Reply: Geographic disparities and deceased donor liver transplantation within a single UNOS region

Abstract

The authors, from well-respected and accomplished liver transplant centers in Houston and San Antonio, write of the geographic disparities and deceased donor liver transplantation within United Network for Organ Sharing region 4.1 They note significant differences in Model for End-Stage Liver Disease scores at liver transplant for non–status 1 candidates, importantly point to data showing greater risk of being delisted, and point out that the risk of being delisted is directly proportional to the donor service area (DSA) size and varies among the four DSAs. Regrettably, this analysis is incomplete and perhaps disingenuous. First, the time period covered in this data analysis precedes the implementation of the mandatory share 15 rule, which may well have a significant impact both in region 4 and nationally on transplant rates and may obviate the differences within DSAs. Second, the authors advocate for increased intraregional sharing of liver allografts, yet they are the same group who brought this issue before the liver intestine committee at the United Network for Organ Sharing, which prompted Scientific Registry of Transplant Recipients modeling of broader geographic sharing within region 4. The Scientific Registry of Transplant Recipients modeling data, which these authors chose not to present, showed no benefit in overall mortality (pretransplant and posttransplant) with broader regional sharing within region 4. Finally, and perhaps most importantly, their analysis completely omits the primary reason for differential delisting rates within region 4: a sharp difference in donor organ acceptance rates within the adult liver transplant centers of region 4. In fact, in some of the DSAs with the lowest delisting rates, the organ acceptance rates are some of the highest in the country and clearly higher than those in the DSAs in which delisting rates are not as favorable. The authors, to their credit, address an important topic. They should be encouraged to present all of the data that are pertinent to the analysis. Marlon F. Levy M.D., F.A.C.S. [email protected]*, * Transplant Services, Baylor University Medical Center, Dallas, TX.