TOO SOON by leavinglasvegas


									A6                                                                                                                                                                                       Monday, March 10, 2008

                                                                                                                                     BY LUIS FABREGAS AND ANDREW CONTE                   TOO SOON

                                   Treat sickest first or
                               give livers to the less ill?
     PHILOSOPHY • FROM A1                          of the lofty height and tradition,
                                                   and so on,” Juhl said.
        Dr. Amadeo Marcos, until last                 With Starzl as its guiding star,
     week director of UPMC’s trans-                the place once known as the trans-
     plant institute, later defended the           plant capital of the world attracted
     medical center’s surgical prac-               sick patients from as far away as
     tices. All patients on the waiting            Jordan and Syria.
     list deserve a crack at a new                    Today, 127 U.S. programs per-
     organ, he said, regardless of how             form liver transplants, compared
     sick they are. UPMC performs sur-             to four in 1981, when Starzl arrived
     geries on some of the nation’s most           in Pittsburgh from the University
     critically ill patients.                      of Colorado.
        “We offer transplantation to                  “Historically, UPMC is the Ford
     everybody,” Marcos said. “We                  or Mercedes-Benz auto manufac-
     look at every patient, really try to          turer of liver transplants,” said Dr.
     help them as much as we can.”                 Jeffrey Punch, transplant director
        Fourteen years ago, UPMC’s                 at the University of Michigan Med-
     doctors called the transplant sur-            ical Center. “But now we know
     geries on the least ill “boutique”            there are a few car companies that
     cases, as breezily fashionable as a           can make a car at least as good as
     trendy clothing store.                        that company.”
        They wrote in the Journal of the              Many doctors who trained at
     American Medical Association                  UPMC moved on to create pro-
     that people at the bottom of the              grams that now indirectly compete
     liver waiting lists — patients                with Pittsburgh, said Dr. Claude
     “called in for operation from the             Earl Fox, the chief of the U.S.
     19th hole of the golf course” —               Health Resources and Services Ad-
     have a “higher survival without               ministration from 1997 to 2001.
     transplant intervention.”                        “You had one factory with a fair
        Recent research from the Scien-            amount of raw material,” said Fox,
     tific Registry of Trans-                               director of the Florida
     plant Recipients at the                                Public Health Institute.
     University of Michigan            Dr. Claude           “Now you’ve got a lot of
     echoes their warnings,              Earl Fox           factories but you haven’t                                                                                                            JOE APPEL/TRIBUNE-REVIEW
     showing nearly identical         Former chief of       got a lot more raw mate-
     findings. The registry,            U.S. Health                                         Dr. Thomas E. Starzl (right) is monitored by Randy Juhl, vice chancellor for research conduct and compliance for the
                                      Resources and         rial, so they’re all compet-    University of Pittsburgh during a February interview.
     under contract to the fed-           Services          ing for the raw material,
     eral government, tracks          Administration        and in this case, the raw
     and analyzes all organ                                 material is organs.”                                                                                                eventually need a liver transplant.
     transplantation data.                                      In 2006, organ procure-                                                                                            But she wasn’t sick enough to get
                                                            ment agencies recovered                                                                                             a liver from a deceased donor, the
     A changing                                             7,305 livers across the                                                                                             most common source of organs for
                                                            United States. Of those,
     of guard                                               surgeons transplanted                                                                                                  Doctors at UPMC made her an

