By Janet Basu
A difficult conundrum for the nation's transplant patients was aired September 22 when the news program California Connected
featured UCSF's Liver Transplant Program.
The story, produced by Jon Dann for public television stations KQED and KCET, highlights the difficult choices that patients, families and doctors face because of the shortage of donated organs for transplantation. Reporter Bob Jimenez pointed out that this shortage in one sense represents success--organ transplants now are recognized as a reliable way to extend patients' lives and the quality of their lives. He also reports on a problem with this shortage--patients face differences in the wait for donated transplant organs, depending on geographical area.
The story shows a living-donor liver transplant operation at UCSF, and interviews with John Roberts, MD, chief of the UCSF Transplant Service, and Nathan Bass, MD, PhD, medical director of liver transplant for adults.
It features three UCSF patients who sought different solutions to their need for liver transplants. A mother whose baby was born with a rare liver-damaging disorder donated part of her own liver to save her daughter's life. A man whose liver cancer was too advanced to meet national criteria for transplant eligibility sought to extend his life with a transplant overseas. And a man who has been waiting seven years on the transplant list must wait still longer, because his liver disease so far has not progressed to a category of high medical need.
Geographic Disparities in Organ Donation
All organ sharing in the United States is managed by a national system with regional roots, the United Network for Organ Sharing. UCSF's transplant doctors have been leaders in efforts over the years that have improved the system--increasing the number of donated organs and improving equal access for all who need transplant.
However, the problem of disparity across geographic lines has been particularly difficult to resolve, said UCSF's John Roberts in an interview with UCSF Today
For example, in Northern California, three liver transplant services, including UCSF, treat patients who live throughout the northern part of the state. Each new liver donated in this area is first offered to the person at any of those three centers who best meets blood type and other criteria and who is medically most in need--the person with the highest Model for End-Stage Liver Disease (MELD) score.
Northern California has the largest waiting list in the nation for liver transplants, followed by the New York and Los Angeles metro areas. Over the past decade in these large regions, the majority of livers from deceased donors have gone to patients with a MELD score higher than 25 (on a scale of 40).
In neighboring organ donation areas, most deceased-donor livers have gone to patients with MELD scores below 25. A patient in New Jersey, for example, often does not have to be as sick as a patient in Manhattan to receive a donated liver. The same advantage applies to people waiting for livers in a small area surrounding Sacramento.
Outcomes, if the System Were Revised
If the system were revised to share organs across a wider geographical region--for example, all of California--transplants would be available sooner to anyone in the region with the highest MELD scores. Patients who are currently eligible for transplant in smaller organ donation areas would have to wait until their liver disease got worse, and hospitals in those areas might be forced to close their organ transplant services. The system would be fairer, but unless many more organs are donated, the wait for most still would be difficult, Roberts said.
As part of her mother's liver is connected to baby Brooke's vascular system, blood flows into the organ and it begins doing the work that livers do to keep people alive...
Patients on waiting lists at major transplant centers have good reasons to trust those centers, Roberts said. Research has shown that transplant surgery is more likely to be successful when the doctors and staff are highly experienced and conduct many operations each year. UCSF has one of the nation's largest liver transplant programs and has among the best results for transplant success and patient survival, even when patients have serious health problems at the time of transplant.
UCSF also is one of the nation's largest centers for living donor liver transplant--a solution that allows a patient to receive part of a liver from a healthy relative or friend. In both the donor and the recipient, the liver regenerates and grows to the right size for that person.
However, Roberts said, living donor liver transplants pose significant risk to the donor. Kidney transplants from living donors have a very high rate of transplant success and good health for donors, but not everyone who needs a kidney has a friend or relative eligible to donate. While living donor lung transplants have been performed, they require two donors for a successful operation. Living donor transplants for pancreas and small bowel transplantation have been rare.
"The most valuable step anyone can take to save lives with transplant is to sign up as an organ donor," Roberts said. Most people do not know that a dot on a driver's license will not guarantee that their organs will be used if they die. The best method is to sign up with the statewide organ donor database at www.donatelifecalifornia.org.
"Also, be sure to inform your family," Roberts said. "The next of kin has the final say on whether a deceased person's organs will be donated. If you should die and your family already knows your wishes, they will be comfortable giving this gift of life to others."
The Wait for Life California Connected
, September 21, 2006
Transplant Inequality Los Angeles Times
, June 11, 2006
Information about transplant donation and how you can help
Information about organ transplants at UCSF
(liver, kidney, pancreas, intestine, heart and lung)
Fact sheet on how the transplant system works
Explanation of the MELD score for liver transplants
For data and statistics about organ transplants:
United Network for Organ Sharing: Organ Donation and Transplantation
US Transplant: Scientific Registry of Transplant Recipients