Correspondence

Geographic Favoritism in Liver Transplantation

N Engl J Med 1999; 340:963-965March 25, 1999

Article

To the Editor:

In their Sounding Board article, Ubel and Caplan (Oct. 29 issue)1 identified many important ethical issues with respect to organ allocation. Unfortunately, they included some factual errors and erroneous assumptions.

The adoption of a single national list for liver transplantation is not feasible. The statement that livers can be “stored for . . . 20 hours without serious damage” is scientifically incorrect. With every hour of storage, the rate of dysfunction of transplanted livers increases. Fortunately, virtually all programs have adopted a policy of prompt transplantation to avoid the loss of livers, reduce morbidity and mortality among the recipients, and reduce the need for a second transplantation.

The philosophy of treating the sickest patient first, the traditional and normally fair policy, assumes that the patients who are less sick will receive treatment later. This is not the case with liver transplantation. Need exceeds the annual supply of 4000 donor organs by a factor of 5 to 10. If a liver is allocated to one patient, another patient may never receive one. Expanding the area over which organs are allocated increases the access of high-priority patients to the organs. According to the computer model of the United Network for Organ Sharing (UNOS), the use of a single national list in which the sickest patients have priority would mean that fewer than 1 percent of patients with a status of 3, the lowest category of medical urgency, would undergo transplantation within seven years after being placed on the list. In effect, most patients who ultimately undergo transplantation would have to endure years of progressive morbidity until critical care or at least hospitalization was required, while simultaneously risking death while waiting. Fairness and efficiency demand a more balanced system. Geographic boundaries, in addition to providing substantial administrative and logistic advantages, also decrease the likelihood that one category of patients will have disproportionate access to donor organs.

I am an organ-transplant surgeon who has chaired two national committees on transplantation ethics and directed a transplantation and health policy center. I am currently the chair of the UNOS Liver Committee, but the views expressed here are my own.

Jeremiah G. Turcotte, M.D.
University of Michigan, Ann Arbor, MI 48109-0331

1 References

1. 1

   Ubel PA, Caplan AL. Geographic favoritism in liver transplantation -- unfortunate or unfair? N Engl J Med 1998;339:1322-1325
   Full Text | Web of Science | Medline

To the Editor:

With respect to the Sounding Board article by Ubel and Caplan, sophisticated computer models have been employed to assess the effects of geographic boundaries on more than 20 liver-allocation plans. When the number of patients who die while on the waiting list and the number of patients who die after transplantation are considered as a single outcome measure, no allocation plan is significantly better than the current system.1 This makes intuitive sense. The discrepancy between the number of patients awaiting transplantation and the number of donors is so large that it will always cancel out any improvement that might be achieved with a national system of allocating the 4000 donor livers that become available each year. The use of different boundaries to allocate these few organs slightly alters the numbers of transplants available in some geographic areas, but it does not significantly increase the number of patients who undergo transplantation or improve survival nationally.

Richard B. Freeman, Jr., M.D.
New England Medical Center, Boston, MA 02111

1 References

1. 1

   ULAM report to UNOS Liver and Intestine Subcommittee, Dallas, October 20, 1998.
   

To the Editor:

As long as there is a shortage of donor organs, any system of allocation will have critics and will put a subgroup of patients on the waiting list at a disadvantage. Ubel and Caplan state that “the federal government stepped in to fix the system only because the transplantation community failed to act.” After analyzing several different models of allocating donor livers, the transplantation community failed to act on the basis of the principle that “if it ain't broke, don't fix it.” If the staff at all 124 liver-transplantation programs in the United States were surveyed, the vast majority would say they were content with the current system. The furor over allocation developed because an extremely small but vocal minority of large centers decided to make this a political issue and made a strong lobbying effort.

For the majority of liver-transplantation centers, but more important, for the majority of patients, the current system works relatively well. Ubel and Caplan state that “the geographic inequities are especially troubling because they create advantages for patients who are informed and wealthy enough to place themselves on multiple waiting lists.” However, 98 to 99 percent of candidates for liver transplantation are on only one waiting list.

Although a geographically based system of allocation may be “ethically indefensible,” it is certainly medically defensible because of the limits of organ preservation. Although preservation of the liver for up to 20 hours has been reported, the current standard of care is to keep the length of storage below 12 hours. There are clear data indicating that longer storage periods are associated with sinusoidal and endothelial injury, especially to the biliary tract. To keep the time below 12 hours with a national system of allocation would be a logistic nightmare because of the need to use commercial airlines for transport, and this would undoubtedly result in prolonged cold ischemia and further organ damage.

Nonetheless, the current system of allocation has responded to improved preservation techniques by enlarging the focal geographic boundaries of organ distribution from individual programs and cities to whole states and regions while minimizing the storage time. In the state of Tennessee, a statewide region was created for the benefit of patients and has worked extremely well.

Robert J. Stratta, M.D.
A. Osama Gaber, M.D.
Santiago R. Vera, M.D.
University of Tennessee, Memphis, Memphis, TN 38163

To the Editor:

Ubel and Caplan downplay the logistic problems associated with a national waiting list for liver transplantation. So as not to interfere with the normal operating-room schedule, organ procurement is most commonly performed at night. This rules out the routine use of commercial flights for organ transportation, necessitating the use of expensive private carriers. The approximately $10,000 that the use of private carriers would add to the cost of transplantation is indeed important.

