Many Kidneys Turned Down at UCI
The transplant program at UCI Medical Center turned down kidneys offered for its patients at an exceptional rate over the last five years, even as 150 people at a time awaited potentially life-saving organs there, a Times review has found.
Many of the patients on UCI’s waiting list would have had a far greater chance of receiving a transplant had they gone to other hospitals, data show.
The problems are similar to those that forced the closure of the hospital’s liver transplant program in November. In addition, UCI’s bone marrow transplant program is struggling.
Tiny transplant programs carry the promise of revenue and prestige, and for years the Orange hospital strove to build its programs and solve their problems out of public view. Some experts question why small programs with limited resources are allowed to exist when data show better outcomes at centers with the capacity to do a high volume of surgeries.
Between July 2000 and June 2005, the UC Irvine hospital accepted only 8.7% of the kidney offers for its patients. It turned down a higher percentage of kidneys than nearly all other adult transplant centers in the country, according to a Times analysis of data compiled by the group that oversees transplantation nationally. During that time, the median annual acceptance rate nationwide ranged from 25.9% to 31.2%.
The data included only the kidneys that were eventually transplanted into patients, at UCI or other hospitals, suggesting that organs rejected by UCI were often found acceptable at other facilities.
“The thing that bothers me the most about underperforming programs is that it means their patients aren’t getting the same opportunity as patients at other programs in the same area,” said Dr. Mark Deierhoi, director of renal transplantation at the University of Alabama at Birmingham Medical Center. “I don’t think patients know that.”
During the five years reviewed, some 35 patients died awaiting kidneys at UCI. It is not clear how many offers were made for those patients or whether they would have survived had they received an organ. The death rate on UCI’s waiting list was not significantly different from what was expected.
What is clear is that patients at UCI waited far longer than expected, if they received transplants at all. Only 16.5% of patients placed on the waiting list between 1999 and 2001 received transplants within three years, less than half the national rate, data show.
Patients with kidney failure can remain alive on dialysis for years, unlike patients waiting for new livers and hearts, although their quality of life can suffer significantly.
UCI Chancellor Michael Drake, who took office in July, acknowledged the program has struggled in the past but said he is confident it turned a corner with the hiring of a new kidney transplant director last summer. Drake said he did not know if patients had been told about past problems, nor could he explain why organs had been rejected at such a high rate in the past.
“The program needed to be beefed up and to grow and to do better, but the new director has really done a good job of that,” Drake said. “If I thought for a minute that there were patient safety issues from now going forward, we would close the program.”
Until the new surgeon was hired, UCI’s kidney program operated for more than a year with only part-time doctors performing operations -- much as the university had in its liver program.
UCI, which performed 30 kidney transplants last year, turned down organs seven times from October 2001 to June 2005 because surgeons were not available, according to data the hospital reported to the national organ network.
By contrast, Deierhoi’s program, which performs nearly 300 kidney transplants a year, accepted 42% of kidneys over five years. It has six kidney transplant surgeons. Only once did the center turn down an organ because a surgeon was unavailable, Deierhoi said. That day, the team performed eight transplants.
The United Network for Organ Sharing, which oversees the national transplant system, collects data on turndown rates but has not made it public and rarely analyzes it. The group released the data under pressure from The Times and U.S. Sen. Charles Grassley (R-Iowa), who has been investigating the inequities in transplantation.
“It takes a lot of turndowns to even get on the UNOS radar,” Deierhoi said. “I don’t think UNOS has a good answer for how to deal with programs that have a problem like that.”
Federal inspection reports show that UCI was warned more than three years ago about problems in its kidney transplant program. In a September 2002 letter, the U.S. Centers for Medicare and Medicaid Services, which certifies transplant units, outlined several deficiencies.
Inspectors found that UCI failed to keep track of the reasons it turned down organs. In a response signed by the hospital’s chief operating officer, Maureen Zehntner, UCI promised that by Dec. 1, 2002, it would monitor its refusals.
While the numbers showed minor improvements, they still lagged.
Last week, the Medicare agency again notified UCI that it had found undisclosed problems with the kidney transplant program and gave the hospital 14 days to respond with a plan of correction. The agency’s policy is not to release details of a review until the hospital has a chance to respond.
Transplant programs routinely refuse organs, most commonly because surgeons deem them to be of poor quality or unsuitable for a particular patient.
“If I have an 18-year-old patient, I will not accept a 70-year-old kidney,” said Dr. Ryutaro Hirose, a kidney, pancreas and liver transplant surgeon at UC San Francisco Medical Center.
Programs with waiting lists of hundreds or even thousands -- or in places where transplant centers fiercely compete for scarce organs -- don’t have the luxury of holding out for optimal kidneys. They are more aggressive in using what is available.
“The organ bank [officials] know that every time a kidney is turned down, they can call us, and we will use it,” said Dr. Goran Klintmalm, head of the Baylor Regional Transplant Institute in Dallas, which accepts more than 50% of kidney offers.
“And lo and behold, the kidney works fabulously.”
The data released Monday do not indicate how each organ functioned after it was refused at one facility and transplanted elsewhere.
At the least, the high turndown rate at UCI should have raised questions about its program, transplant experts said.
The shuttered liver transplant program at UCI also ranked among the worst in the nation for the number of organs it accepted. UCI’s liver acceptance rate of 8.7% was far lower than the national median of more than 32%.
The university closed the liver program in November, the day federal regulators pulled its certification. The Times reported that it performed too few transplants to maintain proficiency, had a substandard mortality rate and didn’t have a full-time surgeon for more than a year.
As regulators threatened to close the liver program last year, the hospital’s chief executive provided misleading information to keep the unit running, according to a government document.
Regulators had relied on a written assurance from Dr. Ralph Cygan, the hospital’s chief executive, that UCI had recruited a full-time transplant surgeon to replace the one who left, according to a letter to Grassley from the federal Health Resources and Services Administration. In fact, the new surgeon, Dr. Marquis Hart, was based at UC San Diego, 90 miles away, and planned to help only part time at UCI.
UCI has placed the chief executive of its hospital on administrative leave while a task force investigated that program. Its report is expected early next month.
It is unclear if Cygan or UCI made the same assurance regarding its kidney program. Officials at UNOS declined to comment, saying such communication would be confidential. (Information on the liver program was released in response to a congressional request.)
Hart had also been performing kidney transplants at UCI -- until Dr. Clarence Foster was hired.
After arriving in July, Foster performed 21 kidney transplants in the second half of the year, compared to nine done at the hospital in the six months before that, UCI spokesman Tom Vasich said.
UCI also recently retained Dr. Craig Smith of City of Hope National Medical Center in Duarte to provide backup. And UCI reached an agreement with UCLA Medical Center to transfer patients there if no other backup is available.
UCI is looking to hire another full-time surgeon to work alongside Foster, Vasich said.
In the last few months, problems also have come to light about UCI’s bone marrow transplant program. That unit, which is still operating, failed to perform enough transplants in all but one of the last 11 years to meet state standards and withdrew from a state program for the poor after repeated criticism by state regulators.