                                                            6,597 and rejected 708.                                                                                             enticing proposition: If she enrolled
        When Venezuela-born
                                      You had one               As those programs                                                                                               in a study aimed at weaning pa-
     Marcos arrived in Pitts-
                                     factory with a         made transplantation rou-                                                                                           tients off anti-rejection drugs, they
     burgh in 2002, transplant
                                                            tine, UPMC sought alter-                                                                                            would do the transplant. The catch:
     program leaders at                 lot of raw
                                                            natives to remain at the                                                                                            She’d have to find a living donor.
     UPMC were pushed to             material. Now
                                                                                                                                                                                   “Our thought was, we’ll do this
     boost volume.                  you’ve got a lot top. It started using more                                                                                                 to keep her from getting more
        The year before had         of factories but livers once considered un-                                                                                                 sick,” said her mother, Kathy
     marked a low for UPMC:                                  usable. It began doing sur-
                                    you haven’t got geries with organs from                                                                                                     Miller of Creekside, Indiana
     Only 132 liver trans-           a lot more raw live donors and stepped up                                                                                                  County. “That is why we did it back
     plants were performed.            material, so          its transplants on patients                                                                                        then. I mean, eventually, she was
     At its peak, in 1990, the          they’re all          at the bottom of the wait-                                                                                         going to need a transplant. So why
     center had done 471
                                     competing for           ing list, those not consid-                                                                                        not do it when she was healthy?”
        Marcos’s predecessor,             the raw            ered critically ill. UPMC                                                                                             Starzl wasn’t part of the team
     Dr. John Fung, left                material.”           also opened a $58 million                                                                                          that recruited Katy, but agreed
     UPMC under pressure                                     transplant center in Sicily.                                                                                       with the decision of allowing her to
     from top administrators,                                   “Now I do want to have                                                                                          take the chance at having a normal
     including CEO Jeffrey             Katy Miller           the biggest, the busiest                                                                                           life.
                                       Received living       and the best transplant                                                            ANDREW RUSSELL/TRIBUNE-REVIEW
                                                                                                                                                                                   On Nov. 1, 2005, Katy received
     Romoff, to do more trans-      donor liver from her
     plant surgeries.                                        program in the world, and      Until last Monday, Dr. Amadeo Marcos was chief of UPMC’s transplant                 part of the liver of her eldest sister,
                                      sister, later died
        “There was always               after second         that’s what we have            institute. He said all patients on the waiting list deserve a chance at a new       Shelly McGinnis.
     that level of emphasis on           transplant          today,” Marcos said in         organ, no matter how sick they are.                                                    It wasn’t meant to be. Katy died
     volume there that,                                      January. “And I want to                                                                                            on May 7, 2007, following countless
     whether consciously or                                  keep it that way. I want       jumped to 25. Last year, there were       ers, and must read and sign lengthy       medical setbacks, including a sec-
     subconsciously, drove                                   this to be the Mecca as it’s   36, the most ever.                        consent forms.                            ond transplant that wound up in-
     how people practiced,”                                  always been, the ultimate         Marcos also was willing to use             Marcos said extended criteria         fecting her body, shutting down her
     said Fung, the transplant                               place for anybody with         livers rejected by other surgeons.        donor organs are tested thoroughly        kidneys and causing internal bleed-
     center’s chief from 1991                                liver disease to come. And        “I did notice that perhaps before I    at UPMC.                                  ing.
     to 2004 and now director                                again, we are going to do      got here they were not willing to             All livers undergo a biopsy that         A picture of Katy on her final
     of surgery at The Cleve-           Her death            everything we can to help      truly consider every organ out            can tell doctors, among other             birthday shows her skin was jaun-
     land Clinic.                      contributed           them.”                         there,” Marcos said.                      things, whether a liver is too fatty,     diced and that she wore a large
        The pressures remain            to the rift             UPMC transplants liv-          So-called extended criteria donor                                                shirt to conceal a drain on her
                                                                                                                                      one of the top reasons for rejecting
     today, Starzl said, who             between             ers into less critically ill   livers are generally flagged because                                                belly.
     recently announced his                                  patients to make the best      they come from deceased donors
                                       Marcos and            use of all available livers                                                  “You can be 20 years old but have        “Now I wish that I had let her
     retirement. Starzl                    Starzl.                                          who don’t meet generally accepted         a lousy liver biopsy,” Marcos said.       run her course,” her mother said.
     stopped doing surgeries                                 — not to keep a high num-      quality standards. That can be be-                                                  “Maybe her own liver wouldn’t
                                                             ber of surgeries, Marcos                                                 “We’re not using that organ, no
     in 1991 and has been in-                                                               cause of anything from being too          matter how young the donor is.”           have deteriorated as fast as it did.”
     volved in UPMC research                                 said.                          old, to too fatty, or too much time
                                         Dr. Adel               “This is not to keep vol-                                                 The scientific registry suggests         Marcos wouldn’t talk about the
     involving weaning trans-                                                               inside a cooler as it was transported                                               case, citing privacy laws. As Mar-
                                      Bozorgzadeh            ume,” Marcos said.                                                       that marginal livers should be
     plant patients from anti-       Director of trans-                                     to the transplant center.                                                           cos resigned, UPMC disclosed it
                                                                “All centers have moved                                               transplanted into the sickest pa-
     rejection drugs.               plantation, Strong                                         Surgeons say using those livers                                                  had begun a study involving com-
                                                             into the reality of 2008                                                 tients — those about to die without
        “You set up a program, Memorial Hospital,                                           helps them expand the pool of or-                                                   plications in surgeries such as Katy
                                                             compared to the reality of                                               a new organ, even if it’s not a per-
     you depend upon it for a         Rochester, N.Y.                                       gans when 17,000 are on a waiting                                                   Miller’s. Administrators have re-
                                                             the early 1990s,” he added.                                              fect one.
     cash flow of an institu-                                                               list nationwide and only 6,000 each
                                                             “We don’t have the luxury                                                    Marcos disagreed. “Nobody in          cruited international experts to
     tion and you try to main-                                                              year get them.
                                                             of having every organ we                                                 his right mind would do a trans-          conduct the review and have ex-
     tain that,” he said.                                                                      “If there was a surplus of organs
                                                             want to transplant those                                                 plant not expecting for it to suc-        pressed confidence in the pro-
     “There are certain expec-                                                              available in this country, I really
                                                             patients.”                     doubt anyone would be using ex-           ceed,” he said. “You’re not going to      gram’s quality.
     tations. … In the change
                                                                                            tended-criteria organs,” said Dr.         take an organ for somebody that’s            Katy’s death troubled Starzl, who
     from a crusade to a busi-

