Guidelines Tightened on Getting Liver Transplants
People suffering chronic liver failure, such as that caused by heavy drinking or hepatitis, will no longer be first in line for transplants.
The Richmond, Va.-based United Network for Organ Sharing, which sets nationwide policies for organ transplants, approved the change at its annual meeting in Boston on Thursday.
The change will purge hundreds of chronic liver patients from the top of the waiting lists, leaving a relatively small number of acute patients. The change will take effect Jan. 20.
Chronic conditions include alcohol-induced liver damage, viral hepatitis, biliary disorders and genetic liver disease.
Supporters said they were not trying to blame alcoholics or intravenous drug users, who often get hepatitis from dirty needles. The idea is to make a patient’s chances for survival the top priority, rather than how close a person is to death.
“We’re trying to select out the smallest group of patients who could benefit the most,” said James Wolf, the network’s director of medical affairs.
Penalizing alcoholics and drug users would be comparable to doctors refusing to treat obese people for heart ailments or smokers for lung disease, he said.
Opponents say bumping the sickest patients from the top of the list will be disastrous.
“My prediction is you’re going to see a massive increase of patients who are going to die,” said Dr. John J. Fung, chief of transplant surgery at the University of Pittsburgh Medical Center, one of the busiest transplant centers in the country.
The board may also consider a proposal that would require alcoholics to remain sober for a certain period of time before becoming eligible for a transplant. Liver transplant physicians in the United States generally require alcoholics to be sober for six months before a transplant.
A few hospitals in the United States will not perform liver transplants on any alcoholic, even one who has been sober for three years, Fung has said. Others require patients to stay in a rehabilitation program after surgery.
At the heart of the debate is one stark fact: There aren’t enough donated livers. About 7,200 people are on the United Network for Organ Sharing waiting list for a liver--the second most common transplant surgery after kidney transplants. Last year, 3,922 liver transplants were performed.
Each day, eight to 10 people on the waiting list die before a suitable donor can be found.
The proposal to remove chronic patients from the top of the list is aimed at shrinking the No. 1 priority group, called Status 1.
That would leave only those with acute liver illness--those who got the disease suddenly and are expected to die within two weeks--in Status 1. It would drop chronic sufferers who had lived with the disease for some time to Status 2, even though they have reached the point where death is imminent.
With so few donor livers available, someone has to decide who gets the first chance at a second life, supporters said.
“We need to get the public to understand that these are value judgments, and there’s nothing wrong with that,” said Dr. Michael Grodin, director of medical ethics at Boston University’s School of Public Health.
The discussion comes amid allegations that money and prestige influence who gets a new liver, especially after the highly publicized transplants of former Pennsylvania Gov. Robert Casey, actor Larry Hagman and the late Mickey Mantle. Organ procurement organizations deny that prestige or fame play a part.
The network lists 11 regions, with the sickest patient in the district of the donor getting top priority, even if the patient is not in critical condition. The network did not consider a proposal to change that system.
