Is organ transplantation in S.C. at risk?

by Prabhakar Baliga, M.D., Director of Liver Transplantation

In South Carolina we have been highly successful in the field of organ transplantation. Since 1968, more than 2,000 South Carolinians have been given “the gift of life” through transplantation of kidneys, hearts, livers, pancreases, small bowels and lungs. The programs at our state’s full service organ transplant center—MUSC—have had a success rate that exceeds the national average for transplant of most solid organs. The only limitation we face is the lack of donor organs to meet the needs of our patients.

Unfortunately, current maneuvering on the federal level could compromise our ability to meet the needs of South Carolinians requiring organ transplantation. Health and Human Services (HHS) secretary Donna Shalala has set the wheels in motion to dramatically alter the way organs are allocated. We fear that the end result would mean organs currently donated by South Carolinians could be diverted to meet the needs of patients in large transplant centers in other regions. In the short run, this means longer waiting times and the strong possibility of not obtaining an organ in time. In the long run, this may discourage organ donation if families know that their donations will not be offered first to patients in their communities.

Currently, organs donated in South Carolina are given priority for use in South Carolina. If no suitable recipients are waiting for transplant here, then organs are offered to a recipient based on geographic accessibility, matching physical characteristics and degree of need. The system now in place is not an arbitrary system. HHS has awarded the contract to coordinate organ procurement to the United Network for Organ Sharing (UNOS) for the past 10 years. It was initially set up so the organ procurement agency was a step away from the federal regulatory agency and would remain free from political influence. With oversight from the federal government, UNOS has diligently addressed the issue of organ procurement using a variety of private, public and voluntary resources. They have developed a sophisticated computer system to control the allocation system in a way which minimizes patient deaths and distributes organs in a fair and medically appropriate manner.

This system has worked as well as can be expected in an environment where there is an overall shortage of donor organs, making allocation a constant issue. What we need are more organs. What we do not need is the federal government instigating politically motivated changes which we feel will be detrimental to the needs of our state’s most vulnerable citizens. Under the proposed changes, organs would be allocated on a national rather than a regional level, and the sickest patients would be given priority. On the surface, this makes sense— organs are scarce, give them to those who need them the most. But giving priority to the sickest patients would result in organs being given to the patients with the poorest outcomes. The post-transplant survival rate for a liver recipient on life support prior to transplant is close to 50 percent, compared to greater than 85 percent for a stable patient. Furthermore, these patients frequently require re-transplantation, which further depletes the scarce donor pool.

To provide fairness and equity to all patients, UNOS developed a system to provide equitable distribution based on sound medical judgment. We, along with several states in our region—North Carolina, Tennessee, Virginia and Kentucky, have piloted a project of sharing livers across the borders for the benefit of our sickest patients for certain defined conditions. This is a limited sharing by a small number of transplant centers who work closely together, meeting several times a year to review data. This works well on a regional basis with transplant centers having similar criteria and physicians having a high level of mutual trust and respect. On a national basis it would be chaotic. Because of competition for organs, each physician, as an advocate for his or her patient, would be driven to a not-entirely-honest evaluation of patient status so as to place the patient higher up on the list.

Simply, there are not enough organs to go around. With a national distribution system, patients would still be dying. The change will be in the addresses of where patients die. Instead of Pennsylvania addresses, patients dying because of lack of available organs will come from South Carolina addresses. In fact, a study commissioned by UNOS showed that with a single national list, overall more patients would die. Furthermore, it showed that South Carolina may lose 15 to 20 percent of organs to larger centers if the system were made national. South Carolinians would end up traveling to distant large centers for transplants. This would be a tragedy for people who must leave their families and community support networks to undergo transplantation surgery miles from their support systems. It is even more tragic for the Medicaid patients who do not have the option of going to another state for medical care. The decrease in the number of transplants could make South Carolina’s program financially nonviable, possibly resulting in closure.

We believe that the HHS intervention in this area stems from an aggressive seven-year lobbying effort on the part of the larger medical centers. The federal government is initially targeting allocation of livers, but if successful, we anticipate they will set their sights on controlling allocation of other solid organs.

In December, Shalala, along with vice president Al Gore announced a major initiative aimed at increasing organ and tissue donation in the United States. This is a positive move, and we applaud the federal government’s help in increasing the level of awareness of the need for organ donors. Allocation would not be an issue if there were sufficient organs to meet the need.

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