WASHINGTON, D.C., June 18, 1998 — A young, critically ill child awaiting a liver and small intestine transplant in Pittsburgh might be alive today had donor organs from another region been transported to Pittsburgh instead of remaining in that region to be transplanted into a less sick child, a surgeon from the University of Pittsburgh Medical Center (UPMC) told a congressional committee today.
"My message to the committee is simple: The current national allocation policy for liver transplantation is inequitable and results in the needless loss of life of patients awaiting transplantation," said Jorge Reyes, M.D., FACS, FAAP, associate professor of surgery and director of pediatric transplantation at the University of Pittsburgh Thomas E. Starzl Transplantation Institute and Children’s Hospital of Pittsburgh.
Dr. Reyes testified for John Fung, M.D., Ph.D., chief of transplantation at Pitt, who was unable to do so because he was performing surgery.
A new federal regulation governing the nation’s transplant system was the subject of the hearing before the House Committee on Commerce’s Subcommittee on Health and the Environment and the Senate Committee on Labor and Human Resources. The U.S. Department of Health and Human Services (HHS) had announced the regulation in April, but the federal contractor that operates the Organ Procurement and Transplantation Network (OPTN), the United Network for Organ Sharing (UNOS), has vehemently opposed the rule. The University of Pittsburgh has been an outspoken supporter of the actions of HHS Secretary Donna Shalala.
"The Secretary, who speaks for no parochial interest, has issued a regulation that leaves issues of medical judgment with transplant doctors, but challenges the OPTN to propose new organ allocation policies that will promote patient benefit and the saving of patient lives as the highest performance criteria," Dr. Reyes testified.
"Critics of the regulation have mischaracterized its contents, and based upon the mischaracterization, have predicted dire consequences."
UNOS and others have inaccurately stated that the regulation calls for a single national waiting list. As such, the Secretary recently wrote a letter to members of Congress to clarify the content and intent of the HHS rule.
"The performance standards set forth in the regulation can be met without adopting a single national waiting list," Dr. Reyes told the committee. He explained that even the UNOS Liver and Intestine Committee had passed a motion that a policy could be developed that met the goals of the regulation while "avoiding some of the logistic difficulties attendant to a single national list."
Among those misconceptions about the regulation being promoted by its critics are:
Donation will suffer. Dr. Reyes cited UNOS’s own surveys and called this assertion "unfounded." "The sharing of the gift of life across state lines bring us together as Americans by breaking down the geographic boundaries of state and [sic] organ procurement organizations."
More patients will need to travel. An analysis of 1994-1995 UNOS data found that one in four patients traveled outside their state of residence to receive a liver transplant. "Patient travel is already a part of the transplant system. Indeed, equalizing waiting times will remove one of the several incentives for patients to travel to a distant center."
Organs will be diverted to large centers. Calling this claim "ludicrous," Dr. Reyes stated that "patients will have equal waiting times and an equal chance of receiving a transplant before dying, independent of where they list." Furthermore, nearly one-third of the transplant recipients at UPMC are status 3 patients, the least sick category. Under the new rule, it is likely that organs normally allocated to these patients will be diverted to more medically urgent patients elsewhere in the country.
An additional point raised in Dr. Reyes’s testimony is the fact that children awaiting transplantation will be better served under a system that meets the requirements of the regulation. Recent UNOS data indicate that as many as 600 pediatric livers are used in adult patients rather than in children, because the current system allows these livers to be trapped within OPO boundaries.
Concluding his testimony, Dr. Reyes stated, "The Secretary’s regulation of the OPTN does not take away any medical decision-making away from me of from any other surgeon...Moreover, it does not dictate any single liver allocation system. Instead, it guides UNOS to develop an alternative policy, perhaps similar to one of the many UNOS has considered over the past several years..."
The University of Pittsburgh believes any policy developed should aim to save as many lives as possible, both the lives of patients on the waiting list and of those who have been transplanted.