Opinion | Donor Livers Must Go to Our Sickest Patients

Liver transplants save lives. I know because my life was saved by one.

As a liver transplant hepatologist, I’ve spent my career taking care of patients who are waiting for or have received a lifesaving liver transplant. But in 2002, my world was turned upside down: I was given the gift of life when I myself became a liver transplant recipient.

After this harrowing and humbling experience, I had the honor of serving on the Organ Procurement and Transplantation Network (OPTN) liver committee for a 3-year term between 2017 and 2020, representing the patient perspective and working to increase transplant access for the sickest patients.

Clearly, I’ve fulfilled a wide spectrum of roles in the world of liver transplantation: I’ve simultaneously been a provider advocating for his patients on the waitlist; an anxious patient who wondered if the donor liver would arrive in time to save my own life; and a member of a committee helping craft policy for patients in need.

What did I take away from all this? There were — and still are – inequities in our organ allocation process. But we now have results that show the vigorous policy development process helped address this issue and increase equitable access to lifesaving organs. Work remains, but this policy represents a bold step in the right direction.

The current liver allocation policy was put into place in early February 2020 after several rounds of statistical modeling, thousands of comments from the public, and hours of debate. Under the previous policy, there was significant variation across the country in how sick a severe liver disease patient had to be before getting a transplant. This created inequities that favored those who had the means to relocate for a transplant. To address this, those of us on the OPTN committee worked to create a proposal for the OPTN Board of Directors for a new allocation system that would save more lives by providing increased access to lifesaving liver transplants for the sickest patients. This would be accomplished by eliminating old geographic boundaries and instead prioritizing the medical urgency and distance between donor hospital and transplant hospitals when allocating organs. Ultimately, the members of the Board — a quarter of whom are patients and donor families — voted 33-7 in favor of a policy that would do just that.

The members of the OPTN committee were impassioned and committed volunteers with a variety of backgrounds who held different, sometimes opposing ideas, but we all shared a common goal: to save more lives through transplant. The process was intense, and the debate was fierce. With lives on the line, how could the debate not be contentious? Dissenting voices and differing opinions were essential. And ultimately, as the numbers attest, the process made the policy better.

Now, 2 years after the liver policy was enacted, we have data on the impact. Fortunately, the early, dire predictions by some critics that the policy would result in fewer transplants and threaten the existence of many liver transplant programs did not hold up against these recent numbers below. Unfortunately, the repetition of these old predictions, especially in the face of new information, is needlessly frightening patients and sowing distrust in the system.

Numbers from an OPTN 18-month report analyzing the impact of the policy reveals several important trends:

• Liver transplants from deceased donors increased by 5.1% (566 more transplants) since the new policy was implemented
• Transplant rates increased significantly for the sickest candidates, as forecasts predicted
• The majority of liver transplant programs experienced similar or higher transplant volume after the policy change
• No programs have closed

This data show that the sickest patients are indeed getting greater access to life-saving donor organs, and geographic inequities in organ allocation have been significantly reduced — the original intention of the policy for which I voted. I’m encouraged the policy is working as intended and the inclusive process resulted in an effective outcome, despite ongoing claims to the contrary.

As a physician and a patient, I implore our elected officials and my colleagues not to ignore this good news, but to use it, share it, and work together to make the system even better. Our patients deserve nothing less.

Terry Box, MD, is an associate professor of medicine at the University of Utah. He has cared for liver transplant patients since 1986 and was medical director of the liver transplant program from 1991 to 2009 at the LDS Hospital in Salt Lake City, where he received his liver transplant in 2002. He joined the University of Utah Liver Transplant Program in 2009.