[MadRiverTurtle]

ScienceDaily & University of Alberta:

The pain is debilitating. The only option: smoking medical marijuana. That's the reality for many hepatitis C patients whose road to health includes a liver transplant. Although Canadian transplant centres are more willing than those in the United States, not everyone says yes to liver patients who smoke marijuana, and a University of Alberta researcher says that decision-making process is unacceptable.

Karen Kroeker, along with three other students at various universities, sent out surveys to a number of transplant clinics across the United States and Canada. Results found that the difference between the two countries were obvious in some patient groups: around 60 per cent of Canadian centres would either do the surgery or consider it for a liver transplant patient who smoked marijuana, while 70 per cent of U.S. transplant programs said absolutely not. Kroeker also found that patients in both countries, who have no social support—meaning they have no family, friends or a social worker—aren't likely to receive the organ they need.

The problem Kroeker has with these results: the lack of literature to support the surgeons' decision. As a result of her findings, which will be published in the November issue of Liver International, Kroeker says physicians need to determine eligibility criteria for liver-transplant patients that pertains directly to the likelihood of a patient rejecting the organ and is based only on empirical medical evidence.

When a patient is being reviewed for eligibility, whether they smoke marijuana shouldn't be a factor, she says. "If we have evidence to say the patients don't do well, then I think that's a reason to exclude people," Kroeker said.

She cites alcohol use as an example. When transplants first began to be performed, those who drank alcohol weren't eligible for a new liver. Kroeker's study found, however, that surgeons conducted studies on the topic of abstinence and liver health and, as a result of that research, transplant rules changed. If the patient has been sober for six months, 94 per cent of the clinics in North America will now consider transplantation.

The same goes for HIV-positive patients. "When they first started transplanting, HIV was an absolute contraindication. No one even considered transplantation because the disease was a death sentence at that time." Kroeker adds that's no longer the case and that there is research being conducted on post-transplant HIV-patients that will help determine the viability of transplants in HIV-positive patients.

In reference to her findings, Kroeker said, "I think there should be a large-scale study," because too-little research is available on post-transplant patients whose eligibility may currently be in question.

"Unless you actually perform transplants for those people, how would you know how they do?"

link

The article in Liver International available for purchase here:

Adult liver transplant survey: policies towards eligibility criteria in Canada and the United States 2007

Authors: Kroeker, Karen I.1; Bain, Vincent G.1; Shaw-Stiffel, Thomas2; Fong, Tse-Ling3; Yoshida, Eric M.4
Source: Liver International, Volume 28, Number 9, October 2008 , pp. 1250-1255(6)
Publisher: Blackwell Publishing



Abstract:
Goals:

To assess the current practice patterns of liver transplant centres in Canada and the USA regarding transplant eligibility. Background:

Liver transplantation is an evolving field and today remains the only life-sustaining treatment for end-stage liver disease. Issues of allocation and transplant eligibility are important factors in the ethical practice of medicine. Study:

Questionnaires were mailed to liver transplant programme directors in Canada and the USA inquiring about current practices regarding recipient eligibility. Results:

This study demonstrates that there is consensus in the use of other eligibility criteria, including non-compliance, social status, abstinence from alcohol and methadone and cocaine use. Interestingly, literature is lacking to support the use of these parameters as eligibility criteria with the exception of alcohol. There is a lack in consensus regarding marijuana use, human immunodeficiency virus status, ability to accept blood transfusions and prisoner status. The literature suggests that liver transplantation in select patients who refuse blood transfusions results in good outcomes. Conclusions:

Important decisions regarding transplant eligibility still have to be made empirically in the absence of scientific literature about various social issues. While consensus among transplant programmes is useful, it is important that we continue to use the evidence in the literature to revise these eligibility criteria, keeping in mind ethical principles applied to the access and allocation of a scarce resource.

Keywords: eligibility; liver transplantation; substance use

Document Type: Research article

DOI: 10.1111/j.1478-3231.2008.01807.x

Affiliations: 1: Department of Medicine, University of Alberta, Edmonton, AB, Cananda 2: Thomas Starzl Institute, University of Pittsburgh, Pittsburgh, PA, USA 3: Department of Medicine, University of Southern California, Los Angeles, CA, USA 4: Division of Gastroenterology, University of British Columbia and British Columbia Transplant Society, Vancouver, BC, Canada