Emory Doctors Oppose Proposal to Reallocate Livers

Low socioeconomic and rural patients in need of liver transplants in Georgia could be at greater risk under an Aug. 15 proposal by United Network for Organ Sharing (UNOS) that would reallocate nationwide distribution of donated organs. Emory University Hospital (EUH) has partnered with other organizations throughout the Southeast that offer liver transplants to create “A Collaboration for Donor Fairness,” a consortium that opposes the proposal on the grounds that it will limit access to donated livers for patients living in the Southeast.

UNOS, a nonprofit commissioned by the U.S. Department of Health and Human Services to assign donated organs nationwide, demanded changes to the current distribution system. Rather than dividing donated organs among 11 regions in the country, the proposal will split the country into eight districts, moving Georgia from a group containing the Southeastern states and Puerto Rico to one that consists of states along the East Coast from Georgia to Maine.

Access to fewer livers could hinder the Emory Transplant Center’s ability to sustain the number of liver transplants that it completes each year — a number which currently exceeds 150, according to the Emory Transplant Center.

The proposed system would cause organs to travel across more state lines, increasing the amount of time it takes for a patient to receive the organ — thereby increasing the risk of complication during surgery, as organs that are preserved outside of a body for long periods of time are associated with a greater increase in complications during transplant procedures, according to TransWeb, a transplantation information organization.

According to Ray Lynch, assistant professor of surgery in the Emory University School of Medicine’s Division of Transplantation, the proposal would create a disparity between rural underprivileged and lower socioeconomic patients in the Southeast, and those in the Northeast with whom they would be lumped if the proposal passes.

The two-month public comment period on the proposal ended Oct. 15, and The Liver and Intestinal Organ Transplantation Committee is currently reviewing the feedback. UNOS members, which consists of doctors and medical professionals representing the 11 regions, will vote on the proposal at an undisclosed date.

Any policy reallocating the use of donated organs must comply with the National Organ Transplant Act of 1984. The act requires policies to “be based on sound medical judgement, seek to achieve the best use of donated organs and …. promote patient access to transplantation.”

Georgia Rep. Lynn Westmoreland wrote an open letter to U.S. Department of Health and Human Services Administrator Mary K. Wakefield in opposition of the proposal, citing the fact that more than 90 percent of livers donated by Georgia residents were used for transplants within the designated Southeast region, and therefore opposes a proposal that would see those livers spread out among a wider portion of the country.

“Our state’s success in realizing the benefit of liver transplant is a testament to the cooperation and trust we have built within our community,” Westmoreland wrote.

Wakefield responded to an open letter with one of her own, writing that any policy passed by UNOS would do so with the goal of decreasing the disparity in access to livers among different geographic regions in the country and comply with the 1984 act.

Doctors across America prioritize patients on the liver waiting list by designating a Model for End Stage Liver Disease (MELD) score for the patient which indicates their risk of dying from liver disease. A higher score means a higher rate of mortality and a greater priority on the list, but according to Lynch, there are aspects of patient conditions and access to medical care that can’t be quantified in MELD’s numerical value.

While the MELD score reveals a patient’s mortality rate, it fails to account for the fact that citizens of rural areas in Georgia and the rest of the Southeast are less likely to be diagnosed with a liver problem and recommended to a specialist because they have less access to healthcare.

Having the same MELD score in rural Georgia and New York City can indicate a large difference in risk of dying,” Lynch said.

The problem persists along racial lines, as well. While African-Americans remain the largest group of minorities in need of donated organs, a 2011 study found that they are disproportionately less likely to be recommended to a transplantation center.

“There’s a large rural, underprivileged population [that may not have easy access to treatment]” Lynch said. “Just the mere fact that a patient is on the list shows the fact that they had the good fortune to get recognized and visit a specialist who placed them on the waiting list. Not everyone can do that.”

The proposal could have additional unforeseen consequences on youth patients in need of a liver transplant, Westmoreland said. The collaborative liver transplant program between EUH and The Children’s Hospital of Atlanta is the only agency completing pediatric liver transplants in the state of Georgia for a population consisting of more low-income minorities than the national average of transplant recipients, Westmoreland said.

According to Lynch, the debate among physicians, patients and organ donors is indicative of a need to re-examine the system used to allocate donated organs.

Across the country, the need for donated livers continues to grow. According to the American Liver Foundation, more than 17,000 adults and children are waiting for livers to become available.

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