Policy has changed how organs are allocated

NEW YORK (Reuters Health) - An organ allocation policy that puts the sickest patients first in line to receive available donor livers for transplantation has created some unintended consequences for those patients low on the organ wait list, research suggests.

Since the new donor organ allocation system was implemented in early 2002, there has been a shift toward using poorer quality organs in patients least in need of a transplant, the University of Michigan, Ann Arbor-based research team has found.

This has reduced post-transplant survival in recent years among these patients.

“What’s striking,” Dr. Michael L. Volk noted in a university-issued press statement, is that these patients typically have a low risk of dying before the transplant, “and ultimately derive limited benefit, in terms of survival, from liver transplantation. In some cases, these patients may actually be harmed by a transplant, even with an organ of average quality.”

The allocation system is dubbed MELD, for Model for End-Stage Liver Disease (MELD).

Although priority for liver transplantation is determined by the MELD score - a formula that uses several factors to gauge the risk of death from liver disease - the quality of organs used and the patients to whom they are given is subject to physician discretion, Volk and colleagues explain in a report in the journal Gastroenterology.

Volk and colleagues set out to determine whether implementation of the new MELD system has affected the quality of organs transplanted, the type of patients that receive the higher-risk organs, and the impact of these changes on post-transplant survival.

To accomplish this, they analyzed data from the United Network for Organ Sharing (UNOS) for adults who underwent a deceased donor liver transplant between January 1, 1997 and August 1, 2007.

The team found that the overall quality of transplanted livers has gotten worse since the implementation of the MELD-based priority system.

“This was accompanied by a shift from using the higher-risk organs in the more urgent patients (in the pre-MELD era) to using the higher-risk organs in the less urgent patients (in the post-MELD era),” according to the investigators.

As a result, post-transplant survival has worsened over time in patients least in need of a transplant

“The most striking finding of this study was the complete reversal from the pre- to post-MELD eras in which organs were deemed acceptable for use in which patients,” the investigators write. “This demonstrates how strongly changes in national policy can affect individual medical decisions.”

Despite the physician being the one to make the final call on an available donor organ, Volk thinks transplant patients should be informed about the quality of a potential donor organ. They also need to have an understanding of the transplant process and the MELD system.

“Few would dispute that patients have the right to know the quality of organ they receive, but it’s unclear how much patients are truly informed,” Volk said. “This is a complex subject, and physicians say that they find it difficult to communicate all the various risks without scaring the patient.”

Although Volk and his colleagues do not advocate for changing the MELD system, they do recommend increased patient involvement in decisions about organ quality; better education of doctors about the harm caused by allocating high-risk organs to less sick patients; and changes in the reimbursement system so that managing and transplanting sicker patients are reimbursed at higher rates to remove any incentive to transplant the more stable patients with lower quality organs.

SOURCE: Gastroenterology, November 2008.

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