Transcript Liver Transplantation: Fair and Equitable Access Jeffery L. Steers, MD FACS Objectives ❖ Discuss liver allocation past, present and future ❖ Outline disparities in liver allocation.

Liver Transplantation:
Fair and Equitable Access
Jeffery L. Steers, MD FACS
Objectives
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Discuss liver allocation past, present and future
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Outline disparities in liver allocation across the nation
❖
Review current national liver donor distribution
Fair and Equitable
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fair
❖
adjective
❖
❖
adverb
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❖
in accordance with the rules or standards; legitimate
without cheating or trying to achieve unjust advantage
equitable
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adjective
❖
fair and impartial
Liver Transplant Volumes
Liver - Waiting List
Post-Transplant Survival
Titanic lifeboat
Lifeboat Ethics
Lifeboat Ethics in
Transplantation
❖
Principles
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Respect for Persons (Autonomy)
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Harms and Benefits (Beneficience / Non-maleficence)
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Fairness (Justice)
Lifeboat Ethics in
Transplantation
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Fairness
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When there are not enough organs for people who
need them, how should they be distributed?
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What is the fairest way to distribute organs?
First in the Lifeboat
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Those who are:
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likely to live the longest if given the resource
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sickest
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youngest
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most valuable to society
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are least responsible for their disease
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win in a lottery
http://science.education.nih.gov/supplements/nih9/bioethics/guide/teacher/module-3-activities.pdf
US Liver Allocation History
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Pre-1984
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Transplant center - private hospital affiliation
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SEOPF - Southeast Organ Procurement Foundation
1984 - NOTA
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UNOS incorporated and receives initial federal contract to operate the Organ Procurement and
Transplantation Network (OPTN)
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OPO’s are established
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Previous affiliations allowed
First liver allocation system determined by patient care setting and shared within OPO first,
regionally and then nationally
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Recognized benefit of using local donor organs for local recipients
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ICU, Inpatient and Outpatient and waiting time at each location
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Tremendous opportunities for “gamesmanship”
US Liver Allocation History
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1998 Congressional Final Rule (implemented 2000)
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Deemphasize waiting time
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Focus on disease severity and mortality risk measured
by objective scoring
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Geographic sharing over as broad a region as feasible
Child-Turcotte-Pugh Score
Measure
1 point
2 points
3 points
Total bilirubin
<2
2-3
>3
Serum Albumin
>3.5
2.8-3.5
<2.8
PT / INR
<1.7
1.71-2.30
>2.30
Mild
Moderate to
Severe
Grade I-II
Grade III-IV (or
refractory)
Ascites
Hepatic
encephalopathy
None
None
Child CG, Turcotte JG (1964). "Surgery and portal hypertension". In Child CG. The liver and portal hypertension. Philadelphia: Saunders. pp. 50–64.
CTP Score and Survival
Points
Class
1 Yr Survival
2 Yr Survival
5-6 Points
A
100%
85%
7-9 Points
B
81%
57%
10-15 Points
C
45%
35%
Child CG, Turcotte JG (1964). "Surgery and portal hypertension". In Child CG. The liver and portal hypertension. Philadelphia: Saunders. pp. 50–64.
Child-Turcotte-Pugh
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Weaknesses in allocation
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40% subjective (ascites & encephalopathy)
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Bilirubin weak indicator of prognosis in cholestatic liver
disease
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Unable to categorize patients with preserved liver
function (cancer, hepatopulmonary syndrome,
hepatorenal syndrome etc.)
MELD / PELD Score
Allocation
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Scoring system developed at Mayo for patients
undergoing TIPS procedures
MELD Score and Survival
Three Month Hospital Mortality
40 or more
71.3%
30-39
52.6%
20-29
19.6%
10-19
6.0%
<9
1.9%
Wiesner et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology (2003) vol. 124
(1) pp. 91-6.
Smith et. al. American Journal of Transplantation 2012; 12: 3191–3212
Adult Liver Allocation
http://www.srtr.org/allocationcharts/files/Liver_adult_donor.pdf
OPTN / SRTR 2011 Annual Data Report.
HHS/HRSA/HSB/DOT.
Effect of Allocation Changes
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Scoring system entirely objective
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Regional sharing for sickest patients
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Standard approved exceptions for commonly recognized
conditions
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Significant waiting time discrepancy remains
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Cumbersome approval process for individual patients
who don’t meet approved criteria
Waiting Time Discrepancies
Waiting Time Discrepancies
Center
Median Time to Transplant
(Months)
Loyola University Medical Center
>72
Northwestern Memorial Hospital
5.6
Rush University Medical Center
5.1
University of Chicago Medical Center
15.4
University of Illinois Medical Center
>72
OPTN / SRTR 2011 Center Specific Reports July 2013
HHS/HRSA/HSB/DOT.
South Dakota Listed Patients
Year Added
2006
2007
2008
2009
2010
2011
2012
2013
Listing Center
AZMC-TX1 - Mayo Clinic Hospital
0
0
0
0
0
0
1
0
COPM-TX1 - Centura Porter Adventist Hosp
0
0
0
0
0
0
0
1
COUC-TX1 - University of Colorado Hospital/HSC
1
1
1
2
0
0
0
1
DEAI-TX1 - Alfred I duPont Hospital for Children
0
0
0
0
0
1
0
0
KSUK-TX1 - University of Kansas Hospital
0
0
0
0
0
0
1
0
MNMC-TX1 - Rochester Methodist Hosp- Mayo Clinic
5
4
6
0
8
7
5
9
MNSM-TX1 - St Marys Hospital (Mayo Clinic)
0
0
0
0
1
0
2
1
MNUM-TX1 - Univ. of Minnesota Medical Center
0
0
0
1
4
1
2
4
NEUN-TX1 - The Nebraska Medical Center
3
2
2
8
8
3
7
5
ORUO-VA1 - Portland VA Medical Center
0
0
0
0
2
0
0
0
PACH-TX1 - Children's Hosp of Pittsburgh of UPMC
0
1
0
0
0
0
0
0
PAVA-TX1 - VA Pittsburgh Healthcare System
0
0
0
1
0
1
0
0
TNVU-TX1 - Vanderbilt Univ Med Ctr
0
0
0
0
0
0
1
1
TXMH-TX1 - The Methodist Hospital
0
0
0
0
0
0
1
0
WISL-TX1 - Aurora St. Luke's Medical Center
0
0
0
1
12
11
15
10
Total
9
8
9
13
35
24
35
32
US Liver Transplant Centers
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112 Active adult liver transplant programs in US
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Annual transplant procedures range from 5 - 170 / yr
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51 of 112 perform 35 or less procedures / yr
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Median annual volume 41 transplants
Conclusions
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Liver transplantation offers excellent benefit to patients
with end stage liver disease
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Allocation of deceased donor livers has evolved to a
more equitable system
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Dramatic waiting time discrepancies will exist regardless
of future allocation changes
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Center and patient differences will never be completely
eliminated