Another live liver donation tragedy

Live liver donation remains much more dangerous than kidney donation: Donor dies after live liver transplant at CU Hospital


AURORA, Colo. - A man who agreed to donate part of his liver to help save his brother died just four days after the transplant procedure at The University of Colorado Hospital.


"It's the first death of a living liver donor in Colorado and only the fourth in the U.S.

"The death has led to a temporary halt of all live donor liver transplants at The University of Colorado Hospital. The hospital has also launched an investigation into what went wrong.

"It has reported the death to the Colorado Department of Public Health, which is conducting its own investigation.

"Ryan Arnold, 34, of Watertown, South Dakota died on August 2nd, just four days after his brother, Chad, 38, of Castle Rock, received part of his liver. "

There was an earlier death this year.

Live Liver donation tragedy

The Boston Globe reports: At the Lahey, a stunning, rare tragedy--Donor dies in liver transplant attempt.

"A man who agreed to donate part of his liver to help a sick relative died while undergoing the transplant procedure at Lahey Clinic in Burlington two weeks ago, the hospital said yesterday.

"It was only the third death of an adult living liver donor in the United States in the two decades since the first procedure was done, according to two leading transplant surgeons. A total of 4,036 have been performed.

"While any surgery carries risks, specialists said the death of a living donor is especially upsetting because they are generally young and healthy and are undergoing an operation they do not need for the benefit of a family member or close friend."

..."“The safety of the donor is foremost in everyone’s mind,’’ said Dr. James Markmann, chief of transplant surgery at Massachusetts General Hospital. “It is a very safe operation, but the risk is not zero. If you do enough [of these operations], it will happen. Our thoughts go out to the donor’s family. They did a wonderful thing, and it’s tragic that it ended up this way.’’

"Markmann put the risk of death at one or two in 1,000 operations and said the risks to donors are like those for any type of major surgery, including infection, but generally are less because patients are healthy. He said these risks are weighed against the benefits to recipients: 10 to 15 percent of people waiting for a liver donation die each year because of a shortage of cadaver donors. About 1,500 liver transplant candidates died last year across the United States."

"Dr. Giuliano Testa, director of liver transplantation at the University of Chicago Medical Center, said there have been just three deaths of adult liver donors, the last in 2002 at Mount Sinai Medical Center in New York. He called the Lahey team one of the most “experienced and most expert’’ in the country."

..."Until 2001, the number of liver transplants from living donors in the United States had been growing, reaching a peak of 524 that year. Since then the number has declined, with 219 operations performed last year. Of those, 24 were done at Lahey.

"Surgeons said that the Mount Sinai death may have had a chilling effect on living liver donor transplants, but that in 2002 the cadaver liver allocation system was reorganized so that organs went to the sickest patients. This change reduced the need for living donors.

"Of the 323 living donor liver transplants done in Massachusetts since 1994, 215 were performed at Lahey. This is the first donor death since the program began in 1999, the hospital said."

Transplant ethics

Two stories reflect different aspects of current debates about transplantation, and who are appropriate recipients, and donors.

Transplant tourism poses ethical dilemma for US doctors

"In the current case, a 46-year-old Chinese accountant (HQ) was placed on the UNOS transplant registry with a Model for End Stage Liver Disease (MELD) score of 18 that increased to 21 while on the candidate waitlist for over a year (MELD scores range from 6 for those least ill through 40 for those most sick). HQ then traveled to the People's Republic of China (PRC) and was transplanted two weeks after arrival. After transplantation, HQ returned to the Mount Sinai program requesting follow-up care, which was provided. HQ then developed biliary sepsis requiring hospitalization and re-transplantation seemed to be the only viable option.

"While the patient was a medically suitable candidate, team members disagreed if it were indeed, morally right to provide him with a transplant," said Thomas Schiano, M.D., one of the case clinicians and lead author of this study. Ultimately, the transplant team proceeded with a liver transplant for HQ and he is currently doing well. "Our consensus to transplant was based on the relevant principles of medical ethics—non-judgmental regard, beneficence, and fiduciary responsibility," added Dr. Schiano. " (emphasis added)

"The Dilemma and Reality of Transplant Tourism: An Ethical Perspective for Liver Transplant Programs." Thomas D. Schiano, Rosamond Rhodes. Liver Transplantation; Published Online: January 26, 2010 (DOI: 10.1002/lt.21967); Print Issue Date: February 2010.

Project to get transplant organs from ER patients raises ethics questions
"The practice could backfire by making an already skeptical public less likely to designate themselves as organ donors, several experts said. "

Allocation of deceased donor livers

Ex-chief of transplant program indicted in cover-up of patient switch

"On Wednesday, a federal grand jury indicted the former director of the liver transplant program at St. Vincent Medical Center in Los Angeles, California, for allegedly lying about a liver accepted for one patient but transplanted instead into another patient who was lower on the waiting list."

Gaming the Liver Transplant Market (by Jason Snyder)

When my colleagues and I began talking to transplant surgeons about the design of kidney exchanges, it was initially sometimes hard to convince them that incentives played a big role in organ allocation. (I sometimes heard a variation of "Professor, incentives may be important in economics, but not in medicine; no one chooses to become sick.") But explanations were made easier by a 2003 legal settlement in which some hospitals paid fines for pretending their patients were sicker than they were, to give them increased priority on the waiting list for deceased donor liver transplants: Illinois: Prosecutor's Diagnosis Is Fraud.

