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