PITTSBURGH, November 5, 1998 — The current system of distributing donated organs to patients needing transplants is wrought with inequities and should give way to one that removes geographic barriers and allows children preferential access to organs donated by children, surgeons from the University of Pittsburgh Medical Center (UPMC) will argue at a national medical meeting in Chicago on Saturday, Nov. 7.
How organs are allocated to patients waiting for transplants has become one of the most contentious public policy issues ever to face the medical community, becoming so divisive that lawmakers have entered the fray. Just last month, Congress voted to delay for one year a government regulation that had called for changes to the national transplant system. Such is the backdrop for a series of debates between surgeons as part of a joint meeting of the American Association for the Study of Liver Diseases and the American Hepato-Biliary Association taking place at the Chicago Sheraton.
Among the 15 topics to be debated during the session "Clinical and Administrative Controversies in Liver and Pancreas Transplantation" are three on issues related to allocation. UPMC surgeons will participate in two of these debates, one of which focuses on how the current system affects children needing liver transplants. The UPMC has strongly advocated for changes in the organ allocation system and in support of the regulation issued last April by the U.S. Department of Health and Human Services (HHS).
The transplant system is operated under federal contract by the United Network for Organ Sharing (UNOS). Current UNOS allocation policy preferentially allows organs donated for transplantation to be used within the local area served by an organ procurement organization (OPO) even if there may be a sicker patient elsewhere in the United States. Because inequities exist with such a system, HHS had issued a regulation that required UNOS to develop different policies that give greater emphasis to patient medical urgency instead of to geography.
Intense lobbying by transplant centers opposed to the HHS regulation resulted in a rider attached to the giant Omnibus Spending Bill championed by House Appropriations Committee Chairman Bob Livingston (R-La.). The rider delays implementation of the rule for one year while a study is conducted by the National Academy of Science’s Institute of Medicine.
The UPMC has argued that such a delay will cost patients’ lives. Furthermore, maintaining the status quo will do nothing to address the plight of children but will simply encourage surgeons to perform more of the types of surgical procedures that have by necessity become more commonplace under the current system.
"Because of a system that traps organs within local OPO boundaries, organs donated by children are not necessarily being allocated on a regional or national basis to children on the waiting list," says Jorge Reyes, M.D., associate professor of surgery at the University of Pittsburgh Thomas E. Starzl Transplantation Institute and director of pediatric transplantation at Children’s Hospital of Pittsburgh. In 1996, there were 936 pediatric donors (under the age of 17) but only 306 pediatric patients received organs from those donors. Meanwhile, 156 other children were transplanted using split livers from adult donors or segments donated by a living parent. Moreover, 75 children under the age of 17 died on the waiting list that year.
"What happened to the more than 600 pediatric donor livers not transplanted into children? Were they used in less-sick adults because of a policy that emphasizes local primacy? Or worse yet, were they discarded because the local OPO did not have a pediatric transplant program? We must have a system that takes care of our children, especially those who are in the greatest medical need," argues Dr. Reyes.
Dr. Reyes will face Ronald Busuttil, M.D., from the University of California Los Angeles, who favors the current local-first system, in a debate about the feasibility of sharing on a national basis split liver segments.
"Yes, of course it is logistically and medically feasible to share liver segments across OPO boundaries, contrary to what Dr. Busuttil has contended in the past. But to spend much time debating the merits of such a sharing arrangement is skirting the real issue, which of course, is the fairness of the current allocation system. Patients, especially children, ought not to be penalized by geographic restrictions. Pediatric organs should go to pediatric patients," urges Dr. Reyes.
Arguing in favor of changes to the overall UNOS allocation process will be John Fung, M.D., Ph.D., professor of surgery and chief of transplantation at the Starzl Transplantation Institute. He will oppose Anthony D’Allessandro, M.D., from the University of Wisconsin. Dr. D’Allessandro hails from one of the four states that have passed laws to assure donated organs are offered first to in-state transplant centers.
"Such laws serve transplant centers, not patients, many of whom are forced to travel to distant centers more capable of treating their particular medical condition or where organs are in relatively greater supply. To preserve the current allocation scheme and allow state laws to further fragment what should be a national system will only result in more geographic disparities in waiting times. Such disparities can influence a patient’s risk of dying on the waiting list," says Dr. Fung.
The third debate on allocation, "The process for how we get to the fairest allocation system: Which is better?" will feature Goran G. Klintmalm, M.D., Ph.D., from Baylor Medical Center in Dallas, and C. Wright Pinson, M.D., from Vanderbilt University in Nashville.