Transplant network proposes 'long-awaited' changes to liver transplant policies

Proposal would change reduce number or liver donation regions from 11 to eight

The United Network for Organ Sharing (UNOS) and the Organ Procurement and Transplantation Network (OPTN) have proposed three new policies that would change the way livers are allocated for transplant.

The proposals, Lauran Neergard writes for the Associated Press, represent "a long-awaited step to ease a serious disparity," that "where you live affects whether you get a timely liver transplant or die waiting."

Background: Current allocation process creates disparities

Under the current rules, which date back to 1984, organs are distributed based on 58 "donor service areas," grouped into 11 different regions.

Organ availability varies significantly within and among regions, and some regions with fewer organs have higher demands. Under the current system, livers are distributed first to the sickest patients as determined by a so-called MELD score that represents their estimated current risk of death. The MELD score is based on a 40-point scale.

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In some instances, a patient in one region could be on the verge of death before he or she qualifies for a liver, while comparatively healthier patients in other regions are allocated livers. Ryutaro Hirose, chair of UNOS' Liver and Intestine Transplantation Committee, explained, "In some areas of the country, you have to reach MELD score of 35—those are patients who are extremely ill and usually will die within a week," adding, "Whereas in some areas, you have to have a score of 23, and those folks are sitting at home and we have to call them in for a transplant."

Individuals seeking a transplant can move to increase their chances of receiving a liver. However, not everyone is aware of or can afford that option, the Associated Press reports.

About 7,100 individuals received a liver transplant last year, while more than 1,400 died waiting for a liver.

Details of new proposals

One of the proposals would redraw the country's transplant regions, reducing the number from 11 to eight.

Hirose said, "When we redraw the lines, it actually matches better the organ supply and demand and ensures more equitable access across the country regardless of where you live."

The sickest patients still would have the highest priority, Hirose said. Priority also would be given to patients who live within a 150-mile "proximity circle" of a donor hospital. Hirose said, "That will keep organs from flying long distances for very small differences in the MELD score."

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If no patient in a transplant region needs or wants a donor liver, UNOS and OPTN then would prioritize sicker patients nationwide, based on their MELD scores.

The groups also are considering:

  • Adjusting the number of MELD points to ensure all liver cancer patients have a fair chance at receiving a liver; and
  • Implementing a national review board, to replace regional review boards, that would determine whether to grant exceptions to the priority system to allow severely ill patients receive transplants even if their conditions are not accurately reflected by their MELD scores.

The groups are accepting public comments on the proposals until Oct. 14.

Possible implications

According to Hirose, the proposal to redraw the transplant regions could reduce the number of individuals who travel to different areas for a liver, which "really disadvantages folks without resources that can't travel."

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In addition, patients in some regions would need higher MELD scores than before to obtain a liver.

Hirose said, "We want to make sure we give everyone a fair opportunity to get a liver transplant," adding "It's pretty much long overdue" (Frieden, "The Gupta Guide," MedPage Today, 8/10; Neergaard, AP/Washington Times, 8/15; Demeria, Richmond Times-Dispatch, 8/10).

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