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Surgeons Take Sides on Transplant Proposal

Analysis  |  By Tinker Ready  
   September 01, 2016

Proponents claim a new donor liver allocation plan would be more equitable for patients; foes say it could raise costs and close programs.

A proposal to change how donor livers are distributed has reignited the battle over which patients should be considered first for transplants.

Currently, organs donated in one of the nation's 11 designated geographic districts are generally offered to patients in a smaller area served by a designated local organ procurement agency. However, districts with many transplant candidates are not necessarily the districts with the most donors.

Although all areas of the country have long lists of transplant candidates, those in some districts must wait longer for a donor liver, or be more ill, than patients in other districts.

The latest plan comes from a joint committee including the federal Organ Procurement and Transplantation Network (OPTN), and the United Network for Organ Sharing (UNOS), which manages the nation's transplant system.


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The OPTN/UNOS plan would create eight larger districts apportioned to allow more equitable access for those in need of liver transplant regardless of their place of residence, according to the plan.

With some exceptions, organs would be shared across these larger districts for seriously ill patients before they would be offered locally.

The current system is tilted toward keeping organs local, says Ryutaro Hirose, MD, a transplant surgeon at the University of California San Francisco Medical Center and chair of the committee that is proposing the new rule.

"A lot of us believe these organs don't belong to one area or center," he says. "Organs are national resource, not a local or provincial one."

The debate over this issue goes back 35 years, Hirose says. In 2000, the Department of Health and Human Services (HHS) instructed OPTN and UNOS to come up with a policy to address differences in access to organs.

Under the new proposal, some centers will lose volume and costs may go up in some cases, but access will be more equitable, Hirose says.

"We want to be the best possible stewards of these organs," he adds.

Opponents of the new plan worry the proposal could force some programs to close, further limiting or delaying access for some patients, says Sean Kumer, surgical director of transplantation at The University of Kansas Hospital, who opposes the plan.

According to UNOS, it would be premature to speculate on the policy's impact on the number of transplants at individual hospitals. However, Kumer says the University of Kansas Hospital's program, which performs about 100 liver transplants annually, would receive about 25 fewer organs.

Under the current plan, East Coast states north of Florida are divided into four districts. The new plan calls for a single district reaching from Maine to South Carolina.

"When you designate certain areas of the country as centers, access to care is going to change incredibly," Kumer says. "You don't take all the organs out of one area of the country and put them in another area."


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Several transplant surgeons and organ procurement agencies opposing the new plan have signed on to an initiative called Collaborative for Donation Fairness. The collaborative's website echoes many of Kumer's arguments.

The group calls for a review of transplant data by an unbiased third party, such as the Institute of Medicine, and a push for more donations.

Some members of Congress have written to HHS to voice concern about the OPTN/UNOS plan's impact on their constituents.

Hirose hopes the issue doesn't play out in the halls of Congress. However, if surgeons don't take action to address access to donated organs, people with little knowledge of transplantation will act.

"If we refuse to do anything about it, it will be taken out of our hands," he says.

Tinker Ready is a contributing writer at HealthLeaders Media.

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