Unfair Organ Distribution

A new study suggests the sickest patients waiting for donor livers may be short-changed by an unfair system, where less-ill patients are getting the organs first. While the intention of organ donation networks is to give first priority to the sickest patients--those closest to dying if they do not get an organ transplant--it appears those in the biggest cities may be the biggest losers in the process of organ donation and organ transplants.

"Our hands are tied." Mt. Sinai Medical Center organ transplant surgeon Dr. Thomas Schiano regrettably advises his patient Catherine Robilotto. She has end stage liver disease and is in desperate need of a liver transplant. There are no livers available. Catherine can barely get out the words as to how she's feeling, and when asked how she came to be so sick with liver failure, she utters, "Hep…hep…hepa." turning to her husband Anthony for assistance. He completes the sentence, recalling how after repeated blood transfusions back in the early 60’s his wife contracted Hepatitis C. "We never thought it would reach this point without getting the liver, but here we are" Anthony says.

It is the sickest patients, like Catherine who are supposed to get first priority on livers, presuming there is a match. But now, new research in the latest journal of the American Medical Association reveals that donor livers are not always distributed according to a patient's need. There is a disparity that leaves patients in large cities on the short end of the stick.

Two years ago, UNOS, the United Network for Organ Sharing, implemented a wait list system based solely on blood tests that mirror the overall health and blood type of the patient. The tests are converted into a score known as the MELD score. Generally, the higher the MELD number, the sicker is the patient. But there's a geography wildcard-- the united network is made up of 11 organ transplantation regions nationwide which vary greatly in population size. Donor organs usually are not sent outside a zone in spite of the fact that the demand for livers is usually greater in the more populated regions. The study found in the least populated areas, only 19% of the patients who got organ transplants were in this "most sick" category. This is compared to nearly 50% in the most populated regions. In other words, livers were going to less sick, less in-need patients, staying in the small regions rather than being transported to a larger region with sicker patients.

Dr. Schiano admits the problem is a difficult one. "No matter what system you devise there are going to be some inequities." Still, Dr. Schiano believes a better nationwide organ sharing system should be tried to eliminate geographic bias. However, he does say there is a bigger issue facing patients like Catherine than allocation rules. Like most transplant specialists, he turns this study's findings into the recurring plea for more organ donors. "The number of organs is the issue, if we could solve that problem, then all of these other things would be moot points."

UNOS provided this statement regarding its current MELD system: The MELD system is intended to ensure that the most urgent liver transplant candidates get first consideration for available organs, and data we have examined thus far suggest that MELD is effective in this regard. There must be some limitations imposed on the distance livers usually travel, given the limits of organ preservation time. And as long as the donor and patient populations are not equivalent among various sharing areas, some variation will exist in MELD scores at transplant. That said, UNOS continues to analyze improvements to the liver transplant system to ensure the maximum benefit of transplantation.

For that reason, there is a proposal currently out for public comment that, if approved, would allow donated organs to be offered for candidates with MELD scores of 15 or higher in the local allocation area, then for those with scores of 15 or higher in the broader allocation region, before any local patients with lower MELD scores would be considered.

For more information on organ transplantation, click here.

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