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A8 Sunday, March 9, 2008 BY LUIS FABREGAS AND ANDREW CONTE TOO SOON Transplanting Patients’ agony: Dilemma of choice MELD 15 hasn’t become magic number Move to cut risky transplants worked at some centers The nation’s liver allocation system had to be fixed. Far too many livers were being taken to transplant centers that were using them on patients on the lower end of the wait list. Sicker patients in the same region of the country never had a chance of getting them. From 2002 through 2004, one in 10 liver transplants in the United States was done in a patient with a MELD score lower than 15. The University of Pittsburgh Medical Center led the nation in doing those surJOE APPEL/TRIBUNE-REVIEW geries with 38 percent of all livers going to patients who weren’t critically ill. Ellen Kerber of North Huntingdon was diagnosed with primary biliary cirrhosis, an autoimmune disease which affects the liver, 15 years ago. She has The MELD — Model End-stage Liver a low-MELD score, and still leads an active life. Doctors say she might need a transplant, but she’s holding off as long as possible. Disease — ranking is based on three blood tests that predict a patient’s need for a new liver within three months. With a limited supply of organs, and Often referred to as the body's cleansing factory, the liver is part of the body's digestive system. It with knowledge that most patients with stores vitamins, sugars, fats and other nutrients from food. It aids in digestion and removes waste MELD scores lower than 15 are better off products and worn-out cells from the blood. It is the largest solid organ in the body, weighing about waiting for a transplant until they are 3.5 pounds. The typical liver measures about 8 inches across, 6.5 inches down and Michael Weekley wanted to wait for the sicker, the federal government sought to is 4.5 inches thick. liver transplant. create a broader sharing scheme. He’d been feeling healthy after years of Some of its major functions: Instead of organs being shared solely in battling liver disease and told his sister he The liver and biliary system descending order by the MELD scale, the didn’t want a new liver just yet. ■ Manufacture proteins, including so-called Share 15 policy, first used in “You wouldn’t have known he was sick,” albumin to help maintain the volume Liver Left lobe 2005, says that those with a score of 15 or said Weekley’s sister, Connie Mayes of of blood and blood clotting factors Esophagus of liver higher get first crack at the liver. First Chester, W.Va. “He was not in favor of getchance at the liver is within the transRight lobe ■ Synthesize, store and process fats, ting the liver.” of liver plant center’s local area. If no one takes it including fatty acids used for energy and Fearful that he’d never get another cholesterol there, the liver is offered within a chance, Mayes encouraged her wider regional area that can inbrother to go ahead with the surgery ■ Metabolize and store carbohydrates, Dr. John Fung clude several neighboring states. at UPMC Presbyterian, even though which are used as the source for the sugar Chairman of People with lower scores are he was leading a relatively normal surgery, in blood that red blood cells and the considered only when doctors for life – walking to his parents’ home The Cleveland brain use all higher-scoring patients in the every day and checking up on his Clinic region have passed on the organ. rental properties. ■ Form and secrete bile that helps Weekley never made it out of the “It was a way to show that with absorb fatty foods and vitamins A, D, hospital. He died at 46 in September a score less than 15, you didn’t get E and K, which are important for night Pancreas 2002, two days after a failed transGall vision, building strong bones, nerve any benefits from transplantabladder plant caused a blood clot to lodge in function and normal clotting tion,” said Dr. John Fung, chairof the blood one of his liver arteries. man of surgery at The Cleveland “Now I second-guess it,” Mayes Clinic and former chief at UPMC. ■ Eliminates potentially harmful said. “He might have had a few more The Share 15 plan worked – to biochemical products produced by (The Share 15 Stomach years.” a certain degree. From 2005 the body, such as bilirubin from the policy) was a The offer of a new liver, no matter through 2007, the number of breakdown of old red blood cells, how sick a patient is, brings with it a way to show Small transplants nationwide on paand ammonia from the breakdown intestine complex and difficult decision for that with a tients with MELD scores below 15 of proteins those who’ve been told they need a score of less dropped to 846 from 1,627 in the Liver transplant. ■ Breaks down drugs, alcohol and than 15, you Duodenum previous three years. The Trib’s Patients and their families must poisonous chemicals didn’t get any analysis of low-MELD patients inweigh the benefits of a healthy liver cludes those who received extra benefits from against the potential complications points for illnesses that do not transplantaof one of medicine’s most complex show up in the MELD tests, such tion.” surgeries. The most medically urgent patients always get first dibs on available livers. Those patients, desigas cancer. The surgery, up to 8 hours long, nated as Status 1, are expected to live less than a week without a new liver. If the available organ Several centers, most notably requires a lengthy hospital stay. doesn't match any Status 1 candidates, then it is offered to people according to their MELD score, UPMC and three others, continue One in six patients dies within a which ranges from 6 for the least ill to 40 for the sickest. Ken Henshaw to do those surgeries. year of transplant. Those who live Received a liver “It’s irresponsible to list paface a lifetime of potentially harmful transplant with a The order in which livers are offered tients and not give them a anti-rejection medicines