By the time of the settlement, the rules for determining priority on the waiting list for livers had already been changed to depend on more objectively verifiable criteria, to reduce the ability of hospitals to game the system on behalf of their patients. A recent paper by Jason Snyder of the UCLA Anderson School of Management looks at the effect of this change:

"Gaming the Liver Transplant Market" Forthcoming at The Journal of Law, Economics, & Organization
"Approximately 6,000 transplants are performed annually and, on average, 2,500 people die while waiting for a liver. There is substantial variation in the number of transplant centers across markets; some markets have only one firm while other markets have multiple participants. Prior to March 1, 2002, a major determinant of whether a patient would obtain a liver was whether they were in the intensive care unit (ICU). Patients in the ICU jumped to the top of the priority list regardless of how sick they actually were. There is considerable anecdotal evidence suggesting that in order to obtain livers for their patients the transplant centers created faux-ICUs where relatively healthy people were put in the ICU to strategically advance their positions on the waiting list. After March 1, 2002, the allocation of livers changed to a system where livers were allocated solely on clinical indicators of sickness. ICU status was no longer a factor in determining whether a patient obtained a liver or not. This policy resulted in, if anything, an increase in the sickness of the average patient at transplant and a dramatic discontinuous decrease in the number of patients who were in the ICU at the time of their transplant. This seemingly contradictory behavior is consistent with centers strategically misrepresenting the health of their patients prior to the policy reforms.

"Using the policy change to examine changes in ICU admission behavior, I find that after the policy changed the use of the ICU decreased more in markets with more firms. I also find that after the policy changed the percentage of relatively healthy people in the ICU decreased more in markets with more firms. Finally I show that these results are non-linear in the number of firms in the market. Moving from one firm to two firms in the marketplace is associated with dramatic changes gaming behavior, but there is little difference between two firms and three or more firms."

Living donor liver transplants

One of the reasons that kidney exchange is proving successful is that the dangers to donors seem to be quite low. In principle, liver exchange is also a possibility: a healthy donor can donate one lobe of his liver, and expect it to grow back. But a recent study of live-donor liver transplants at the pioneering University of Pittsburgh Medical Center reveals that the rate of complications for live liver donors may be quite high: UPMC liver transplant study finds flaws: Study reveals high rate of complications from UPMC procedures that used living donors .

"The study looked specifically at operations in which the larger, right lobe of the donor's liver was removed, and said that "no matter how carefully right lobar [living donor liver transplant] is applied, the historical verdict on the ethics of this procedure may be harsh. There is no precedent of a surgical procedure that exposes healthy persons to such a high risk on behalf of others."
While all 121 liver donors were still alive at the time the study was written, more than 10 percent of them also suffered serious postoperative complications.
The study also concluded that while some people argue that living donor transplants keep recipients from becoming critically ill while waiting for an organ, "in a reversal of fortune," 11 of the 121 recipients became so sick after their initial transplants that they had to get second livers from deceased donors. Only five of the 11 were still alive at the time the study was written."

The article also offers a window on the complicated decisions facing transplant surgeons generally (and not just liver transplant surgeons) about which patients should be offered a transplant. The news story quotes one doctor summarizing the issue as follows:

""I think the study's authors are ...also are bringing out the whole issue that we need to be careful and not just charge ahead and let cowboys do this procedure" "

Liver Transplant for Jobs in Tennessee

The title of this post doesn't mean that people are donating organs in return for work, but that Apple's founder Steve Jobs has received a liver transplant. In Tennessee.

This reveals something about the regionalized waiting system for deceased donor organs in the United States, picked up in a WSJ article by Laura Meckler: Jobs's Transplant Highlights Differing Wait Times

"Apple Inc. CEO Steve Jobs's decision to travel to Tennessee for a liver highlights the significant disparities in transplant waiting times across the country -- the source of a longstanding controversy over the fairest way to distribute scarce organs.
For liver transplants, the wait is particularly agonizing. Kidney replacements can often be put off for years through dialysis, where a machine does the work of the kidneys. But there is no such treatment for liver disease.
There are 15,771 Americans waiting for a liver today, according to the United Network for Organ Sharing. Last year, 1,481 people died awaiting a donor.
Faced with a sometimes years-long wait, patients typically have only a few options. They can wait their turn at a home-state transplant center, knowing that their chances will improve as they get sicker; look for a friend or family member willing to undergo major surgery to contribute half of his or her liver; or seek out a hospital where the waiting times are typically shorter.
Those who travel out of state must be evaluated at the new hospital, but there is no prohibition to being on the wait list at more than one transplant center. UNOS doesn't keep statistics on how many people choose to travel out of state."
The story, incidentally, seems to be something of a scoop for the WSJ. Other newspapers are reporting the story on an "as reported in the WSJ" basis (apparently the transplant was two months ago). E.g. here is the Washington Post: Jobs, on Leave From Apple, Reportedly Had Liver Transplant

Update (6/23/09): Memphis Hospital Says It Did Jobs’s Liver Surgery.
"Methodist University Hospital in Memphis acknowledged Tuesday that it had performed a liver transplant on Steven P. Jobs, the chief executive of Apple."
...
"Methodist has one of the shortest waiting times of any liver transplant center in the country, according to a transplant registry operated by the Arbor Research Collaborative for Health and the University of Michigan."
...
"A scoring system, known as a MELD score, determines where a patient ranks on a transplant waiting list. The higher the score, the sicker a patient is and the higher the ranking. Any ties are decided by who has had that score the longest.
In its statement, Methodist said that Mr. Jobs had received a liver transplant because he was the patient of his blood type with the highest MELD score and thus “the sickest patient on the waiting list at the time a donor organ became available.” "

Further update (6/24/09): A CNN story discusses the regional allocation system, and how it favors those who are healthy and wealthy enough to be on waiting lists at multiple places around the country, under the provocative headline: Did Steve Jobs' money buy him a faster liver transplant?