North Carolina sees an ‘exodus’ of donated livers after national transplant rules change

The “exodus of organs” from North Carolina began three years ago, just as Dr. David Gerber had predicted.

Gerber, who runs a transplant surgery division at UNC Health, suspected a shift in organ assignments would mean most livers donated in North Carolina would be sent to other states, meaning that fewer people here would qualify for a life-saving transplant.

“We knew our region was going to turn into an export region,” he said.

Recent data confirmed his worst fears.

More than 75% of North Carolina’s livers were shipped elsewhere in the country in 2021 as a result of the rule change, an investigation from the Washington Post and The Markup found. This stands in stark contrast to 2019, before the policy change took effect, when most livers donated in North Carolina were received by patients within the state.

This decline happened even though the state’s organ procurement organizations found more liver donors and became more successful at extracting viable organs during the same time period.

Help those nearest or sickest?

For many years, donated livers, a scarce resource, were often given to the sickest people who lived near where donated organs were harvested.

But in 2020, The United Network for Organ Sharing changed the system, requiring livers to be shipped to the sickest patients, regardless of where they lived.

The rule change has been deeply contentious within the organ transplant community.

Transplant doctors in New York and California — who lobbied for the new approach— argued the prior policy was unfair because it prioritized healthier patients from states with shorter wait lists over their sicker patients.

Gerber and other transplant doctors from rural southern states say the new policy unfairly punishes states that are already facing health inequities as a result of gaps in health care access and insurance coverage.

The debate about whether geography or severity of sickness should take priority has been the subject of lobbying, lawsuits and intense debate.

Even within North Carolina, at transplant centers 12 miles away from each other, doctors disagree about how this rule change has impacted patients.

Dr. Ian Jamieson, vice president of the Duke Transplant Center, quibbles with data that shows liver transplants dropped by 10% between 2019 and 2021.

He said that doesn’t take into account the loss of patients from states like New York who used travel to North Carolina to have a better shot at getting a liver under the old distribution rules. They account for about 15 patients a year on average, he said.

“When you subtract out those 15, we can sort of see where we are,” he said. “I don’t get the sense that citizens in our state were adversely impacted.”

Jamieson also said the number of transplants in 2019 was unusually high, inflating the decline before and after the rule change.

Jamieson said he thinks the policy has generally had a positive impact.

Fewer people die waiting, others get sicker

In North Carolina and nationwide, data shows that fewer patients died on the liver waiting list in the two years after the policy went into effect.

Opponents of this change generally argue that’s at the expense of people in rural states with less severe liver disease. More of them might have received a liver in 2019 early enough to increase their chances at better long-term outcomes. Now they must be much sicker to qualify.

Jamieson understands both sides of the argument in this life-or-death debate.

“They care for patients on their waitlist and they want to get them transplanted as quickly and safely as possible,” he said of those favoring local organ sharing.

Livers flying further

In the years following the policy change, donated livers had to be transported twice as far on average to reach their recipients, resulting in higher transportation costs, the Markup investigation found.

In 2021, the number of wasted organs was higher than it had been for almost ten years, according to the investigation.

On at least one occasion, UNC Health had to turn down a liver it procured because it was in transit for too long, increasing the chances that the transplant surgery would have complications, Gerber said.

“We have livers crossing in the middle of the night all over the place,” he said. “If a delay occurs, suddenly that liver that would have been usable if it was local isn’t used: it’s out of the body for too long.”

Jamieson said that was an unfortunate, but expected, consequence of switching to an allocation model that prioritizes sharing organs across state lines.

“We also have to realize there’s no perfect solution here,” he said. “The only perfect solution is more organs.”

Teddy Rosenbluth covers science and health care for The News & Observer in a position funded by Duke Health and the Burroughs Wellcome Fund. The N&O maintains full editorial control of the work.