Jay S. Markowitz, M.D.
University of Medicine and Dentistry of New Jersey, Newark, NJ 07078

To the Editor:

Ubel and Caplan acknowledge that “well-established transplantation programs often attract patients from across the country,” thereby swelling their waiting lists and increasing waiting times — and mortality rates — for their patients. But what is not discussed or even mentioned is that the reputation and size of a program are intertwined with considerations that may or may not be related to patients' best interests. For instance, increased patient loads in larger centers mean larger staffs, bigger facilities, and greater numbers of supplies, all of which reflect economic considerations that extend far beyond transplantation. Moreover, larger centers require more patients and more procedures to maintain standards of efficiency (including acceptable mortality rates for patients on the waiting list), their reputation, and their national drawing power. And this may or may not be best for all candidates for transplantation, although it is most likely good for the patients who use such centers.

Stuart G. Finder, Ph.D.
Vanderbilt University Medical Center, Nashville, TN 37232-4350

To the Editor:

I am concerned that if the proposed federal regulations are enacted, some liver-transplantation programs will be forced to close. This would not be in the best interest of the people who depend on those centers for their care. Many of these centers serve primarily the medically disadvantaged, who would no longer have access to this lifesaving therapy. Ubel and Caplan acknowledge that “a national system is likely to reduce the number of programs,” but unfortunately they do not adequately appreciate the harm that such a change would inflict on patients.

The authors have also relied on information that is quite dated. More timely data are readily available through the UNOS data base and more clearly represent the evolutionary changes in the system that UNOS has administered for the past 12 years. This system seeks to strike a delicate balance between helping extremely sick patients and helping as many patients as possible.

Ubel and Caplan leave readers with the misguided notions that the current system not only is inequitable but also harms patients. Neither of these is true. An accurate presentation of the current system would refute their conclusions.

John M. Rabkin, M.D.
Oregon Health Sciences University, Portland, OR 97201

Author/Editor Response

The authors reply:

To the Editor: It is true, as noted by the letter writers, that the proposal by the Department of Health and Human Services to revise organ-allocation procedures has a number of serious flaws. As we pointed out in our article, the proposal places too much emphasis on directing organs to severely ill patients, even if such patients have little chance of benefiting from transplantation. Indeed, although the current system of liver allocation emphasizes the urgency of illness, the number of organs going to the most seriously ill patients would increase if the proposal is adopted, because all patients would be put on a single national waiting list. As we noted, any proposals to change the geographic basis of the allocation system should be accompanied by proposals to decrease the emphasis on giving organs to severely ill patients.

As a number of correspondents point out, the proposal is also flawed in its inattention to the practical limitations of transporting solid organs across the country. The proposal emphasizes the benefits of a single national list for all candidates for solid-organ transplantation. But this approach ignores the serious damage that would be incurred by attempts to transport hearts and lungs from cadaveric donors across long distances. A number of correspondents suggested that we made the same mistake and that livers cannot be transported great distances. These correspondents contradict a number of published studies that have shown that the outcomes are similar for organs transplanted less than 12 hours after harvesting and those transplanted 12 or more hours after harvesting.1-5 But if these studies are flawed, then clearly any revisions of the allocation system must reflect the way in which transporting organs would influence outcomes.

The Institute of Medicine is leading an effort to revise the proposal. One of its major challenges will be to strike a balance between an efficient system of allocation that maximizes the rates of organ survival and an equitable system that gives patients throughout the country a fair chance of receiving organs. To the extent that livers (and eventually other solid organs) can be transported great distances without seriously worsening the outcomes of transplantation, the revised system should strive to reduce, if not completely eliminate, geographic inequities in organ allocation. A fair system that reduces geographic inequities will not necessarily save more lives, but it will save lives more fairly.

Peter A. Ubel, M.D.
Philadelphia Veterans Affairs Medical Center

Arthur L. Caplan, Ph.D.
University of Pennsylvania Center for Bioethics, Philadelphia, PA 19104

5 References

1. 1

   Furukawa H, Todo S, Imventarza O, et al. Effect of cold ischemia time on the early outcome of human hepatic allografts preserved with UW solution. Transplantation 1991;51:1000-1004
   CrossRef | Web of Science | Medline

2. 2

   D'Alessandro AM, Kalayoglu M, Sollinger HW, Pirsch JD, Southard JH, Belzer PO. Current status of organ preservation with University of Wisconsin solution. Arch Pathol Lab Med 1991;115:306-310
   Web of Science | Medline

3. 3

   Belzer FO, D'Alessandro AM, Hoffmann RM, et al. The use of UW solution in clinical transplantation: a 4-year experience. Ann Surg 1992;215:579-583
   CrossRef | Web of Science | Medline

4. 4

   Padbury RT, Attard A, Mirza DF, et al. Extended preservation of the liver with UW solution -- is it justifiable? Transplantation 1994;27:1490-1493
   

5. 5

   Southard JH, Belzer FO. Organ preservation. Annu Rev Med 1995;46:235-247
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Fran??oise Roudot-Thoraval, Philippe Romano, Francis Spaak, Didier Houssin, Isabelle Durand-Zaleski. (2003) Geographic disparities in access to organ transplant in France. Transplantation 76:9, 1385-1388
   CrossRef

2. 2

   David H. Howard. (2001) HOPE VERSUS EFFICIENCY IN ORGAN ALLOCATION1. Transplantation 72:6, 1169-1173
   CrossRef