                                                                                            Adel Bozorgzadeh, director of solid       desperate when you know it’s going        had collaborated in her care. Al-
     ness, it’s just that sim-
                                     If there was a                                                                                   to fail. That doesn’t happen.”            though he and Marcos agreed on
        UPMC is now a mas-              surplus of        novelties                         organ transplantation at Strong
                                                                                            Memorial Hospital. “What are you              Before coming to Pittsburgh,          giving her the transplanted liver,
     sive medical network           organs available                                        supposed to do? Let the patients          Marcos hesitated about taking the         Katy’s mother said the doctors dis-
                                                                An aggressive work-
                                                                                            die?”                                     job at UPMC because the transplant        agreed over how to proceed when it
     with more than $60 mil-       in this country, I horse with soap opera star                                                                                                failed.
     lion in annual profits.                                                                   At Strong Memorial, the livers         center had a reputation for not
                                       really doubt          looks and the deep voice of
                                                                                                                                      doing many live-donor transplants.
        Marcos, who remains                                                                 had caused trouble, partly during                                                      “I’ve never faced a death that
                                   anyone would be a broadcaster, Marcos                                                              It was Starzl, however, who ulti-         caused so much sorrow,” Starzl
     on the faculty of the Uni-     using extended- brought to Pittsburgh a                 Marcos’ tenure as head of solid
     versity of Pittsburgh                                                                  organ transplantation.                    mately convinced Marcos to make           said.
                                    criteria organs. pair of transplant novelties              From 2000 to 2004, the New York        the move, Marcos said.                       At 81, Starzl said retirement
     until June 30, said              What are you           poised to alter the field.
     UPMC’s administrators                                      He began doing trans-       Department of Health found 10 vio-            The relationship quickly became       seems logical. Saying he has “battle
     did not pressure him to
                                    supposed to do?                                         lations related to the use of ex-         strained. Starzl said there was           fatigue,” he will no longer do re-
                                                             plants using live donors, in
     do more transplants.           Let the patients which a portion of a                   tended-criteria donor livers. Mar-        never a rift, but merely distance.        search and, instead, focus his time
        Romoff declined to                  die?”            healthy donor’s liver is cut   cos left Strong in 2002.                  A “grand canyon,” he said.                on his wife, Joy, their dogs and his
     comment. Bill Morris, ex-                               off and given to an ailing        One patient received a liver so            The thin string that held them        love of Mozart.
     ecutive director of UPMC Trans-               recipient. The surgeries had been        bad, the complications forced a sec-      together broke with the death of             “These are devastating hits,”
     plant Services, said in an e-mail             his specialty at Strong Memorial         ond transplant. Others got risky liv-     21-year-old Katy Miller.                  Starzl said. “In the course of a long
     that medical center officials would           Hospital, in Rochester, N.Y., where      ers without even knowing about it.                                                  and tough life doing difficult cases
     “not discuss financial issues re-
     lated to transplantation.”
                                                   he worked two years before coming
                                                   to Pittsburgh in 2002.
                                                                                            State regulators slapped the hospi-
                                                                                            tal with a $20,000 fine.
                                                                                                                                      Katy’s story                              and being always right at the edge
                                                                                                                                                                                of tertiary care problems, you build
        The university’s Juhl said dur-               Prior to that, UPMC had per-             Bozorgzadeh said surgeons at             The college sophomore had been          up layers of grief, but you can take
     ing the meeting with Starzl that all          formed only 18 of those transplants.     Strong continue to use the livers,        diagnosed in 2005 with a rare ill-        those if they are thin. When you
     transplant surgeons have financial               In the first year after Marcos        with one major difference: Patients       ness called primary sclerosing            have a deep rip in the fabric, that’s
     pressures and decisions to make.              arrived, UPMC’s annual number            now get detailed explanations about       cholangitis that doctors predicted        a different matter. And Katy was
        “It could be worse here because            of living-donor liver transplants        the possible background of the liv-       would destroy her liver. She would        like that.”

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