As a transplant community, we have experienced record high organ transplant volumes for the past 5 years, surpassing 30,000 organs transplanted annually. However, the grossly mismatched supply-and-demand issue has forced transplant professionals to ‘push the envelope’ of innovation in efforts to transplant more patients with the same or less donors. This includes the use of organs from live donation, donation after cardiac death (DCD), “marginal” or extended criteria donors, extremes of age, increased risk donors, organ preservation pumps, and active research into xenotransplantation.
However, we are currently facing considerable external challenges and conflicting ethical dilemmas as a result of our success. One of the hottest topics in organ transplant is geographic disparity, or the disconnect between supply and demand of organs to transplant centers.
There are a multitude of reasons why geographic disparity exists. Death rates are not equal throughout the country. Type II diabetes rates are not equal throughout the country. End-stage renal disease is not equal throughout the country. Obesity rates are not equal throughout the country. Organ donation rates are not equal throughout the country. New York is not Alabama, Colorado is not Florida. There are considerable geographic differences in virtually every aspect of life throughout our country whether comparing race, religion, sex, socioeconomic status, financial compensation, etc. Yet, the overarching theme in organ transplantation is geographic disparity and how to “equalize” it. Ongoing debate has been aimed at rearranging the current system such that livers from one part of the country be shipped or shared to other parts of the country in order to ‘normalize’ the disparity at the expense of increased costs associated with travel, potentially higher organ discards, and even the prediction of a lower number of liver transplant performed overall. There has been much debate with little compromise.
In addition to geographical disparities, the punitive use of outcomes data in organ transplant have become a double-edged sword, both on the organ procurement organization (OPO) side and the transplant program side. This distinction is crucial to understand as summarized below:
- An OPO’s primary responsibility is placing the most organs possible from as many donors as possible, regardless of the quality of the organ(s)
- Current metrics that determine OPO performance are based on numerous factors such as age, race, comorbidity, mechanism of death, number of eligible donors converted to actual donors, number of organs procured/transplanted per donor, etc.
- Transplant outcomes are monitored for graft survival and patient survival (or graft loss, patient death) for 1, 3, and 5 years. Centers are expected to maintain “acceptable” outcomes, which typically must exceed 90+% 1-year survival to be considered a “good program”, based on risk-adjusted models that determine observed to expected outcomes. These models carry a c-statistic slightly higher than 0.6, which equates to slightly better than the flip-of-a-coin. Deaths before 1 year that are unrelated to complications of the transplant (i.e. fatal car wreck, brain hemorrhage, lightning strike, etc.) are still included in adverse graft/patient outcomes
- Transplant surgeons are charged to “do more transplants, discard less organs, save more lives” per the local hospital administrators, OPOs, and regulatory organizations.
Herein lies the crucial dilemma. The metrics by which the OPO’s performance is graded are mal-aligned with that of the transplant center. For example, OPO metrics suffer if the 21-year-old donor with a gun-shot wound to the head doesn’t have several organs recovered and transplanted such as kidneys, liver, pancreas, heart, lungs. However, the disseminated intravascular coagulation, aspiration event, multiple pressors, and renal thrombotic microangiopathy with elevated terminal creatinine may decrease the transplant surgeon(s) enthusiasm to use those organs, regardless of what the models and metrics might predict. The transplant surgeon has to decide if the risk of graft non-function, or worse, death of the recipient is worth pushing the envelope to get one more transplant done, rather than the OPO ‘taking a hit’ with a discarded organ from a “good” donor. The OPO is pushing to optimize their conversion rates, organs per donor, and discard metrics, and yet the transplant center is bound punitively by the outcomes of placing those organs that are “on the fringes” for risk of adverse outcomes. Too many graft failures and/or recipient deaths than what is predicted (by the previously mentioned flip-of-a-coin models) and that center can end up on probation or even terminated from a CMS Medicare/Medicaid standpoint.
I loathe the fact that when a post-transplant patient dies, I immediately check the date of transplant and the date of death, selfishly hoping that it exceeds 1 year so our program’s survival outcomes don’t take a hit. We must reach a compromise between our administrators, regulatory organizations, insurance companies, lawyers, and OPOs to critically evaluate the challenges associated with optimizing organ donation, allocation, transplantation and the punitive use of outcomes data, or suffer the unintended consequences.