Critical analysis of the allocation policy for liver transplantation in Brazil

Abstract

Liver transplantation is now the standard treatment for end-stage liver disease. Given the shortage of liver donors and the progressively higher number of patients waiting for transplantation, improvements in patient selection and optimization of timing for transplantation are needed. Several solutions have been suggested, including increasing the donor pool; a fair policy for allocation, not permitting variables such as age, gender, and race, or third-party payer status to play any role; and knowledge of the natural history of each liver disease for which transplantation is offered. To observe ethical rules and distributive justice (guarantee to every citizen the same opportunity to get an organ), the "sickest first" policy must be used. Studies have demonstrated that death has no relationship with waiting time, but rather with the severity of liver disease at the time of inclusion. Thus, waiting time is no longer part of the United Network for Organ Sharing distribution criteria. Waiting time only differentiates between equally severely diseased patients. The authors have analyzed the waiting list mortality and 1-year survival for patients of the State of São Paulo, from July 1997 through January 2001. Only the chronological criterion was used. According to "Secretaria de Estado da Saúde de São Paulo" data, among all waiting list deaths, 82.2% occurred within the first year, and 37.6% within the first 3 months following inclusion. The allocation of livers based on waiting time is neither fair nor ethical, impairs distributive justice and human rights, and does not occur in any other part of the world.

Impact of acute kidney injury exposure period among liver transplantation patients

“…All transplantation recipients were admitted to the intensive care unit (ICU) in the immediate postoperative period. Transplantation organ allocation at the time of the study was ordered chronologically [11]. …”

Aplicação do escore MELD em pacientes submetidos a transplante de fígado: análise retrospectiva da sobrevida e dos fatores preditivos a curto e longo prazo

“…Alguns autores, no Brasil, procuraram estudar a utilização desse critério de ordenação de gravidade, seja comparando a classificação de Child-Turcotte-Pugh (CTP) mostrando sua validade ou questionando a alocação de órgãos por lista única pela gravidade do doente com doença hepática crônica (6,14,36,47,48,49,50) .…”

Perioperative Care of Liver Transplant Patients in Brazil

“…Controversial issues regarding these criteria have been intensely discussed in Brazil. 4 Some authors state that waiting time criteria resulted in an extremely elevated mortality rate (60%) while on the waiting list. In addition, 15% to 20% of the transplanted patients with stable preoperative clinical status could have postponed liver transplant.…”