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Kaiser Denied Transplants of Ideally Matched Kidneys

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Twenty-five Kaiser Permanente patients in Northern California were denied the chance for new kidneys that were nearly perfectly matched to them last year during the troubled start-up of the giant HMO's kidney transplant program in San Francisco, a Times investigation has found.

The patients missed this opportunity because they were in effect stranded between two transplant programs.

Kaiser never properly completed the paperwork to transfer the patients' cases to its program from UC San Francisco Medical Center, which had been under contract to care for them until September 2004. At the same time, Kaiser would not authorize UC San Francisco to continue accepting kidneys and transplanting them into Kaiser patients, according to interviews, internal memos and transplant records.

UC San Francisco transplant officials said they asked Kaiser if they could transplant some of the offered organs and Kaiser representatives told them no, said Dr. Stephen Tomlanovich, medical director of the university's renal transplant service. An e-mail from Tomlanovich to a UC San Francisco colleague in February 2005 confirms his account.

After several of these turndowns, Tomlanovich said, UC San Francisco automatically declined the organs — though no one told the patients.

"Certainly it was frustrating," he said. "If the offer goes by, the question is, 'Would they ever get another one?' "

As late as Wednesday afternoon, Kaiser officials adamantly denied that they had ever instructed UC San Francisco to turn away such organs.

But after being confronted with evidence to the contrary by The Times, the officials called back to say that they could not stand by that position. One of Kaiser's own kidney specialists had confirmed that he directed UC San Francisco to turn down at least one of the near-perfect-match kidneys, they acknowledged.

In a statement to The Times, that doctor, W. James Chon, said he paged Kaiser's transplant medical director, Dr. Sharon Inokuchi, when he received one such offer from UC San Francisco more than a year ago.

"I was told by her that she would not give permission for this transplant to take place and was instructed to relay that message to UCSF," said Chon, who was placed on administrative leave in February after criticizing the way the program was run.

Inokuchi said through a Kaiser spokeswoman Wednesday that she does not recall such a conversation with Chon.

The 25 rejected kidneys were offered between January and December 2005, according to the California Transplant Donor Network, which oversees the distribution of organs in the San Francisco area.

When matching a donated organ to a patient, transplant specialists look at six antigens, molecules that help define a person's immune response. In the organs offered for the Kaiser patients, none of the antigens were incompatible.

These "zero mismatch" organs from cadavers are prized, because they offer patients a greater chance of long-term survival and minimize the risk of rejection. They are generally the best possible option in a transplant, aside from a living donor's kidney. And they allow patients to get their transplants immediately, no matter where they are on the waiting list.

But these organs are relatively hard to come by; fewer than one in five kidney transplants involves one. An offer does not guarantee a transplant, because other factors, besides antigens, might make the organ a bad fit. Often, the donors are too old or their organs too damaged. Even so, the head of the California Transplant Donor Network called the blanket turndowns "alarming."

"That's really significant," executive director Phyllis Weber said this week.

She said it would be hard to track what happened to the rejected organs or the patients to whom they were first offered.

The Times reported Wednesday that Kaiser patients were imperiled by the massive start-up of the HMO's first kidney transplant program, which now has a waiting list of more than 2,000. Since Kaiser took over, the number of transplants has plummeted. Patients have complained of inexplicable delays. And paperwork snafus have left hundreds of patients stuck between programs with no hope of receiving a life-saving organ.

The Times could not determine whether any Kaiser patients died as a direct result of the transition. However, the shift has meant that hundreds of patients have remained on dialysis, an often grueling regimen that removes impurities from the blood. Prolonged dialysis can lead to deadly complications and decrease the chances of a successful transplant later.

But a Kaiser official said dialysis is manageable. "It isn't as if waiting another six months or nine months for a transplant is a death sentence," said Dr. Sharon Levine, associate executive director of the Permanente medical group in Northern California. "There are patients who choose to stay on dialysis rather than going through a transplant."

UC San Francisco struggled internally over how to handle the organ offers for Kaiser patients left on their list. In one February 2005 e-mail reviewed by The Times, medical director Tomlanovich wrote that he had spoken with Inokuchi, his Kaiser counterpart, and that she said "she will not authorize 0-mismatch transplants at UCSF. I think the best way to handle this issue is to let Kaiser work it out."

Inokuchi told The Times earlier this week that she had never told UC San Francisco not to perform a transplant.

Transplant experts and bioethicists said the emerging problems at Kaiser, the nation's largest HMO, are disturbing.

"Something is simply out of whack with the health plan's priorities," said Arthur Caplan, director of the University of Pennsylvania Center for Bioethics.

Before Kaiser opened its program in 2004, it sent letters to more than 1,500 members receiving care at UC San Francisco and UC Davis, informing them that they had to move to Kaiser's new center if they wanted their transplants covered. Kaiser's Northern California region serves 3.2 million members from Fresno to Sacramento.

The patients had little choice. Kaiser members are part of a unique healthcare entity that runs both a health plan and a hospital system. Except in rare circumstances, members get their care only from Kaiser hospitals and affiliated Permanente medical group doctors.

But the transition did not go as expected. Delays and paperwork errors by Kaiser left hundreds of patients in limbo.

When patients switch from one transplant program to another, it is essential they get credit for the time they've already spent waiting. Otherwise it will appear they are new additions to the list with no seniority, and their waits will start from scratch. UC San Francisco continued to receive offers for the Kaiser patients whose waiting time hadn't been transferred.

The United Network for Organ Sharing, the national group that coordinates such transfers, said the forms Kaiser submitted to transfer the time were full of "errors or inconsistencies."

On Wednesday, a top Kaiser official in Northern California said the program plans to contact all 2,000 patients on its waiting list in coming weeks to assuage their concerns. The HMO also vowed to look for an independent third party to evaluate the transplant program and plans to disclose the results publicly, said Levine of the Permanente medical group.

"Our goal is to deliver the highest quality care pre-transplant, during transplant and post-transplant to our members," she said.

Separately, the state Department of Managed Health Care, which regulates Kaiser, said it is investigating the HMO's Northern California operation. In Southern California, Kaiser continues to contract with outside hospitals to provide transplant care for its patients.

"We want to make sure that the plan is fulfilling its obligations and make sure that they're sending people to places and treatment centers where people can get the care," agency spokeswoman Lynne Randolph said.

Copyright © 2014, Los Angeles Times
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