Geographic Disparities in Access to Organ Transplantation

Newswise — Does where you live affect how long you'll have to wait for an organ transplant? The United States and other countries consistently show geographic differences in access to organ transplantation, according to a special Forum section in the November 15, 2003 issue of Transplantation, official journal of the Transplantation Society.

The Transplantation Forum on "Geographic Disparities in Access to Organ Transplantation" includes five studies documenting regional variations in access to organ transplants in France, the United States, the United Kingdom, Spain, and Australia.

In the lead article, researchers found significant variations in access across the seven French transplant regions. The percentage of waiting-list patients who received transplants ranged from 63 percent in western France to 43 percent in the Paris region. Death rates varied accordingly, from 2 to 7 percent.

A U.S. study found showed similar variations for patients waiting for kidney, liver, and heart transplants. For kidney transplant candidates, the 4-month transplant rate averaged 10.9 percent overall, but ranged from a low of 5.6 percent in New England transplant region to a high of 19.8 percent in the Southeast.

There were also discrepancies in heart transplants: 4-month rates were 43.9 percent overall, from a low of 39.6 percent (for a Northeastern region extending from Pennsylvania to West Virginia) to a high of 55.8 percent (for the Northwestern states, Alaska, and Hawaii). For liver transplants, the nationwide average was 22 percent, ranging from 11.8 percent (New England) to 36.5 percent (the Southeast).

The U.K. study also revealed significant discrepancies, with kidney waiting list times ranging from about 300 to over 1,200 days. A study from Spain found inequities in liver transplantation, while an Australian study showed regional differences in kidney transplant rates.

Why are such geographic disparities found so consistently? The experience and locations of transplant centers seem to play a role, along with regional variations in organ procurement activities and severity of organ failure.

The regions also seem to differ in when they place patients on transplant waiting lists. In some regions, patients are placed on the waiting list as soon as it becomes clear that they will eventually need a transplant, while other regions list patients only when their condition becomes urgent.

Various approaches are being explored to reduce these geographic discrepancies. For liver transplantation, the boundaries for U.S. organ distribution areas may be redrawn, although this is unlikely to eliminate regional variations completely. A new scheme for prioritizing liver transplant candidates was introduced in 2002, with the goal of ensuring that the available livers go to the patients in most urgent need. Early results suggest that the number of patients added to the waiting list has actually gone down, apparently because doctors realize that less severely ill patients won't receive livers even if they are listed.

Other approaches are being considered to reduce disparities in heart and kidney transplantation. However, no new approaches to prioritizing patients have been developed so far.

Although all agree that access to organ transplantation should be equal, the new studies clearly show consistent and widespread regional variations. "[E]quitable access to organ transplantation should be considered a national responsibility to the public at large," the Forum editors conclude. Although complete equity will be difficult to achieve, boundary adjustments, new prioritization schemes, and other approaches should be studied to level out these geographic disparities to the greatest extent possible.