“One of the main issues with using MELD scores to allocate donor livers is that at any given MELD score, your chance of dying in the Southeast is substantially higher than in New York,” DuBay said.

Geography plays a large role in the debate. Patients with end-stage liver disease in rural South Carolina face much greater challenges than those in the Northeast or California. “If you live in a highly urban area and you get sick, you can access health care quicker and are much less likely to die,” DuBay said. “If you get sick in a rural area, with poor access to care and fewer specialists, you have a much higher risk of dying.”

Another issue with using MELD scores is that certain areas of the country, especially the Northeastern states, use a high proportion of “exception MELD scores” that give the appearance that their patients are sicker than patients in South Carolina (that typically use real MELD scores), he said. Even if every region in the country started playing by the same calculation rules and there were no exception points, a MELD of 32 in Colleton County, for example, is going to be deadlier than a 32 in New York City because of access to care issues, DuBay said.

“Under the new policy, a patient will have to have a really high MELD to get a liver. You have to survive in South Carolina to get to that MELD. South Carolina already has the highest waitlist mortality rate in the continental U.S. Shunting donor livers away from South Carolina is going to exacerbate the very problem UNOS is attempting to address. More waitlisted patients are going to die. We do not want our patients to die.”

But that’s not the whole story, DuBay said. The Centers for Disease Control and Prevention reports that the highest frequency and largest proportion of people who die with liver failure are in the Southeast. "This proposal would shunt livers away from the regions of the country that have the highest rates of people dying with liver failure to areas of the country with a lower rate of liver disease." 

DuBay said the UNOS proposal doesn't take these regional disparities into account, and the worst effects will be felt by low-income, minority and rural patients.

“Only 5 to 6 percent of people in South Carolina and much of the Southeast who will die of end-stage liver disease make it onto the waiting list. In contrast, up to 35 percent of patients with end-stage liver disease in the Northeast end up on the waitlist.  Patients in the Southeast already have a marked decreased chance of even making it onto a liver transplant waitlist, and now this proposal will make it harder for those few that do make it onto the waitlist to receive a transplant.”

Under the UNOS proposal, a much higher proportion of livers would be shipped around the country, including some that South Carolina would get. “They wouldn’t be local, making it a logistical nightmare and far more costly. A liver needs to be reperfused within 12 hours, ideally within six to eight. The livers will get sent around the country, transported across much longer distances to reach patients. Some will get discarded. Some will not be good. Logistically, there will be many issues,” DuBay said.

“When you prioritize highest MELD, you are transplanting sicker patients, and they have a much higher chance of dying after transplant. While the proposal is predicted to decrease waitlist deaths, it also predicts that there will be fewer patients alive with a successful liver transplant. It is against the stated goals of the redistricting proposal to shift livers from regions of high waitlist mortality to those areas with lower waitlist mortality.”

Areas of the country with the poorest organ donation rates benefit the most from this proposal, he said. “Should South Carolinians bear the brunt of that? Livers donated by South Carolinians who want to see them remain local to help other people in their state would instead be taken away from our state and sent to areas of lesser need and greater privilege, such as New York City.” 

DuBay also is worried that South Carolina will lose organ donors if the proposal is approved. “This truly concerns us. We look at the people in South Carolina who donate. There should be local priority for them. It’s hard to encourage families to donate organs that will be shipped off.”

DuBay suggested that instead of overhauling the distribution system, states with poor donation rates use awareness campaigns to get more people to donate their organs. A better alternative is for UNOS is to focus on improving access for disadvantaged patients, reducing costs associated with transplants and increasing the number of livers donated nationwide, he said.

How Can You Help?

MUSC Health transplant surgeons are asking the public to help.

UNOS will accept public comments on this new proposal through Oct. 2. You can comment directly through this site.

For more information about recommendations from MUSC Health, visit the MUSC Health page that summarizes the main issues. It explains how the proposal will affect South Carolina. For example, the proposed model — based on a series of concentric circles — means that for coastal areas like Charleston, more than half of the proposed 150-mile radius area is the Atlantic Ocean. In addition, these concentric circle models create major areas of overlap across state lines. 

Dubay said other important points that South Carolinians should weigh in on include:

● While the policy is supposed to correct "geographic differences," these disparities are artificial, and the designers have refused to consider the real difficulties faced by rural, low-income, and minority patients.

● The proposal does nothing to increase organ donation and may actually decrease it in areas that are currently underperforming.

● The proposal will increase costs and add greatly to the complexity of the transplant process.