that can MELD score of 16 chance,” said Dr. Amadeo Marwreak havoc on their immune syscos, UPMC’s chief of transplantatems. tion until his resignation last “You just don’t know what you’re week. getting, how the body will react,” said Ellen Kerber, 65, of North HuntFederal officials are pleased ington, who was diagnosed with priwith Share 15, saying it has rein local area, or less in local nationwide, or higher in mary biliary cirrhosis 15 years ago sulted in a “considerable dethen wider area, then followed by those local area, and has been warned by doctors she regional regional area with highest then regional crease” overall of low-MELD I never really area may need a transplant. “The transMELD scores area liver transplants. nationwide planted liver comes with its own set said I regret Dr. James Burdick, director of doing it because of problems.” the division of transplantation at SOURCE: UNITED NETWORK FOR ORGAN SHARING BOB NEWELL/TRIBUNE-REVIEW Kerber is not on a waiting list — I had to do it to the U.S. Health Resources and and she’s unsure whether she wants Services Administration, said the be alive.” to be — because her MELD score is information they can get their hands on,” she parents said to him. agency has no plans to stop or 11. MELD is a measure of a patient’s said. “So we understand all of the risks. But, Henshaw, who was eager to move on with discourage programs from roumortality, ranging from 6 for the honestly, what choice does anyone have? his life and put behind the endless medical tinely doing transplants on paDr. Michael M. least ill to 40 for the most critically Transplant or death? Pretty easy decision.” tests, didn’t think about it twice. He had a tients with scores lower than 15. Abecassis ill. Doctors say transplant candidates must rare blood type and worried another match “An important principle is to Chief of transplanShe lives relatively well. Despite balance the benefits against potential risks. would never come. allow some physician-patient tation, Northwestthe disease, Kerber gets around well Though some people may suffer from side“I was doing nothing but waiting to get judgment for specific cases,” Burern Memorial Hosenough to watch her grandchildren effects like itching and fluid retention, that sicker anyway,” he said. “I didn’t want to die pital, Chicago dick wrote in an e-mail. one day a week. This winter, she enalone is no reason to put yourself through a waiting. I wanted to have an opportunity to Marcos said the patients with gineered the painting and carpeting transplant, said Dr. Michael M. Abecassis, get better.” lower MELD scores who get of her 40-year-old home on a dairy chief of transplantation at Northwestern The transplant didn’t go well. transplants are often people who farm where she still helps out. Memorial Hospital in Chicago. He was awake only for a few days when are sicker than their scores “What am I giving up to get a “We tell patients, ‘It’s one thing to be tired, his condition went downhill. He slipped into would indicate. liver?” she said. “But if I wait until it’s another to be dead,’ ” he said. a coma. Within 10 days, he received a second “We are absolutely in the I’m unable to move anywhere, then Patients who face those problems can seek transplant. That surgery, too, led to complimainstream of what centers are I’ve waited too long.” to increase their MELD score by making a recations, including infections and a bout with doing,” Marcos said. There are plenty of sick patients quest for so-called exception points to a repancreatitis, an inflammation of the panWe tell “Now, still, you have to leave across the country who don’t wait. gional review board comprised of doctors. creas that is deadly in one of five cases. patients, ‘It’s some room for that patient-doctor Ken Henshaw of Emory, Texas, for Dr. Amadeo Marcos, the former transplant Henshaw recovered, but veins and arterone thing to be example. chief at UPMC, said he believes low-MELD ies connected to his liver have clogged. His decision of when it’s best to help tired, it’s In 1999, he was diagnosed with a patients who need a transplant should get it, condition has worsened to the point where them.” another to be liver illness so fierce it forced him to even if they don’t qualify for exception he needs another liver and an upper bowel He said patients go to UPMC dead.’” quit his job as a restaurant waiter. points. transplant. not because they do low-MELD The disease, called primary sclerosAbecassis disagrees. He expects to travel to Pittsburgh’s UPMC transplants but because they ing cholangitis, made him fatigued, “We don’t let patients talk us into transwithin a month for that procedure. have good outcomes. At UPMC, 84 percent itchy and turned his skin yellow. planting,” he said. “This isn’t plastic surgery. “I never really said ‘I regret doing it’ beof all patients were alive one year after His physical stamina just wasn’t there. If somebody says, ‘I don’t like my nose. cause I had to do it to be alive,” he said. transplant. Henshaw, 33, was placed on the waiting Change it,’ that’s fine, but this is a pretty seHis mother, Barb, who is an active mem“We cannot expect all transplant surlist at Baylor University Medical Center in rious operation plus you are using up a liver ber of several online support groups, said geons to have the same philosophy, but Dallas, two hours from his home. Last June, that may cause someone else to die because Ken might not have survived had he not been they are doing, to the best of their knowlwith a MELD score of 16, doctors called with it’s not available to them.” in relatively good shape. edge, what helps patients,” Marcos said. an offer of a new liver. “You have to remember people who have a “And that’s the bottom line.” “Don’t you think you should wait?” his fatal disease arm themselves with any and all Offer of a liver only the beginning of a long road The amazing liver ‘‘ How livers are allocated Status 1 MELD 15 MELD 14 Status 1 ‘‘ ‘‘