Waiting lists for organ transplants were the topic of discussion for organ transplant experts and their views were published online first as a Viewpoint by The Lancet. They believe that such lists can be artificially inflated as not all patients requiring a transplant actually opt to receive one (and it varies depending on the organ). The Viewpoint is by Professor Rinaldo Bellomo, University of Melbourne, and Department of Intensive Care, Austin Hospital, Melbourne, Australia, and Dr Nereo Zamperetti, Department of Anesthesia and Intensive Care Medicine, San Bortolo Hospital, Vicenza, Italy, and colleagues.
Patients are marked either active or inactive on the transplantation list based on their interest in receiving the transplant.
The authors state:
“Crucially, not all the patients on waiting lists are
actually eligible for transplantation.”
They refer to an old article that was published in the Washington Post in 2008 which stated that inactive patients were a major chunk out of an approximate 100,000 patients in the USA waiting for various transplants.
Although it is expected that some patients can become temporarily inactive due to infections, moving locations, and other reasons, the Washington Post article went on to say that:
“..more than 55 percent of the patients on the list for hearts, and nearly 49 percent waiting for livers, had been inactive for more than two years. Nearly half of those waiting for kidneys had been inactive for at least a year – and nearly a third for more than two years..In some cases, evaluations of patients’ suitability for a transplant were never completed..[as in] more than 36 percent of kidney transplant candidates”.
The authors have also made a comparison of organ transplant lists with the diagnosis and treatment of diabetes. They stated that the levels of blood sugar that define diabetes have evolved over the years and gradually more and more people have become eligible for treatment with drugs.
They say:
“A waiting list shorter than the reasonable amount of transplantable organs might guarantee that every listed patient will receive a transplantation but will leave some patients without a life-saving organ that might actually be available. Thus, some inflation is inevitable and allows the option to choose the most adequate recipient for a given organ (according to size, immunological compatibility, and so on). Yet, over a certain upper threshold (seemingly exceeded in many countries), this list inflation can become unacceptable.”
The authors have suggested that the criteria to be on the wait list need to be reviewed at three levels, with the first level being the national and international level. Considering that not everyone can be cured due to limited resources and that the costs involved in transplantation are very high, every country needs to decide the importance that they will give to transplantation programs and the resources that they are willing to invest in this area of medical care.
They commented:
“Every time we treat a patient, we make an allocation choice. Perhaps a reflection is needed on how much we want to help a patient who is present to survive, while overlooking the needs of the patients who are absent.”
The second level of review they suggest should be the end-stage organ disease which needs to be looked at overall, since transplantation is just a small part of the multi-faceted care required.
The authors say:
“Transplantation programmes should not lead to the misallocation of resources away from the best care of all patients affected by organ failure.”
Addressing the needs of the patients and their families, the organ transplant experts stated:
“Being listed for transplantation should be discussed with a patient only if subsequent transplantation is reasonably possible. Having strict and rigorous entry criteria would lead to short lists and, ideally, to no patients dying while on waiting lists.”
In Italy, which also happens to be the home country of one of the authors, it has been suggested that the waiting list for liver transplantation should be shorter than double the organs transplanted each year.
In Tuscany, doctors are gradually moving from compatibility to the new concept of transplantability. Compatibility is the process by which a best match for ABO blood group antigens, age, HLA etc is identified, whereas transplantability is the real probability of receiving an organ.
The authors believe that it is not justified to have a patient enter an organ transplant waiting list just because the patient has an end-stage organ failure. Patients may not always choose transplant as an option.
They say:
“Medicine (and transplantation with it) is not a means to defeat death but rather to help people live, at their best, the life they consider worth living.
(conclusion) On the data publicly available, list inflation seems to vary in extent from country to country but this inflation occurs worldwide. The size of waiting lists and the consequent mismatch between needs and resources is not a scientific or biomedical construct alone – but also a social construct. We contend that more open discussion could lead to the formulation of clear, transparent, publically available, and socially accepted criteria for inclusion. These criteria could then be transparently applied and could ensure better protection of all patients affected by end-stage disease, fairer use of resources, and the long-term success of the transplantation system itself.”
Nereo Zamperetti MD, Prof Rinaldo Bellomo MD, Pasquale Piccinni MD, Claudio Ronco MD
The Lancet, Early Online Publication, 12 July 2011 doi:10.1016/S0140-6736(10)62343-4
Written by Anne Hudsmith