US sets new priorities for liver transplants

BMJ 1996; 313 doi: (Published 30 November 1996) Cite this as: BMJ 1996;313:1350

The United States has announced a major shift in the way that waiting lists for liver transplantations are organised so that patients with acute liver failure will get priority over those with chronic conditions such as alcoholic liver disease, hepatitis B and C, and liver cancer. The decision has sparked controversy as most chronic liver conditions are associated with high risk behaviours, and rationing in this way could therefore imply a moral judgment.

The United Network for Organ Sharing, the organisation that maintains the national registry of donor organs and the waiting list, says that it has authorised the new rationing system to favour those patients who have the best prospects for survival rather than those who may have been on the waiting list longer but have a worse overall prognosis.

In 1995 only 3922 people out of the 7279 on the waiting list received a liver transplant and 522 people died while waiting. Patients who develop acute liver failure usually have fewer comorbidities than those with chronic liver disease and therefore generally fare better with the transplants. The policy shift is predicted to save about 200 livers as there will be less need for retransplantation.

Historically, transplant priority was determined by a regional ranking system in which those who were the most ill and had been on the waiting list the longest took precedence over those who were newly ill. The patients who are the highest priority are designated as “status 1.” The new rules, scheduled to take effect on 20 January 1997, will assign this highest status to patients with sudden liver collapse from such causes as mushroom poisoning, Reye's syndrome, and exposure to hepatotoxins.

Status 1 will also be assigned to children with liver failure of any cause and to liver transplant recipients whose donor organs have failed within one week of transplantation. Children will be given this higher status because they generally do well with transplants and also because with their fragile blood-brain barrier they are at risk of kernicterus or damage to the central nervous system from liver failure.


Patients with alcoholic liver disease will go to the bottom of the list for liver transplants

Walter Graham, executive director of United Network for Organ Sharing, disputes the contention that the rationing change is an attempt to deny livers to people dependent on alcohol. He maintains that transplant priority is based on medical criteria and not moral judgments. According to Mr Graham, patients with acute liver failure currently receive a mere 3.3% of all liver transplants. Under the new policy that number will increase to 4.4%. This still leaves 95% of transplants to those with chronic liver failure. He said that patients with acute hepatic failure have the greatest need as they die quickly, within hours or days. That acutely ill patients survive transplantations better was a secondary consideration, he added.

Some surgeons, however, refute this assessment. Dr Charles Miller, a transplant surgeon at Mount Sinai Medical Center in New York, said: “It hasn't been demonstrated that acute patients do better than chronic—it depends on who and where you are.” Indeed, some experts maintain that the revised regulations do not go far enough in revamping organ allocation protocols, as they do not address regional disparities in the availability and procurement of organs.

In both the old and the new regulations, lists of potential transplant recipients are matched with donors by locality—first by city, then by region, and finally nationally. And some states have more centres and greater availability of organs for transplant than others, so where people live affects their chances of getting a transplant.

The rationing controversy has caused such an uproar that the Department of Health and Human Services is convening a public forum, to be held at the National Institutes of Health, on 10 and 11 December to discuss these issues and could decide to supersede the policy of United Network for Organ Sharing.—DEBORAH JOSEFSON, medical journalist, Norwalk, Connecticut

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