hen physicians advocate for their patients, who ensures that there is an equitable system, particularly when the need for organs exceeds the supply? Anesthesiologists are a logical source of objective patient advocacy within the transplant community. This article describes the transplantation network and the level of ASA involvement in a system designed to facilitate optimal care for transplant patients.

As of January 2007, there were nearly 95,000 individuals in the United States awaiting organ transplantation. Nearly three-fourths of these wait-list registrants need kidneys, one-fifth livers and less than 3 percent of the total await a heart, lung, pancreas or intestinal transplant. Approximately one-third of wait-listed candidates received a transplant in 2006, yet the number on the wait-list grew as even more were added than removed. For every four patients transplanted, one died waiting.

The governance of the organ allocation system, beset by supply/demand inequalities for the last several decades, has evolved as demand continues to grow faster than supply. In 1977, the first computer-based organ matching system was implemented. In 1986, the United Network for Organ Sharing (UNOS), a nonprofit organization within the then-newly formed national organ placement system, was awarded the federal contract to operate the Organ Procurement and Transplantation Network (OPTN). The primary goals of the OPTN are to ensure equity of organ sharing within the national allocation system and to increase the supply of donated organs available for transplantation at the nation’s 259 transplant centers.

To accomplish these objectives, UNOS currently constitutes 22 committees to oversee and facilitate national organ procurement, allocation and transplantation within the 11 UNOS-specified geographic regions. The committees’ primary task is to review proposed policies and provide assessments to the UNOS Board of Directors. ASA members sit on the Liver/Intestine Committee, the Communications Committee, the Ethics Committee and the Membership and Professional Standards Committee (MPSC).

This past fall, Sue McDiarmid, M.D., the current UNOS President and a transplant team colleague of mine at the University of California-Los Angeles, set annual goals for each of the UNOS committees (posted at www.unos.org/members/committeeAnnualGoals.asp). Notable goals include expanding the donor pool, defining guidelines for establishing transplant programs and refining the factors and adjustments used in organ allocation policies. Living donors, a group that has grown in recent years to surpass deceased donors in size, has been specifically targeted within the UNOS Strategic Plan. As anesthesiologists we are uniquely qualified to contribute to safety initiatives that address the selection, evaluation and perioperative care of living donors.

Donation after cardiac death (DCD) — organ donation after the cessation of cardiac function following the withdrawal of futile life support — is increasing in frequency more rapidly than donation after brain death. Yet DCD donors represented only 5 percent of all deceased donors in 2004. The potential of this group to expand the donor pool is substantial as only seven of the 58 national geographically defined donation service areas (DSA) accounted for 58 percent of all DCD donor procurements. The UNOS Strategic Plan includes a five-fold increase (from 400 to 2,000) in DCD donation by 2013. This represents a challenge to the 17 (of 58) DSAs that did not participate in DCD procurement in 2004. The Joint Commission mandates that all hospitals, and not just those with transplant centers, have a policy in place to promote DCD organ procurement.

Other UNOS Strategic Plan goals include the development of allocation policies that match donor risk to recipient benefit, policies that minimize the regional variation in access to transplantation and an improvement in compliance with OPTN/UNOS policies designed to protect patient safety and preserve public trust.

Transplant program compliance falls under the MPSC, which also makes recommendations to the UNOS Board of Directors regarding the approval of new transplant programs. This committee reviews programs’ outcomes for patient and graft survival and makes recommendations to the UNOS Board of Directors. The process of outcome evaluation utilizes data analyses provided by the Scientific Registry of Transplant Recipients (SRTR), which is available at www.ustransplant.org. A common misconception is that programs serving higher-acuity recipients are disadvantaged during their outcome reviews. In calculating programs’ expected outcomes, however, a number of factors are taken into consideration (see the SRTR Web site for a full list of covariates used in the adjusted models for the various organ programs).

An MPSC review of the program is triggered if all of the following criteria are met: the risk-adjusted observed minus expected deaths is greater than three, the ratio of risk-adjusted observed to expected deaths is greater than 1.5, and that these findings are unlikely to be due to chance as indicated by a one-sided P < 0.05. The MPSC initiates an inquiry to programs flagged under all three criteria and can deem the program’s response satisfactory or recommend one of the following escalating responses: a warning, a letter of admonition, a letter of reprimand, probation and the designation “member [program] not in good standing.” The latter designation may result in notification of patients and the public in the program’s area. Finally, the MPSC may recommend to the UNOS Board of Directors that the program’s rights be suspended or terminated, which would result in a loss of the right to receive organ offers and to list patients for transplantation. Suspension or termination requires the action of the secretary of the U.S. Department of Health and Human Services.

Anesthesiologists should take an active role in evaluating their program’s outcomes to ensure that high standards are met. Examples of interventions taken by programs to improve outcomes include standardization of protocols to minimize variability, communication of safe and consistent standards for medication use, oversight of evaluations for coexisting disease that might contraindicate transplantation (for example, severe pulmonary hypertension in liver transplant candidates) and participation on selection committees that evaluate candidates and determine the frequency of follow-up testing. Anesthesiologists can serve in all of these roles and as liaisons with other transplant team members. For example, is perioperative dialysis being utilized for consistent indications? When is right and/or left heart catheterization indicated during pretransplant evaluation? Anesthesiologists are in a unique position to affect outcomes by ensuring that best practice standards are identified and consistently met.

The ASA Committee on Transplant Anesthesia, chaired by Steven R. Rettke, M.D., provides a link between ASA and UNOS by addressing items put forth by UNOS and ASA members. As discussed by Dr. Rettke in the June 2005 ASA NEWSLETTER article “Sharing Information About Organ Transplantation,” UNOS has not specified experience-based or training-based criteria for anesthesiologists providing transplant care. This differs from the UNOS-specified qualifications for transplant center surgeons and medical directors. The Committee on Transplant Anesthesia is considering the merits of establishing liver transplant program criteria for the director of anesthesia. This discussion has not concluded, and the committee welcomes your input on this and other transplant-related topics. Please send your comments or questions to rsteadman@mednet.ucla.edu.

Regardless of whether you get involved nationally, your expertise and input is needed in your transplant program.

Randolph H. Steadman, M.D., is Professor and Vice-Chair, David Geffen School of Medicine at University of California-Los Angeles. He is ASA Representative to the United Network for Organ Sharing.