Who Gets a Liver, Where and Why?

April 1, 2023 8:35 AM

Where do livers come from, and where do they go? Life-saving liver transplants have plummeted in some Southern and Midwestern states with higher death rates from liver disease, while New York and California have made big gains. Not everyone is cool with this. Malena Carollo and Ben Tanen report for The Markup, co-reported with the Washington Post.
posted by Hypatia (20 comments total)

Considering that healthcare has plummeted in those places, why would this come as a surprise? Perhaps if one of the major political parties didn't spend time demonizing Dr's and healthcare in these places the disparity wouldn't be so large.
posted by evilDoug at 9:16 AM on April 1, 2023 [4 favorites]

All the problems actually listed in the article are problems with public health care policy in those particular states. But no, it's the coastal elites taking their livers away. It's the usual message in response to yet another domestic problem.

Maybe California and New York should give them even more money through federal funding. Oh wait, they've tried that...
posted by tigrrrlily at 10:06 AM on April 1, 2023 [20 favorites]

That’s some pretty strong mood affiliation rather than reading the actual article y’all. The changes highlighted are purely reflections of changing rules. It used to be that lower acuity patients in some states would have earlier access to organs based on the higher availability in their locality. The new rules have caused net flux towards the coast, where there is high demand (due to more common liver disease and problems that you were pointing to) and a smaller supply. It is unfortunate that the new policy decouples the success of a locality in increasing organ donation from the rate of transplant for patients in that location. The old policy was always pretty tenuous in its justification, however.
posted by a robot made out of meat at 10:39 AM on April 1, 2023 [8 favorites]

“Everyone has to have insurance,” said J. Steve Bynon Jr., chief of abdominal transplantation at Memorial Hermann in Houston, when asked about its policy. “There are no freebies.”

But they’ll surely take your healthy liver if you die precipitously, whether you have insurance or not. That’s why this pressure to make everyone put DONOR on their driver license is pernicious bullshit. Give everybody free healthcare or fuck off.
posted by toodleydoodley at 11:45 AM on April 1, 2023 [1 favorite]

The argument presents an argument seemingly twisted to certain political tropes, i.e., the rich are hoovering up all the organs while poorer Southern and Midwestern patients do not benefit from donated organs from ‘their’ state. But the actual data (graphically presented in this figure from the article here) shows NY now exports the majority of their donated livers whereas under the previous regime most were used in state. Further, the argument is based on the finding that 7 states with average incomes below the US median performed less liver transplants. Yet, the same data shows that in 11 other states with below average median income, liver transplants are up, almost 100% in one case.

Certainly there are winners and losers but this seems like a weak argument by certain interests who are on the short end of the stick. In fact, in almost all states - and certainly here in FL where essentially all locally procured livers are used in state - patients are dying every day because of lack of organs. The problem is low availability of organs, not rich states somehow taking advantage of poorer regions.
posted by sudogeek at 11:48 AM on April 1, 2023 [7 favorites]

So… this is super interesting, and not something that was previously on my radar (thank you for sharing, Hypatia!) However… this is not good reporting. I spent half of the article wondering what the core arguments were on either side of the policy debate. I was also suspect of the data analysis presented, as it seemed like a pretty blunt instrument and left a lot of room for confounding variables. I found a couple of recent articles on the topic (here, here) that found an important variable in the discussion is transplant centers’ acceptance criteria for donation livers.

It does sound like there is reform needed on the waitlist criteria side of things. At face value, the policy of giving the organs to the sickest patients sounds reasonable. But if there are issues with who gets on the list and how “sickest” is calculated, that doesn’t mean much.
posted by bluloo at 11:51 AM on April 1, 2023

Livers can be shared! After a living donation, the remaining liver regenerates to 80-90%+ capacity, and the donated part of the liver can grow back up to ~80% of the original.

Aside from bone marrow (much of the time, you don't even need that giant needle into your femur, there are growth factors that can mobilize haematopoietic stems cells from the marrow to peripheral blood where it can be harvested), the liver is the sharingest organ around.
posted by porpoise at 11:58 AM on April 1, 2023 [2 favorites]

That’s some pretty strong mood affiliation rather than reading the actual article y’all

Or maybe I actually read the article, saw the maps, read what the people were saying, and saw right through the blindingly familiar framing?
posted by tigrrrlily at 12:02 PM on April 1, 2023 [5 favorites]

The problem is low availability of organs

Or high demand. Until the nifty stem-cells-on-scaffolding approaches work, I’d rather reduce demand.
posted by clew at 12:08 PM on April 1, 2023

Is it accurate to take-away that the poorest states are also producing lots of healthy lives because their citizens die of opioid overdose, which seems - after MVA's - to be an ideal way to harvest a nice healthy liver from a likely younger patient? I cannot parse the policy behind this but one way or another I cannot imagine this disparity is not exacerbated by living somewhere where governance deliberately shuns tax dollars for better health care and infrastructure.
posted by docpops at 12:13 PM on April 1, 2023 [1 favorite]

But the actual data (graphically presented in this figure from the article here) shows NY now exports the majority of their donated livers

Remarkably similar to how taxpayers in coastal elite states subsidize non-coastal non-elite states.
posted by They sucked his brains out! at 12:35 PM on April 1, 2023

Yes, I read this trying to sort it out, and the only aspect of the national policy (as opposed to the state-by-state health disparities) that seems potentially problematic is the increase in "waste," and it's not entirely clear to me that (a) it's a persistent phenomenon or (b) that it's really being caused by the change in the size of the "circles." More data needed on that one. If the liver can be safely and effectively transported further, to the sicker-but-still-qualifying patient, equity seems to demand that it should be. If the MELD scoring system doesn't accurately reflect need for transplant, that should be adjusted, too, but that's not a result of the circle size expansion.

