In a Viewpoint published Online First by The Lancet, organ transplantation experts discuss how waiting lists can be artificially inflated, since only a proportion of those listed as needing a transplant are actually ready 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 deemed active on a transplantation list if they are ready to have a transplant, and inactive if they are not. The authors say: "Crucially, not all the patients on waiting lists are actually eligible for transplantation." They refer to a newspaper article (in the Washington Post in 2008) that showed that of almost 100,000 patients in the USA waiting for various transplants, inactive patients represented 69% of those "waiting" for a pancreas, 26% for a liver, and 33% for a kidney. While of course 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 also make a comparison with diabetes diagnosis/treatment, in which blood sugar levels that define diabetes have changed over the years, thus increasing numbers labeled with the condition and eligible for drug treatment. 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 call for waiting list criteria to be reviewed at three levels. Firstly, at the national and international level. Resources are not sufficient to cure everyone, and transplantation is very cost-intensive. Every country should decide the relevance to be given to transplantation programmes and the resources that are devoted to this part of medical care. They say: "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."
Secondly, they say that end-stage organ disease needs to be looked at overall; transplantation is only one part of this care. 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."
The clearly vital issue of the needs of patients and their families is addressed, with the authors saying: "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 the authors' home nation of Italy, recommendations are that the waiting list for liver transplantation should be shorter than double the organs transplanted every year. In Tuscany, clinicians are attempting to move from compatibility (best match for ABO blood group antigens, age, HLA) to transplantability (real probability of receiving an organ)—ie, replacing the abstract concept of a best organ with the realistic expectation of the best possible organ among the reasonably available ones. Finally, the authors note that end-stage organ failure is not enough on its own to justify entry into waiting lists—what if it is not what the patient wants? The authors 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."
They conclude: "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."
Professor Rinaldo Bellomo, University of Melbourne, and Department of Intensive Care, Austin Hospital, Melbourne, Australia. T) +61-3-94965992 E) rinaldo.bellomo@austin.org.au
Alternative contact: Dr Nereo Zamperetti, Department of Anesthesia and Intensive Care Medicine, San Bortolo Hospital, Vicenza, Italy. E) nereo.zamperetti@ulssvicenza.it
Journal
The Lancet