"For patients with end-stage liver disease, transplantation is the only treatment option to extend life," explains lead investigator Dr. Josh Levitsky from Northwestern University Feinberg School of Medicine in Chicago, Ill. "With donated livers in such short supply, selecting candidates becomes an ethical exercise for transplant specialists who must balance equal access to transplantation with graft and patient survival."
Currently, the model for end-stage liver disease (MELD) is used to measure the severity of liver disease. The MELD score provides transplant providers with standardized criteria to allocate donated livers. However, the authors point out that subjective assessment of the candidates' medical and psychosocial characteristics could influence the providers' selection process. Medical evidence shows that controversial characteristics such as alcohol abuse, HIV status, obesity, or advanced age may impact allocation, leading to an inequity among patients being waitlisted.
To further understand the ethics involved in selecting transplant candidates, Dr. Levitsky and colleagues sent an online survey to hepatologists, surgeons, psychiatrists and social workers at 102 liver transplant centers across the U.S. Responses were received from 251 providers who answered questions regarding their opinions of characteristics that could prevent patients from receiving a liver transplant.
The majority of responders were male (71%), between 41 and 60 years of age (68%) and mainly white (77%). The three characteristics ranked most controversial were incarceration, marijuana use, and psychiatric diagnoses. Responses from transplant providers indicate that 63% would not waitlist patients 80 years or older, 57% would not transplant patients with a body mass index (BMI) greater than 45 kg/m2, and 55% specified incarceration with lifetime sentence a contraindication to liver transplantation.
Furthermore, less than half of the providers reported their centers had written policies regarding controversial characteristics that would prevent some patients from receiving liver transplants. "We found significant variation in provider opinions of criteria that are contraindications for liver transplantation, which may be why many centers do not have formal policies for selecting candidates with questionable characteristics," concludes Dr. Levitsky. "Standardized eligibility criteria, supported by evidence-based data of outcomes, are necessary to develop formal policies for selecting controversial candidates for liver transplantation."