After years of often-intense debate, the Organ Procurement and Transplantation Network (OPTN) and the United Network for Organ Sharing (UNOS) on Monday approved policy amendments that change the way livers are allocated for transplant.
Background: How the United States distributes livers for transplants
The United States currently is divided into 11 regions in which livers are allocated by need. Under the current system, livers are first offered to the sickest patient within the region where the liver becomes available. Transplant patients are given a so-called MELD score, estimating their current risk of death, which is based on a 40-point scale. Pediatric transplant patients are given a PELD score. If a there is no match for a liver within the region where it was donated, the liver can be distributed to other regions.
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 receive livers in other regions. 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.
About 7,100 individuals received a liver transplant in 2015, while more than 1,400 died waiting for a liver.
OPTN/UNOS Board of Directors voted 36 to 3 with one abstention to approve the policy amendments, which are the result of a five-year process of studying and discussing alternative proposals to change the way livers are allocated in the United States.
The new plan will extend the area where a liver is offered to include individuals with MELD or PELD scores of at least 15 who are within 150 nautical miles of the donor hospital, even if they reside in a different region. According to the Washington Post, the policy change is expected to make hundreds more livers available to patients in areas where patients have historically waited the longest for transplants, such as New York and Chicago. Livers donated from individuals who are at least 70 years old or who die from, cardiorespiratory-related issues will not be subject to the expanded donation zones.
In addition, the new amendments would prioritize adult liver candidates who have a calculated MELD score of 32 or higher, as well as pediatric candidates younger than age 18 with a MELD or PELD score of 32 or higher.
OPTN/UNOS Board of Directors said simulation modeling show the revised policy is likely to increase transplant access for candidates younger than 18 and decrease pre-transplant deaths among liver candidates.
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The board of directors did not establish an implementation date for the policy amendments. Implementing the changes will require new education for donation and transplantation professionals, as well as new system programming and testing.
Yolanda Becker, president of the OPTN/UNOS Board of Directors, said, "The revised policy reduces the effect of geography on transplant access and puts more appropriate emphasis on medical criteria that save and lengthen lives." Becker said, "Every transplant policy is reviewed for intended and unintended effects," and OPTN will "continue to seek ways to make the policy work most effectively and address any issues that suggest it's not giving everyone similar benefit."
David Goldberg, a hepatologist at the University of Pennsylvania's Perelman School of Medicine who has studied liver donations, said the policy raises some concerns because it does not take into account liver donation rates, which vary significantly across the United States. However, Goldberg said that "in the spirit of compromise and maintaining the value of democratic debate and discussion within our transplant community and the broader public, I can support this proposal" (Bernstein, Washington Post, 12/4; OPTN release, 12/4).
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