New queue
If you're a registered organ donor, you've requested that, after you die, your heart, lungs, and other organs be used to save the lives of others who need them. But who decides which "others" will benefit—and when?
Since 1986, organ allocation has been overseen by the United Network for Organ Sharing (UNOS), a national nonprofit organization under contract with the federal government. For many years, the standard procedure for lungs was to add people in need of an organ to a “first-come, first-served” list, requiring them to wait in line for a transplant. When a donor organ became available, the search for a good-fit recipient began at the top of the list—regardless of the degree of medical urgency. The result: Those who lived long enough to make it to the top of the list received lungs, while more desperate candidates died waiting.
Transplant surgeon Cynthia Herrington, M.D., was a key instigator of a "lung summit" that revamped the process by which lungs are allocated, making more lungs available to the people in greatest need.
"The old system was unfair to everybody," says Cynthia Herrington, M.D., assistant professor of cardiovascular and thoracic surgery at the University and surgical director of lung/heart-lung transplantation at the Transplant Center.
In 1998, recognizing the limitations of the original allocation system, the federal government ordered UNOS to revamp it. After much discussion, the UNOS Thoracic Organs Committee came up with a ranking system that assigned lung transplant candidates over age 12 a score from 0 to 100 based both on medical urgency and potential benefit from a transplant. In May 2005—the month Broberg signed up—the new queue system went into effect.
Its impact was instantaneous. Immediately, donor lungs began going to individuals such as Broberg who were judged to be in the toughest shape and, therefore, with the most to gain. As a result, the national waiting list got shorter, and the number of people who died while waiting for a lung transplant dropped from 489 in 2004 to 220 in the first 11 months of 2006.
"[The new system] focused lung transplants on those who needed them most," says John Lake, M.D., professor of medicine and surgery and executive medical director of solid organ transplantation at the Transplant Center.
LIVING DONORS
If they can't wait for a lung from a deceased donor, persons with life-threatening lung impairment may pursue a living-donor transplant, in which two individuals each provide a lobe of one of their own lungs to replace the function of the recipient's faulty organ. But few people choose this option. Last year, only four living-lobar transplants were performed nationwide, and the year before there was only one.
"What barriers are preventing living-donor lung transplantation from becoming more widely acceptable?" asks Maryam Valapour, M.D., assistant professor in the Department of Medicine and the Center for Bioethics at the University. Last fall, the National Institutes of Health awarded Valapour a $750,000 grant to find out.
Valapour hypothesizes that a perception of high donor risk is the principal factor preventing living-donor lung transplantation from becoming widely available. By interviewing physicians and other transplant professionals and studying existing policies, she hopes to develop guidelines for living-donor lung transplantation in the future.
"I'm doing this research to understand and improve the process for living donors and their recipients," she says.
The new approach to allocating deceased-donor lungs has taken some of the pressure off living-donor programs, since the sickest people have a shorter wait than they would have under the old system. But hundreds of Americans still die each year while waiting for a lung transplant. And the need could rise even higher, says Cynthia Herrington, M.D., transplant surgeon at the University of Minnesota Medical Center, Fairview, as lung problems emerge among the tens of thousands of people exposed to lung-harming substances in the aftermath of the 2001 World Trade Center disaster. If it does, Valapour's research may prove invaluable in helping to ensure that the supply of donor lungs can keep pace with growing demand.