National proposal aims for fairer liver transplant distribution

The organization that oversees the nation's transplant system said Wednesday that it believes a new proposal would greatly reduce geographic disparities that make getting a liver transplant harder in some areas of the country and easier in others.

"Unfortunately, for many reasons, (right now) there is a big difference in your chances of receiving a transplant based on where you live," said Ryutaro Hirose, a liver transplant surgeon at the University of California at San Francisco Medical Center and chairman of the United Network for Organ Sharing's national liver transplantation committee that came up with the new proposal. He made the comments in an online news conference Wednesday.

The committee's proposal, which will be made public in full on Monday, would try to reduce those disparities by reducing the number of districts across the country in which organs are primarily shared. The current 11 districts would be reduced to eight districts, and their boundaries would be redrawn to try to create a better balance between districts of the ratio of livers available for transplant compared to how many people are waiting to receive them.

Currently, some areas of the country - primarily the heavy population centers on the West Coast and Northeast - have many more people who need a liver transplant compared to the number of donated organs. Patients in these areas tend to have to wait longer and are much sicker before they get a transplanted liver.

Other districts - primarily in the South and Midwest - the ratio is better and patients tend to get a transplant sooner and are healthier before getting a transplant.

Hirose said the committee's study found that the average Model for End-Stage Liver Disease, or MELD, score for patients receiving transplants in some parts of the country is 35 - on a scale from 6 to 40, with 40 being the worst. That means they are probably hospitalized and potentially within days or weeks of dying of liver disease if they don't get a transplant.

But in some other areas the average MELD score is just 23 for the average patient getting a new liver, and they are probably still resting at home and in much better health before they have a transplant.

Hirose said one of the hopes of reducing the disparity among regions is to stop primarily wealthy people from getting on multiple lists for organs at transplant centers around the country, as Apple founder Steve Jobs did when he traveled from California to Tennessee in 2009 to get a liver transplant.

The idea to redraw the districts has been debated for more than a decade, said Hirose, because early on the districts were not formed with the modern transplant world in mind.

The districts were created in the late 1980s more for administrative purposes, not liver allocation, because there were only five transplant centers in the entire country at that time doing liver transplants.

"There are over 100 (centers doing liver transplants) now," Hirose said. "So the maps created (in the 1980s) really don't help with distribution now."

Every time it has come up, the same parochial issues are debated.

"Everyone is concerned about how it will affect them," he said. "It's a charged subject, and not an easy one to deal with."

The liver committee has been intensely studying the issue for the last two years, and the feedback about the first proposals to redraw the districts resulted in concern from some areas that have a better ratio of livers to people waiting for them that they would lose out.

In response, the current proposal creates a "proximity" area that gives three additional MELD points to any person on the waiting list who lives within 150 miles of the donor's location.

Using that, the number of livers that would stay within the redrawn districts would be about 95 percent, according to statistical models the committee used, but nationally the variance between the average MELD score at transplant would be cut roughly in half. That means there should be fewer very ill patients getting liver transplants, resulting in better long-term outcomes.

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