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Hot Debate on Organ Distribution Proposal

Organ supply and demand varies sharply by geography in the US. "The status quo is intolerable-there is too much geographic disparity," said Michael Charlton, MD, speaking at a Sept. 16 meeting in Chicago where transplant surgeons and others debated a controversial proposal to consolidate the nation's current regional organ distribution districts. The forum was convened by the United Network for Organ Sharing (UNOS), a non-profit organization that under a contract with the federal Organ Procurement and Transplantation Network (OPTN) runs the current system of deciding which donor organs go where.

Organ supply and demand varies sharply by geography in the US.

“The status quo is intolerable—there is too much geographic disparity,” said Michael Charlton, MD, speaking at a Sept. 16 meeting in Chicago where transplant surgeons and others debated a controversial proposal to consolidate the nation’s current regional organ distribution districts.

The forum was convened by the United Network for Organ Sharing (UNOS), a non-profit organization that under a contract with the federal Organ Procurement and Transplantation Network (OPTN) runs the current system of deciding which donor organs go where.

All who attended the meeting agreed there is a problem: In some states, a patient who needs an organ transplant can move up the waiting list quickly.

In others where donor organs are much more scarce and patients can die waiting.

The reason for the disparities is that places like the more densely populated urban centers of the Northeastern US have more people with illnesses that lead to organ failure. These health conditions, like diabetes, are less common in the Midwest. So residents of New York and Philadelphia, for instance, are likely to wait a long time when they need a donor and residents of Florida and Louisiana, for example, can get transplants while they are relatively healthy.

UNOS and OPTN, whose recommendations generally set US Health& Human Services policy, are trying to change that situation.

The big question is whether the current system of dividing the US into 11 organ transplant regions should be replaced with a system with as few as 4 regions.

Charlton, medical director of the Intermountain Medical Center Liver Transplant Program, in Murray, UT, said that would benefit the large metropolitan transplant centers on the East and West Coasts.

But it would have “the unintended consequence of shifting resources away from rural, relatively poorerpopulations, and centers, thereby decreasing access for communities with high donation rates.” It could also mean transplant centers in these regions would no longer be economically viable.

Another expert, Devin Eckhoff, MD, of the University of Alabama at Birmingham, calculated that because of the potential for increased costs in getting donor livers to patients when longer distances are involved, the cost per life saved would be more than $500,000. He also estimated that the number of successful liver transplants would likely only increase by about 1%.

Still more opposition may come from organ procurement organizations (OPO)s—at least at the ones that are doing a good job of convincing people to agree to become donors when they die.

At the Gift of Life, a 40-year-old OPO in Philadelphia, its president and chief executive Howard Nathan said his organization, has the highest number of donors per population of any in the nation “Maybe in the world,” Nathan said.

Its success rate is measured in the fact that there are currently 47 designated donors per million residents in his OPO in Region 2, an area that includes PA and New Jersey. That compares to the national average of 26 donors per million—and a low of 18 per million in one OPO.

“We are the highest performing OPO and we just want to make sure that others are pulling their weight” if a redistricting plan were to happen, Nathan said.

David Reich,MD, chief of the division of multi-organ transplantation and hepatobiliary surgery at Drexel University College of Medicine and Hahnemann University Hospital in Philadelphia, PA said redistricting would not solve all the problems of allocating organs fairly. Nor would it guarantee that viable organs do not go unused. Reich said about 20% of donated organs end up being discarded.

Sometimes that happens because of delays or problems in transporting organs. Or a transplant surgeon will agree to accept an organ that’s not perfect and then when it arrives decide not to use it after all.

One solution, Reich said, might be pending federal approval of new medical devices that can keep donor organs like hearts and livers at body temperatures and artificially perfused. That means they can “live” for longer periods than they can survive in the current transport method of keeping them on ice. Reich hopes that would make it possible to extend the “fly time” in getting organs to patients.

But Nathan was less sanguine about that solution. “I totally disagree with Dr. Reich that this would mean a lot more organs would be available,” he said. “Most of the discards are because of fatty livers, due to more people having them” a consequence of obesity and diabetes. Nathan said expanding the districts would also raise costs.

The debate goes on.

Both agreed that if UNOS decides on a change, it would likely take years to implement. Meanwhile, patients are waiting. Some choose to be “transplant tourists” and travel to regions where waits are known to be shorter—despite the expense and inconvenience of having to live in a new place temporarily.

Once they are successfully transplanted, patients tend to return home, and go to a local liver transplant center for follow-up. That can put these home doctors at a financial disadvantage, since the big insurance payments go to the transplant surgeon and center.

Redistricting would open a wider pool of organs, but at the UNOS forum, Reich said, “The general agreement was that it would not be a panacea.”