Public Health

Donor livers not always allocated to the sickest patients

Last Updated: 2004-04-20 16:00:10 -0400 (Reuters Health)

By Megan Rauscher

NEW YORK (Reuters Health) - Donor livers are not always distributed according to patient need, as current US organ allocation policy dictates, a study released on Tuesday suggests.

Some of these scarce organs are being retained by smaller organ procurement organizations (OPOs) and transplanted into less-sick patients instead of being allocated to sicker patients at larger OPOs, two investigators report in the April 21st issue of the Journal of the American Medical Association.

In an interview with Reuters Health, Dr. James F. Trotter emphasized, however, that the liver allocation system "is not broken." For the most part, it is a "fair and equitable" system that has "improved dramatically over the last 2 to 3 years," he said. "So in that context, this is a chink in the armor of organ allocation."

Dr. Trotter and Michael J. Osgood, from the University of Colorado Health Sciences Center in Denver, compared the Model for Endstage Liver Disease or MELD scores for liver transplant recipients transplanted in small (< 100 people on the waiting list) vs. large (100 or more people on the waiting list) OPOs. Data analysis centered on 4,798 patients who had end-stage liver disease and received deceased-donor livers between February 2002 and March 2003.

The MELD score is an objective scoring system used by the United Network for Organ Sharing (UNOS) "whose stated principle is to allocate livers according to a patient's medical need," the investigators explain. In general, the patient with the highest MELD score should get the donor liver.

The investigators found that the distribution of MELD scores was the same in small and large OPOs. Ninety-two percent had a MELD score of 18 or lower, 7% had a MELD score between 19 and 24, and 2% had a MELD score higher than 24.

However, there was "significant disparity" in MELD scores among liver transplant recipients in small vs large OPOs. Fewer transplant recipients in small OPOs compared with large OPOs had MELD scores > 24 indicating severe liver disease (19% vs 49%; respectively, p < 0.001).

"The most likely explanation for this disparity is that deceased-donor livers are preferentially retained for transplantation in the local OPO, where the number of patients with high MELD scores is smaller than that in large OPOs," the authors write.

Dr. Trotter said that the transplant community "has recognized this as a problem and this study numerically describes it in detail." It is important to note, he added, that this is a "relatively small problem representing just 8% of all transplants in the United States."

Nonetheless, "transplant professionals should be aware of this disparity and its implications as they continue to amend regulations for organ allocation," the investigators conclude.

JAMA 2004;291:1871-1874.