This is a really tough one. Having been successfully transplanted
and living a completely normal life I know a big part of this outcome
was that other than my liver disease I was very strong and healthy it
was also that I was blessed to have been treated at one of the best
clinics in the country. I have also met people through the transplant
comunity who were very ill prior who have far exceeded all
expectations. I would suspect the solution to this dilema is to
increase donors. I see many people on these boards who may at some
point be on the list and most who will not I would like to see every
one get the same chance that I have. I am going to sugest something
that may help, it is something that I have done already. If each of
us would get at least 10 people to sign donor cards and ACTIVLE AND
VOCALLY PUSH ORGAN DONATION. we could put a big dent in the shortage.
Do all on this board have singed donors cards as we even though we
have this virus can donate.

livers available for transplant is forcing closer scrutiny of
transplantation criteria. The Model for Endstage Liver Disease (MELD)
developed at the Mayo Clinic falls short of the mark, according to a
presentation on Nov. 4 by
Sciences Center, at the 53rd Annual Meeting of the American
Association for the Study of Liver Diseases in Boston, Massachusetts.
In a study of 66 liver transplant recipients with a right lobe
transplant from a living donor,
(UCLA) have developed a new model which is a far better predictor of
outcome, according to a report in the September issue of the Annals
of Surgery. In 46,942
variables identified as independent predictors for recipient survival
include recipient age and recipient creatinine, donor age, sex, total
bilirubin, prothrombin time, retransplantation, and warm and cold
ischemia times. To learn more about the UCLA model and its
implications for liver transplantation, Medscape's Laurie Barclay
interviewed lead author Rafik M. Ghobrial, MD, an associate professor
of surgery in liver and pancreas transplantation at the Dumont-UCLA
Transplant Center and the David Geffen School of Medicine at UCLA.
Dr. Ghobrial is also the first author of a study of donor and
recipient outcomes in right lobe adult living donor liver
transplantation (LDLT), which appears in the October issue of Liver
Transplantation.
survival but of death, that is, how quickly the recipient is likely
to die while awaiting transplant.The MELD model was designed to give
priority to the sickest patients in greatest need of transplantation.
So, for example, if a score of 1 represents the sickest patients who
are currently in the ICU, and a score of 3 represents those at home
but still in dire need of a transplant, patients scored 1 are
considered better candidates even though patients scored 3 are more
likely to survive after transplantation.
transplantation are always changing because there aren't enough
organs to go around, so we're trying to maximize distribution of this
precious resource. MELD factors in both waiting time for
transplantation and how sick the patient is. But with time, how long
the patient has been waiting for transplantation loses its
effectiveness as a criterion. The MELD assigns a score to every
patient, and
waiting for a transplant, as well as the chance of dying after
transplantation. The UCLA model differs in its overall focus and in
its specific criteria. It uses a combination of recipient, donor, and
operative factors to predict good outcome. For example, we know that
renal failure negatively impacts survival because some patients may
actually need a double organ tranplant, so the UCLA model includes
recipient creatinine. There's nothing in the MELD model to indicate
that a patient has gone too far to justify transplantation. No one
wants to be unsympathetic to a dying patient, or to tell his family
that he can't be transplanted because he's likely to die anyway. But
at the end of the day, using the MELD model leads to transplanting
the sickest patients, while the UCLA model attempts to select those
patients who will make the most use of the organ.
model in predicting outcome? Dr. Ghobrial: The UCLA model was
developed over many years in hepatitis C patients, and it accurately
predicts outcome and survival. It selects those patients most likely
to survive the operation, to have a quick recovery, to have survival
of the transplanted organ, and to live longer after transplantation.
The battle between the two models is like a tug-of-war, but
more logical and practical approach. We have to offset the urgency of
the recipient's need with the predicted efficiency of organ
utilization.
Ghobrial: It's very well accepted among groups awaiting transplant
because it's an understandable model. The UCLA model accurately
predicted outcome in the 25,000 patients studied retrospectively.
Before this model,
study the model and validate it prospectively. Prospective validation
will take years.
Winfrey show and other media, has helped increase awareness slightly.
But I think education has gone about as far as it can, and it has not
translated into a dramatic increase in the number of available
organs. The key is in changing legislation. Right now, the
legislation is that no one who dies is an organ donor unless the
family agrees to it. We should change that so that everyone who dies
is a potential organ donor unless the family objects. But there are
not a lot of politicians willing to do that.
than 70% in one year, if it falls below threshold criteria, we
shouldn't transplant. If one-year survival probability is at least
80% to 90%, it's okay to
patients who are very sick, recognizing the pressures of third-party
insurers, decreased reimbursements, and the high cost of drug
therapy. The most common cause of death following transplantation is
sepsis, which is very expensive to treat. We have to take into
account that the costs of treating one patient for sepsis - who
ultimately dies - could have been used to treat two
determine the optimal interventions and decisions. But in general,
the sicker the recipient, the less effective any interventions will
be.
threshold indicating low probability of survival, they should be
delisted. Everyone agrees in principle that that's a great idea. But
I'm a physician - I've sworn to preserve life. I am going to do my
best for my patient no matter what. If there's a predetermined
national agreement about who should not be transplanted, it makes my
decision easier and more justifiable, even though it's
psychologically, practically, and medicolegally difficult to tell a
patient and his family that he's too sick to qualify for transplant.
before the recipient gets too sick. On the other hand, LDLT is
relatively new, and we have a 15- to 20-year history of cadaveric
transplantion, so we have a better understanding of the complications
and operative technique. There has not yet been a comparably rigorous
analysis of LDLT. We also have to consider risk to the donor with
LDLT.
and recipient factors, LDLT is clearly a good thing, but it shouldn't
be done in hopeless situations where the recipient is not likely to
survive. We should subject criteria for LDLT to rigorous analysis.
When do you get the best
deaths in healthy donors. Last year, there were about 400 LDLTs
performed in the U.S. The risk of donor death is less than 1.0% -
very low, but real. A donor
complications, the complication rate in donors ranges from 9% to 67%;
probably 20% is a reasonable overall estimate. It's not like a bone
marrow transplant - it's an extensive procedure. The complications
are mostly