Henry Ford Transplant Institute Director Speaks Out Against New Proposal on Dispersing Organ Donor Livers in the United States

May 31, 2017


DETROIT – Doctors at the Henry Ford Transplant Institute are speaking out against a proposal to change the way livers are dispersed for transplant – a move they say could lower the overall number of successful, life-saving transplants in the United States.

Henry Ford Transplant Institute Director Marwan Abouljoud said there are multiple reasons to oppose the new system proposed by United Network for Organ Sharing (UNOS), the private, non-profit organization contracted by the federal government to oversee the distribution of organs to patients in America.

He is part of an alliance of liver transplant centers speaking out against the proposed changes, through the website KeepTransplantsFair.org. The centers include Emory Healthcare, the largest hospital system in Atlanta; Baylor Scott & White Health, the largest non-profit health care system in Texas; Washington University School of Medicine; the University of Kansas Hospital; Vanderbilt Health System, and a number of others across the United States.

“The redistricting the way it was proposed is flawed for many reasons,” says Abouljoud. “This proposal does not address the root cause of this disparity – the need for more donors. Instead it utilizes a great deal of resources with a very low overall yield that is dubious at best. Furthermore, the estimated increased number of lives saved is no more than shifting the decision points to ‘who will live and who will die.’”

Once donated, livers are currently allocated to recipients in 11 regions across the United States. The new proposal designates eight larger regions.

The biggest issue with the current 11-region system is the rate of donation and wait times for recipients. Wait times can be significantly longer in highly populated regions that have a lower organ donation rate and shorter in more remote areas where the donation rate is higher. That can lead to people who have the ability and resources to travel quickly and relocate temporarily to list themselves for organs in different regions. Apple’s Steve Jobs did this when he left his home in California to receive a liver in Tennessee in 2009.

Those who support the proposed change say this gives an unfair advantage to people who have significantly more resources than others in need of an organ.

The proposed 8-region system disperses the livers more in line with population density. That means as many as 75% of organs may be shipped by plane over larger areas. But this adds a risk of complications before, during and after a potential transplant, says Abouljoud.

“The added logistical and behavioral changes arising from remote organ offers will result in more organ discards and turndowns than expected and will likely wipe out any net benefit in lives saved,” Abouljoud says. “It is not logical to think of livers as a commodity to be shipped and accept longer ischemia times, more flights and broader travel as an acceptable added burden. Such added burdens, challenged with weather conditions and logistics with last-minute changes in acceptance will likely result in more turndowns that cannot be reallocated. We already lose many organs because they cannot handle longer ischemia times due to travel.”

He said that the proposed new 8-region system could also contribute to disparities in transplant in minority communities, including Michigan. The new proposal greatly disadvantages communities that, because of their rural or poor economic surroundings, may have worse health due to lesser access to quality healthcare and unhealthy habits like smoking and drinking. A recent study by doctors at Emory University and University of Pennsylvania in Philadelphia that compared patients needing a liver in the rural South versus the East Coast found those in socially disadvantaged areas are more apt to die on the waiting list than those in New York City or the East Coast.

Abouljoud said he does not know if the proposal would increase or decrease the number of livers transplanted at Henry Ford and in Michigan, which has slightly shorter wait times than other areas of the United States. The Henry Ford Transplant Institute, one of the busiest in the Midwest, performed 112 liver transplants in 2016, more than any other transplant center in Michigan. As of May 11, there were 401 people in Michigan on the liver transplant waiting list.

Abouljoud said transplant centers have been using multiple innovative approaches to increase the number of livers available for transplant: for instance, using more livers from older patients; splitting one liver for 2 people; using livers with higher fat content, and transplanting Hepatitis C-positive livers to Hepatitis C-positive patients. In addition, Henry Ford is part of a multinational study testing the use of the Ex-Vivo support pump to improve preservation of livers. Adding the uncertainty of factors involving travel and recovery could result in worse outcomes or centers feeling they need to turn down some livers that become available for transplant.

“Hence I can see a practice where more marginal organs would be locally utilized and more optimal organ being shipped,” says Dr. Abouljoud.

Abouljoud said other changes could help strengthen the transplant process. He said evaluating patients’ health and need for a transplant is not evaluated consistently. He said programs that transplant livers from older or sicker donors – increasing the number of transplants but slightly increasing complications – need to be accommodated so as not to be negatively affected or judged for trying to save more lives.

“I am certain this proposal was conceived with good intent to save lives,” says Abouljoud. “But it is mathematical rather than practical. It turns what is a complex and unpredictable set of behaviors and decisions into a ‘perceived science.’ We do not recall ever a more divisive proposal coming across in the past 25 years. With so many opposed, scrap it and let’s go back to the drawing board and focus on having more organ donors and saving lives. The Liver Alliance is collaborating in establishing fair standards and a process to achieve the goals of more organs and a sound approach to distribution that saves more lives.”

Tammy Battaglia
Henry Ford Health System

Members of the Liver Transplant Alliance include:

Goran B. G. Klintmalm, MD, PhD, FACS, Baylor University Medical Center, Dallas, TX
William C. Chapman, MD, FACS, Washington University School of Medicine at St. Louis, MO
Seth J. Karp, MD, FACS, Vanderbilt Medical Center, Nashville, TN

Marwan S. Abouljoud, MD, FACS, Henry Ford Hospital, Detroit, MI

Diane Brockmeier, MHA, President & CEO, Mid America Transplant Services. St. Louis, MO

Kenneth D. Chavin, MD, PhD, FACS, University Hospitals of Cleveland, Cleveland, OH

Derek DuBay, MD, MSPH, Medical University of South Carolina, Charleston, SC

Devin E. Eckhoff, MD, University of Alabama Hospital, Birmingham, AL

Jill M. Ellefson, MBA, UW Health, Madison, WI

Lon B. Eskind, MD, FACS, Carolinas Healthcare, Charlotte, NC

Jonathan A. Fridell, MD, FACS, IU Health, Indianapolis, IN

Jonathan C. Hundley, MD, Piedmont Healthcare, Atlanta, GA

Vivek Kohli, MD, FACS, Integris Baptist Medical Center, Oklahoma City, OK

Rob Linderer, CEO, Midwest Transplant Network, Kansas City, KS

George E. Loss, MD, PhD, Ochsner Health System, New Orleans, LA

Joseph F. Magliocca, MD, FACS, Emory Healthcare, Atlanta, GA
Susan L. Orloff, MD, FACS, Oregon Health Sciences University, Portland, OR

Jorge D. Reyes, MD, University of Washington Medical Center, Seattle, WA

Timothy M. Schmitt, MD, FACS, The University of Kansas Health System, Kansas City, KS

Malay B. Shah, MD, FACS, University of Kentucky Healthcare, Lexington, KY

Shimul A. Shah MD, MHCM, FACS, UC Health - University of Cincinnati Medical Center, Cincinnati, OH

Kevin Stump, President & CEO, Mississippi Organ Recovery Agency, Flowood, MS

Linda L. Wong, MD, Queen’s Medical Center, Honoulu, Hawaii

Gazi B. Zibari, MD, FACS, Willis-Knighton Health System, Shreveport, LA