The majority of patients on the liver transplant waitlist who died received offers of high-quality donated livers that were declined prior to their death, according to a new study in Gastroenterology, the official journal of the American Gastroenterological Association. Therefore, efforts other than simply increasing the availability of donated livers or the number of offers are needed to substantially reduce the deaths among those waiting for a transplant.
"Our findings suggest that waitlist deaths are not simply due to lack of donor organs, as many of us assume. Rather, deaths result from opportunities for transplantation that were declined," said John P. Roberts, MD, of the University of California San Francisco and lead author of this study. "Efforts should also be made to reduce the stigma associated with non-ideal livers and set realistic expectations for waitlisted candidates."
Researchers analyzed data from the United Network for Organ Sharing (UNOS) registry on all U.S. liver transplantation candidates who were offered livers from Feb. 1, 2005, to Jan. 31, 2010. Candidates were excluded if their Model for End-Stage Liver Disease (MELD) score—which is used to prioritize the urgency for liver transplant—was less than 15. Of 33,389 candidates for liver transplantation, researchers found that 20 percent died or were removed from the list, and 64 percent received a transplant. Among the subgroup of 6,787 transplant candidates who eventually died or were removed from the waitlist for being too sick, 84 percent had received at least one organ offer. More surprisingly, these candidates received not just one or two, but a median of six liver offers during their time on the waitlist.
"Donor quality/age" was cited as the most common reason for why transplant centers refused the organ. However, when organs considered "high quality" were analyzed, researchers found that 55 percent of transplant candidates who died or were removed from the waitlist before being transplanted had been offered at least one of these high-quality organs. This suggests that data from the UNOS/Organ Procurement Transplantation Network does not accurately or fully capture the true reason why these organs are refused. Understanding the real-time factors involved in these decisions is vital to improving the waitlist process for liver transplant candidates.
In a related editorial, Michael L. Volk, MD, MSc, and Carl L. Berg, MD, state that this study highlights the need to better inform patients about organ offers and to engage them in deciding whether to accept or decline such offers, rather than leaving this decision solely up to their physicians. Although it is assumed that most of these decisions are made with the best intent, it would be of interest to learn of patients' opinions about multiple organs being declined on their behalf.
Patients waiting for a liver transplant are prioritized by their risk of waitlist mortality, which is determined by their MELD score. Once a liver transplant becomes available, it is offered to the candidate who is first on the waitlist. Depending upon the quality of the donor liver relative to the perceived need of the candidate, this liver offer may be accepted for transplantation. However, the center to which the liver was offered can decline the organ, in which case, it will be offered to the candidate who is next on the waitlist, and similarly down the waitlist, until it is finally accepted for transplantation.