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June 25, 1998

Children needing liver transplants face disadvantages under current system, Pitt surgeon tells Senate committee

Children awaiting liver transplantation are at a special disadvantage under the current allocation system, which favors local use of donated organs and often prevents children from receiving organs from pediatric donors, according to a Pitt surgeon citing data from the United Network for Organ Sharing (UNOS).

The transplant system is operated under federal contract by UNOS. Current UNOS allocation policy allows organs to be donated for transplantation to be used preferentially within the local area served by an organ procurement organization (OPO) even if there may be a sicker patient elsewhere in the United States. Because inequities exist under such a system, the U.S. Department of Health and Human Services (HHS) announced a new regulation that requires UNOS to develop different policies greater emphasis to medical emergency over geography. The regulation, which UNOS opposes, is the subject of congressional hearings that began June 18.

Jorge Reyes, associate professor of surgery and director of pediatric transplantation at Pitt's Thomas E. Starzl Transplantation Institute and Children's Hospital, supports the regulation that compels UNOS to reform its policy.

"In areas where an OPO does not serve a pediatric liver transplant program, there is often reluctance to procure organs from pediatric donors or to share outside the service area adult livers that could be surgically reduced and transplanted into children sicker than local patients," Reyes said.

Data from the UNOS scientific registry, presented by researchers at the 29th annual American Pediatric Surgical Association meeting in May, raise serious concerns about the current system, said Reyes, who wrote to HHS Secretary Donna Shalala.

Following are some of Reyes's observations, based on data from the UNOS registry from 1990-1996:

* Pediatric donations have increased between 1990 and 1996 from 800 to 936, but not at the same pace as the pediatric waiting list, which nearly doubled from 768 to 1,285.

* Despite the increase in pediatric donors, children needing those organs are being bypassed. This is more true in recent years than in 1990, just before the allocation system became more geographically based.

* In response to the limited number of pediatric livers allocated regionally and nationally, surgeons have resorted to other life-saving procedures, such as living-relatives transplantation and transplantation using reduced or split cadaveric adult livers. In 1990, 86.5 percent of pediatric transplants used whole organs from pediatric donors, compared to 70.8 percent in 1996.

* There were 936 pediatric (under age 17) donors in 1996, but only 306 pediatric patients received organs from those donors. Some 156 other children had transplants using reduced adult livers or segments donated by a living relative; 75 children under 17 died on the waiting list in 1996.

Reyes testified at the June 18 joint hearing of the Senate Committee on Labor and Human Resources, subcommittee on Public Health and Safety, and the House Commerce Committee's subcommittee on Health and the Environment.

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