approved by a vote of 36 to 3 with one abstention, would extend the area in which an organ can be offered by drawing a 150-nautical-mile circle around donor hospitals, although some exceptions would apply. It is expected to make hundreds more livers available to patients in areas where they wait the longest.