LIVER TRANSPLANT

Michael L. Volk, M.D., M.S., led research on patient preferences about donor livers.

The Waiting Game

Transplant candidates seek best quality livers, even if it means waiting longer

issue 14 | winter 2012

Liver transplantation candidates want to be involved in decisions regarding quality of the donor organ, and many are reluctant to accept organs with a higher risk of failure, according to University of Michigan researchers.

More than 42 percent of patients would choose to remain on the waiting list rather than accept a "lower quality" liver, according to a recent study led by Michael L. Volk, M.D., M.S., published in the journal Liver Transplantation. Volk is an assistant professor in U-M's Department of Internal Medicine, Division of Gastroenterology.

Quality counts

As of Nov. 30, 2011, the Organ Procurement and Transplantation Network (OPTN) reports that 16,124 candidates are on the waiting list to receive a liver, with only 5,375 deceased donor organs recovered through August.

Additionally, there is a large variation in quality of deceased donor livers, due to donor characteristics such as age, cause of death and ischemia time. Previous research has shown that donor characteristics can make the difference between a 20 percent and 40 percent risk of graft failure by three years following transplantation.

"Organ quality is an important issue for all liver transplant candidates, increasingly so, given the aging donor pool and more frequent use of organs that carry a higher risk of failure," says Volk, who is a hepatology specialist. "The decision to accept or pass on an organ could mean the difference between life and death for patients with end-stage liver disease. Communication of the risks versus benefits of accepting a 'lower quality' organ is critical, and understanding patient views on the subject is essential for physicians caring for transplant candidates."

Risk assessment

Volk's research showed that patients are reluctant to accept higher-risk organs. Of those who participated in the survey conducted by his team, 58 percent would only accept organs with a 25 percent (or less) risk of graft failure and 18 percent would only accept the lowest possible risk of 19 percent at three years following transplantation. Risk tolerance was increased by presenting organ quality as "average quality" rather than "best quality" and by providing feedback about the implications of these preferences on the likelihood of receiving a transplant.

Additionally, 83 percent of candidates were found to prefer an equal or dominant role in deciding whether to accept a higher-risk organ. This finding is striking given that, in most transplant centers, patient involvement in these decisions is minimal.

"Up until now, it has not been clear how much patients want to be involved in this complicated decision," says Volk.

"Furthermore, explaining the intricacies of this topic to sick patients is easier said than done. Our findings offer transplant physicians some useful guidelines for how to counsel transplant candidates on issues of organ quality."

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