Transcription:

Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals. Providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole: Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Robert Cannon. He's an Assistant Professor and the Surgical Director of Liver Transplantation Program at UAB Medicine. And we're discussing the access to transplantation and geographic disparities today.

Dr. Cannon, thank you so much for joining us again. Can you discuss a little bit about the mismatch between disease burden and transplant rates in the US today?

Dr. Robert Cannon: Yeah. Well, thank you for having me. I'm happy to be back on here. So yeah, what we've been seeing essentially is both in liver and kidney transplant, this is where we do our research, that the parts of the country that have the highest disease burden in many cases are actually also the parts of the country where unfortunately we have the lowest rates of transplant, and this creates a significant mismatch. You know, there's always an organ shortage. So no matter where you are, there's never enough organs for the number of recipients or people with end-stage organ failure who need a transplant. But we found that this gap is the widest and most glaring in the areas that have the highest disease burden. So you could argue that where we have the most need, we're actually seeing the lowest rates of transplant.

Melanie Cole: Yeah, that is frustrating, and must be for you, doctor. So while much has been made of combating geographic disparities in organ transplant in general, has the focus been on the population of patients who've already made it to the waiting list or the ones that are still trying to go through the system?

Dr. Robert Cannon: So I think that's been the issue is that, you know, I think the lens through what we've been looking at geographic disparity and transplantation has been wrong, or at least we have not been looking at it as completely as we should. Because, yes, what we focused on as a community in the past has been access for those who are on the waitlist already. And when you look at transplant rates in terms of, you know, transplants per number of patients on the waitlist, that looks very different than when you look at transplants in terms of how many transplants are performed in comparison to the overall population who could potentially benefit from a transplant.

So it's really helpful to think of sort of two phases of the transplant process. First, when you have, let's say, you go on dialysis or you develop end-stage kidney disease. First, you actually have to get on the waitlist and then from there, so that's sort of phase I. And then phase II is once your wait-listed, you have to be transplanted. So the vast majority of the efforts of our transplant community had been on phase II, getting people who are on the waitlist transplanted. But that misses out on a very large and wide population of patients who never have access to the transplant list. And that's what the recent work we've been doing in both liver and kidney transplantation focuses on. And that's why if you look at transplant rates as a measure of overall disease burden, you see a much different picture of disparity than what you see if you only look at the waitlist.

Melanie Cole: That's a great point that you just made. And stepping back for a second about that disease burden and transplant rates and where you mentioned that some places in the country where they need it the most is where it is the least available and thinking about long-term solutions, how do you think the healthcare industry can be reformed to better serve these patients? If you have any research or, you know, just expand a little bit more on the fact that the disease burden in these areas, whether it's because of lifestyle behaviors, obesity, environment, I mean, it's an obvious complex situation, how can the healthcare industry help to better reform this situation?

Dr. Robert Cannon: Well, broader access to care is really the ultimate thing we need to do. And that's where we see many people suffering. If you don't have access to a good nephrologist or someone who can refer you to transplant, then even if you'd potentially be a good candidate and benefit from one, you'd never get one, for example.

And those problems were most pronounced in our poor and generally underserved communities. So I think, one recognition of the problem that we do have these large underserved areas is a start, but then we need to increase, for example, our outreach efforts. So on our transplant center, we've opened a number of outreach clinics where we actually essentially bring the transplant center to the community.

Many patients just have a hard time getting to us, for all the evaluation appointments on a societal level, if we need to just work to actually provide access to care for all. From a research standpoint and from actual transplant policy, again, I think we need to stop focusing solely on the waitlist. Because if you do that and don't pay attention to the larger population, you can make some changes that can actually be harmful.

