Most liver transplant candidates who died or were removed from the transplant list actually received one or more liver donation offers, according to a recent UCSF study.
“What we found challenges the simplistic view that transplant dynamics are driven simply by organ availability,” said lead author, Jennifer Lai, MD, assistant clinical professor in the UCSF Division of Gastroenterology and Hepatology. “Efforts to reduce wait-list mortality must target all aspects of mismatch between supply and demand.”
Recognized as a world leader in organ transplantation since 1964, the UCSF Organ Transplant Service has performed transplants for more than 10,000 patients and has played a key role in defining the field. The UCSF Liver Transplant Program, designated as a “Center of Excellence” by the U.S. Department of Health and Human Services, performs more liver transplants than any other hospital in Northern California – over 2,300 liver transplants for adults and children since it began in 1988.
For this study, the research team analyzed data from 33,389 candidates listed in the United Network for Organ Sharing (UNOS)/Organ Procurement and Transplantation Network (OPTN) registry during the time frame of Feb. 1, 2005 to Jan. 31, 2010. Out of the candidates who had died or been delisted, 84 percent received one or more liver offers prior to death/delisting, indicating that they had an opportunity to undergo transplantation. Reasons for liver offer refusals were reported as donor quality/age or other donor-related factors, size compatibility or recipient readiness.
“Understanding the real-time factors involved in the decisions regarding liver transplant offers is vital to improving the wait-list process,” said senior author, John Roberts, MD, professor of surgery and chief of the UCSF Division of Transplantation. “While some of the factors are beyond control, others can be managed.”
Simply increasing the availability of deceased donor livers or the number of offers may not necessarily reduce wait-list mortality, according to the study, published in the leading journal in its field, Gastroenterology. Instead, the study suggests that efforts must be made to understand multiple factors involving candidates, donors and transplant centers to help influence what is often a complex and dynamic decision to accept or decline a liver offer.
More specifically, the study recommends that wait-list candidates efficiently complete their pre-transplant evaluations so they are ready for liver offers as soon as possible. Patients with a Model of End-stage Liver Disease (MELD) score of 15 or higher also should be thoroughly educated about the survival benefit of transplantation with any liver graft, as opposed to continued waiting. The MELD is a scoring system for assessing the severity of chronic liver disease and is used by UNOS for prioritizing allocation of liver transplants.
The team also suggests improving efforts within the transplant community to reduce the stigma associated with non-ideal livers and setting realistic expectations for wait-listed candidates regarding the available donor organs.
“The decision to accept a liver offer is not just about minimizing complications after transplant, but about reducing the unpredictability of death before transplant,” Lai said.
Sandy Feng, MD, PhD, professor of surgery in the UCSF Division of Transplant Surgery and director of the UCSF Abdominal Transplant Fellowship Program, is a co-author.
Funding for this research was provided by the National Institute of Diabetes and Digestive and Kidney Diseases and the UCSF Liver Center.