Board addresses liver allocation, lung allocation, living donor policy

Published on: Wednesday, June 24, 2009

Richmond, Va. -- The OPTN/UNOS Board of Directors, meeting June 22 and 23, adopted a policy to broaden access to donated livers for candidates at greatest short-term risk of dying without a transplant (Status 1A and 1B). At any given moment there are usually fewer than 10 of these candidates nationwide, with a life expectancy of seven days or less without a transplant. Liver offers from adult donors will be considered for any medically compatible Status 1A and 1B candidates throughout the OPTN region of the donor before being offered to any less urgent patients either locally or regionally. There are 11 multi-state OPTN regions nationwide.

Status 1A candidates are adults or children who either have fulminant liver failure (a rapid, life-threatening loss of liver function) or have recently received a liver transplant that failed shortly afterward. Status 1B candidates are children who have chronic liver disease with severe and life-threatening complications. Experience gained in three OPTN regions that have allocated livers region-wide for Status 1A/1B patients through Board-approved alternate allocation systems, some since 1990, was an important factor in the decision to institute a national policy.

"For candidates in these two statuses, the opportunity for a liver offer is truly the difference between life and death," said Robert S.D. Higgins, M.D., president of the OPTN and UNOS and chair of the OPTN/UNOS Board of Directors. "This policy recognizes their extreme need and gives them appropriate consideration for a lifesaving organ."

In related discussion, the Board endorsed a public forum to be convened in the spring of 2010 to discuss additional potential improvements to liver allocation policy. The need for additional discussion was prompted in part by a recent public comment proposal to allocate all livers thoughout the OPTN region instead of the current tiered local/regional sequence. Based on significant concerns raised during public comment, the proposal was not presented for Board consideration at this time.

In other action, the Board endorsed the concept of incorporating into the Lung Allocation Score (LAS), which prioritizes candidates for lung transplantation, each lung candidate's laboratory measure of total bilirubin (commonly used to assess liver function) and whether candidates in Diagnosis Group B have a bilirubin score that has increased by 50 percent within a six-month period. Data analysis suggests this addition would reduce waitlist mortality primarily among Group B candidates, most of whom need a transplant due to pulmonary hypertension. To further assess how this concept should be implemented and the priority of programming, the Board will consider implementation options at a later meeting. In the interim, the Board endorsed measures to educate lung transplant centers about the process they may use to seek additional priority through the national lung review board for candidates with pulmonary hypertension.

The Board additionally approved establishment of a section of OPTN policy specifically to house living donation requirements. This new policy section distinguishes current living donor policies from others meant only to apply to deceased donor transplantation and will be the destination for additional living donor policies as they are developed.

The Organ Procurement and Transplantation Network (OPTN) is operated under contract with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Transplantation by the United Network for Organ Sharing (UNOS). The OPTN brings together medical professionals, transplant recipients and donor families to develop organ transplantation policy.