For a concrete example in liver transplant, if you look at transplant access on a proportion of the waitlist, there's some parts of the country that looked like they were doing very poorly and have a great need for transplant because the transplant rate as a function of the waitlist size doesn't look very good. But then when you step back, you realize this is actually a part of the country that has very good access to care and a relatively large proportion of patients suffering from liver failure actually are on the waitlist. And if you look overall, the overall disease burden is not that high compared to other parts of the country and really the number of transplants relative to the overall liver disease burden looks good in that part of the country. But we ignore that and we've essentially designed policies to shuttle more donor livers to that area because it looks bad in terms of access just focusing on the waitlist, but really they're doing quite well. And so we're shifting livers away from areas that are more underserved on a population level. So, again, that's why we need to change this in our focus. So when we do adjust transplant policies, that we're keeping the population health in mind.

Melanie Cole: This is such an interesting issue and you are certainly one of the experts to help solve it, Dr. Cannon. Tell us about your manuscript in press regarding your work in liver transplantation. Share briefly some of the highlights from your presentation, won't you?

Dr. Robert Cannon: Sure. So, I mean, we've got two manuscripts in progress right now. One is in liver transplant and the main highlight from that one is what I just said, is that essentially using the metrics based on the waitlist, we're worsening the disparity. So we've created a liver allocation system that essentially shuttles livers to areas that actually are doing quite well in terms of transplants versus the overall population of liver disease, because we are only focused on the waitlist. And that's our main highlight of what we found on the side of liver transplantation.

A more recent work apply the same methods to kidney transplant, and that's also what we're finding, is that some of the areas with the actual highest burden of kidney disease in the country, some of which are actually right here in Alabama, in the Southern part of our state, are areas with the lowest rates of transplant. So we're really just wanting to call attention, just raise this issue, that again our scope and our borders need to extend beyond our waitlist and our responsibility actually extends to all patients suffering from organ failure, not just those who are already on our list.

Melanie Cole: Taking into account the disparities and, as you say, the geographic disparities in transplantation, what else do you see as the greatest challenges facing the field of liver and kidney transplantion, the constraints to meeting that annual demand for liver transplantation? And is there anything that you can tell us that's really exciting about things that you're doing at UAB Medicine that can help meet that annual demand?

Dr. Robert Cannon: You know, The greatest challenge in transplantation will always be the organ shortage and the fact that we've just never had enough organs available for all those who would benefit from it. That's why here at UAB, we're expanding use of living donation. We've always been very aggressive about that on the kidney side. And we're starting a living donor liver transplant program as well for that same reason to expand access. There's the work on xenotransplantation, so making genetically modified pig organs potentially available for transplant, that work's being done at number of centers, including right here at UAB.

Melanie Cole: That's so cool. I did a podcast on it, and that is very exciting work that you're doing. Final thoughts, Dr. Cannon, what you would like other physicians to know about timing of referral and referral, obviously to the experts and specialists at UAB Medicine, but really access to transplantation and the geographic disparities, what you would like them to know about things that you are doing to tackle this and things that community physicians can also do.

Dr. Robert Cannon: Certainly. Yeah. I mean, I think the best thing is to refer early, right? We can't help the patient if we don't know about them and if they're not in the system, so don't need to worry about whether the patient's a candidate or not. You know, that's our burden there. So, you know, I don't think the referring physicians need to worry about that. You know, if they just want to refer the patient, we're happy to get the patient in and we want to be able to meet the patient where they are in many cases. So if the patient's got barriers for being able to get to us, for being able to undergo the evaluation, please let us know. We're happy to help with that. Because really, again, we want this to be centered on the patient and how to meet their needs.

Melanie Cole: You're such an excellent guest, Dr. Cannon. You have so much knowledge to impart. Thank you so much for joining us today. And I hope that you'll come on again and update us as you learn more and your manuscript increases. So please come on and join us again absolutely anytime. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or that you can always visit our website at uabmedicine.org/physician.

That concludes this episode of UAB MedCast. For updates on the latest medical advancements, breakthroughs and research, be sure to follow us on your social channels. I'm Melanie Cole.