“Everyone has to have insurance,” said J. Steve Bynon Jr., chief of abdominal transplantation at Memorial Hermann in Houston, when asked about its policy. “There are no freebies.”

The way he phrased this struck me, in a bad way. I hope he was being bluntly critical rather than...how it reads.

In the end, though, it shouldn't be a surprise that, without a thumb on the scale to keep livers more local than the technology actually requires, the states that refuse to take care of their own people because then they might accidentally help some black people among them end up both with more donated livers from young people dying (tragically) preventable deaths and fewer recipients among older people not receiving the support to be able to be eligible in the first place.
posted by praemunire at 12:40 PM on April 1, 2023 [5 favorites]

Until the nifty stem-cells-on-scaffolding approaches work

Don't, ah, hold your breath on that one.
posted by praemunire at 12:46 PM on April 1, 2023

It seems like the intended thesis of this article is that the policy changes benefited the states who lobbied for them. AFAICT that seems to be somewhat true, but not in a way that actually indicates corruption or bad policy. Coming into this without much knowledge of organ transplants, it seems like the basic problem is that there aren't enough livers for people who need them, so any policy change that shifts or changes geographical criteria is always going to lead to more people dying for lack of a liver in one place and fewer somewhere else. Meanwhile, the article briefly notes an increase in wasted livers, but never explains the causal mechanism that links the policy change to the increase in waste (I assume it has something to do with longer transit times?)

It's important to hear from people who are harmed by policy change, but it feels like the authors ended up with a bit less of an exposé than they were aiming for.

NY now exports the majority of their donated livers whereas under the previous regime most were used in state.

This is where some more policy detail in the article would have been helpful, because it seems like a great reduction in the salience of geographical criteria would likely lead to all states exporting the majority of their donated livers. Yet per the map, that isn't the case.

Remarkably similar to how taxpayers in coastal elite states subsidize non-coastal non-elite states.

It's really not. In fact, if we were for some reason to read an export rate of < 50% as a sign of being subsidized, then the states that New York (and almost every Midwestern and Southern state, Puerto Rico and all of the Eastern Seaboard except Florida) "subsidizes" would include California and Washington. Oops!

(But not to worry, this is not actually a reason to reconsider MeFi's culture of reflexive bicoastalism, because the map has nothing to do with one state subsidizing another. That said, it's kind of weird that there isn't a map of net organ flows. Was that an editorial decision or is the information not available for some reason?)
posted by Not A Thing at 1:42 PM on April 1, 2023 [2 favorites]

Where do livers come from, and where do they go?

Great, thanks! Now I'm going to have a "Cotton-Eye Joe" earworm for the rest of the day.
posted by Harvey Kilobit at 2:10 PM on April 1, 2023 [6 favorites]

Livers can be shared! After a living donation, the remaining liver regenerates to 80-90%+ capacity, and the donated part of the liver can grow back up to ~80% of the original.

Unlike say, South Korea, living adult to adult liver donation is a small piece of transplant in the United States. This is something of an unfortunate paradox based on the pretty successful deceased donor allocation that we have. if your loved one is reasonably likely to get a deceased donor offer, it is a big ask to go through a right hepatectomy. This was most visible in the pediatric liver world; when the rules were changed earlier in the decade to improve access to splittable livers for children, the rate of adult (usually family member, usually parent) living donation to those kids went way down. Partial liver donation is a way more invasive and morbid surgery than kidney donation, where adult donation is more common.
posted by a robot made out of meat at 2:56 PM on April 1, 2023 [3 favorites]

The relatively higher rates of morbidity (and occasionally mortality) for liver donation are unfortunate, because not only does it regenerate, it does so in under two months. Livers are amazing.

I wonder if there's anything inherent in the surgery that is the reason, or just that there are fewer lobectomies than kidney extractions, and that outcomes could be equalized with more research?
posted by ivan ivanych samovar at 3:52 PM on April 1, 2023

As others have said, this isn’t a liver problem, it’sa healthcare problem. A basic tenet of healthcare in the UK, for example, is that cases are triaged according to need, i.e. urgency, emergency, and that’s the failure here, where places with their shit together are exposing places that don’t, because US heathcare is fucked fifty ways to Fools’ day
posted by bookbook at 2:07 AM on April 2, 2023 [2 favorites]

You can see the bias in this article from the graphs that are missing. The policy in question is meant to increase fairness of organ distribution, regardless of the state of the donor or the recipient. Has it? You can ask this as "if you're critically ill, what's your chance of getting a liver?" Show me a graph of that, before and after, broken down by state. I'll bet it's a lot more even now than it was. And yes, that represents a change for the worse for states that have a higher ratio of donors to recipients, like states that have worse opioid problems or younger populations. But are they now objectively worse off than other states, or just worse off than they were before?
posted by qxntpqbbbqxl at 6:54 PM on April 2, 2023 [1 favorite]

There's a lot missing from this analysis, as qxntpqbbbqxl points out. It's not really possible to see if, overall, outcomes are better or worse. They're maybe better for some areas and worse for others, but that's not completely clear either - just 'getting a liver' is not the desired outcome here, an actual increase in life expectancy and quality of life across the board is surely the goal?

Everyone has to have insurance,” said J. Steve Bynon Jr., chief of abdominal transplantation at Memorial Hermann in Houston, when asked about its policy. “There are no freebies.
While this is unsurprising in a US (lack of) health care context, it's also quite tragic. Your odds don't seem that great even if you do have insurance but, if not, you don't even have the slightest chance and just have to fuck off and die, I guess.
posted by dg at 9:56 PM on April 2, 2023