Saturday, February 3, 2007

USC Liver Transplant

Hearing that a transplant program has unexpectedly low graft or patient survival rates brings the assumption that the program's staff must be unqualified or inexperienced (not doing enough), or uncaring or incompetent (not trying hard enough). But what if the problem is actually that they're doing too much and trying too hard?

At the end of the year, the Los Angeles Times reported on the unexpectedly high death rate of patients in the liver transplant program at the University of Southern California (USC). They told the stories of several individual patients who were extremely sick, who would likely die with or without a liver transplant, who may have received marginal donor organs, but ultimately were transplanted at USC when other programs had turned them down. The available data support the notion that USC has a very high-risk patient population: the "expected" survival rate for USC was lower than the national average, and USC patients had a higher risk of dying before a transplant, not just afterwards. There were also systems problems within the program, as detailed both by the LA Times and the USC Daily Trojan student newspaper--these should be corrected, and plans to do so are in place. But the USC dilemma generates the more vexing question of who is an appropriate transplant candidate and who is "too sick" to receive a treatment designed for "end-stage" presumably fatal disease.

Much of the response to this story was defensive, with letters to the editor in defense of both the field of liver transplantation and the USC program in particular. For a field founded on treating otherwise untreatable diseases, and that has made untreatable diseases treatable, this defense is perfectly understandable. Also, the line between acceptable and untenable transplant candidates is a moving target that has generally become more permissive over time. Personally, I can't imagine the despair of being "too sick to transplant" and can fully understand why patients would seek out any program that would offer them a chance, and why a program would strive to give them that chance.

Yet the fact remains that the outcomes of patients treated at USC are poor by national standards, and as insightfully stated by Dr. David Mulligan, chairman of transplant surgery at Mayo Clinic Hospital in Phoenix: "They're pushing it as hard as they can and having the results that you'd expect to see." Beyond the "push" for individual patients, though, is a "push" on much larger systems:

  • The staff is devoting its considerable training and talents to some patients who stand little chance of benefitting from them.
  • USC is dedicating resources to a program that may ultimately harm it more than help it as an institution.
  • Organizations such as OneLegacy (the organ procurement organization serving Southern California) and UNOS are spending their time and energy matching donors and recipients who may have very little chance of success.
  • Medicare, Medicaid, or private insurers are paying for an expensive treatment that has less chance of succeeding than it may under more normal circumstances.

The follow-up to this story indicates that, however good the intentions of USC's previous practices, they are changing. It will take time to see if these changes improve their survival rates and repair their reputation. But the patients who are too sick to transplant are still out there, and someday treating them successfully is a challenge to the field of transplantation and medicine in general.

4 comments:

Anonymous said...

very good post---one needs to look at all views not just that of the media who often times more than not, have a distorted picture of the entire process. As someone who "matches" the organs to those waiting, we often are faced with "those too sick to transplant" and "those in dire need" of a transplant.

The first thing I can tell you I have learned in this business is....we all do die....unfortunately, we as society have come to think that if given the "right" care, the "right" organ, the "right" whatever, we will live forever.

The second thing is, it is most dishearting for a donating family and transplant coordinators who work as many as 24+ hours, when we were unable to place a organ or on the transplant side, unable to get an organ for those we care for.

One must understand how emotional the donation process is...not only for the family but coordinators and recipients alike. Families so graciously offer to give someone else a chance....key word here "chance"! Transplant coordinators work very hard to offer and get the best possible organ to those VERY sick...at least it might give them a chance. Know, there are no promises or guarantees in life that is for sure.

I applaude transplant centers willing to accept organs that might not be the best BUT they often do give more of a chance than not having an offer at all and can often be used as a bridge while awaiting a "better organ". One needs to think of donor families...it means so much to a family that unselfishly, in a time when most are very selfish, to be able to help someone else...even if for a short bit. Shoot for high standards YES but take into concideration the big picture NOT one side of it! Great work USC...you have things to fix but you owned up to mistakes and are doing it...we are all human afterall and we all have things to "fix" that is for sure. Let us all look at this "glass" as "half-full" instead of "half-empty"

Anonymous said...

i agree whole hardily with all you said and i don't understand why so many have to die. Yet i see nowhere about the hundreds of end stage liver diease was just recently told i will have to have wait a liver transplant because...... are you ready for this? i am not sick enough! i have hepatic portable hpyertension ihave brain encephalopathy i now weigh90 lbs. have cryoglobulin anemia and much more but i'm not sick enough? wouldn't it make more sense to work on a slightly healthier body and maybe get better results? doesn't a living donor work better

Anonymous said...

MY SISTER NEEDS A TRANSPLANT, LIVER.I BELIEVE THE DOCTORS HAVE GIVEN HER THE IDEA THAT AS SOON AS SHE IS ON THE LIST, THAT ANY DAY SHE WILL GET THAT CALL,MEANING THEY HAVE GIVEN HER THE GIFT OF "ANYDAY NOW" WHILE SO MANY OTHERS HAVE THE SAME DREAM. I WANT FOR HER TO REALIZE THAT HER DAY ISNT GOING TO BE SOONER RATHER THAN LATER.I DONT WANT HER TO PUT OFF LIVING EVERYDAY TO THE FULLEST.I PRAY FOR YOU ALL WAITING FOR THAT SPECIAL DAY. MWILLIAMSSTABE

Anonymous said...

MY brother is waiting for a liver transplant almost 6 months i dont't think people at usc is honest he is very sick and dont't have much time but they dont't care they playing with his life puting him up and down they said no donors are avaliable but i see they do transplants mostly every week how this is posible who go firs the poor people or the rich people the espanis or the white people can somebory explain me i love my brother this people is making me crazy