Monday, August 31, 2009

The Evolving Debate Over Who Gets a Liver Transplant

For at least two years after my liver transplant I was so frustrated, depressed and confused about the complications and show recovery from my surgery that I never truly experienced a sense of peace or - I'm embarassed to admit - gratitude that my life had been saved. It goes without saying that my expectations were completely off-target, and my futile attempts to return to my previously "normal" life were unrealistic.

The luxury of a summer vacation from being a patient (as I think of the past few months) has lifted my spirits like nothing else has and for the first time in years, I feel like myself - optimistic, glass half-full, etc. And I'm so VERY, VERY grateful for my transplant and this extra time I'm living, enjoying my husband, children, travel and all the things that I treasure in my world.

So I gasped a bit when I read a news report about a study in the August 2009 issue of Hepatology:

According to Dr. Michael R. Lucey of the University of Wisconsin, Madison, and colleagues: "Except in patients with very low or very high Model for End-Stage Liver Disease (MELD) scores, HCV status has a significant negative impact on the survival benefit of liver transplantation..."

Hmmm. Certainly, given that a liver transplant doesn't eradicate the virus, which impacts the new liver (at different rates and to differing degrees, depending on the individual), it stands to reason that ultimate outcomes, especially over the long-term, would be worse for people with Hepatitis C.

The article continued:

In an editorial published with the study, Dr. Sumeet K. Asrani and colleagues from the Mayo Clinic College of Medicine, Rochester, Minnesota, discuss the implications of these findings if a "benefit-based transplant policy" were to be adopted in the face of an organ shortage that mandates rationing of a scarce resource.

The data, they write, suggest that "compared to patients with ALD (alcoholic liver disease) who have comparable MELD (Model for End-stage Liver Disease) score, patients with HCV (Hepatitis C virus) should be given a lower priority when their MELD is intermediate (score of 9 to 29), whereas patients with HCV who have higher MELD score should be given an even higher priority than candidates at the same MELD score with another diagnosis."

For such a benefit-based transplant policy to be implemented, Dr. Asrani and colleagues note, the transplant community "must be willing to accept this departure from the traditional thinking: because some patients with hepatitis C will experience poor outcome, they will be placed at lower priority than patients without HCV who are faced with the same (or even lower) risk of death while waiting."

Summing up, Dr. Asrani and co-authors say this study is "an important step" in the continued debate on which variables matter in predicting survival benefit of liver transplantation and whether an organ allocation system based on predicted survival benefit can be equitably implemented.

I had a MELD score of 24 prior to transplant, which puts me in the lower-priority group noted in this study. I have such mixed emotions about this matter. Who should receive priority when it comes to liver transplants? Given the surgical complications and my ongoing, costly health issues, should this liver have gone to someone else? Someone younger, or perhaps more likely to survive many years without serious health issues like mine?

I can't imagine being asked to make these God-like determinations. Let's pray that God is guiding the people who do.

Photo by Nick Cowie

1 comment:

AM said...

I got very lucky - or maybe very unlucky - that my MELD score had hit 35 and I was young so my chances of recovery were high. But I had to wait to the edge of the abyss before I got a liver because of the lack of organs available in the Northeast! I was the sickest person in the Northeast for a month, and even then they had to try an experimental procedure on me because they couldn't find a match, failed, and then I was really up the creek - 72 hours to live with no liver at all. And then my luck turned, I got a perfect match and am now doing very well even with the Hep C regimen (virus negative, though not dead).