Balancing Accountable Care With Risk Aversion: Transplantation as a Model—We Cannot Forget the Outcomes


To the Editor:

The allocation of health care resources has been a challenge faced by several countries in all over the world. Transplantation represents a very complex scenario, in which we have to deal not only with a limited budget, but also with a shortage of organs. Moreover, transplantation of high risk patients and the use of high risk organs are associated with a higher cost and mortality. On the other hand, a healthcare system centered exclusively in postoperative outcomes could stimulate an avoiding risk behavior. As proposed by Dr. Axelrod, if we shift accountability to a population with end-stage organ failure, it will be possible to expand the total number of transplants, once more risk could be accepted [1].

However, the huge gap between organ supply and demand has limited the indications for transplantation to those patients who have the greatest likelihood of survival. Liver transplantation in HCC, for instance, should be restricted to those patients who are expected to have the same posttransplant survival as that of patients with nonneoplastic end-stage chronic liver disease [2]. The difficult task of selecting patients for treatment according to the best chance of survival is not a privilege restricted to the transplantation scenario. According to the ALTS guideline, during a catastrophe, when number of patients and severity of injury do exceed capacity of the treatment center, patients are selected for treatment according to best chance of survival with least expenditure of resources (time, personnel, equipment, supplies) [3].

Despite the efforts of the transplant community to decrease waiting list mortality, we are still far from reaching a solution. As a matter of fact, we are always making decisions to optimize resources according with each institutional experience and specific logistic conditions. Every time we accept donors with extended criteria or perform transplantation in sicker patients, it will be reflected in the outcome and cost [4]. Whereas, if we run away from risks, the total number of transplants will be inevitable reduced. Therefore, organ transplantation is based in a tripod composed by operative outcome, donor and patient risk and cost. In the actual scenario, all these three issues cannot be totally satisfied, and no formula has been capable to equilibrate this tripod. Every time we push too much to one direction, the other two parts are jeopardized. Thus, the act of matching a donor to a specific recipient is not only a matter of avoiding risk, but it is also a socioethical choice of weighting utility versus equity, that should be individualized based on each specific local reality.

The debate around this complex issue is crucial to improve patient care and refine health care systems. It seams that our blanket is too short, and acceptance practices should be taken into consideration in assessing center performance, as a means of encouraging centers to accept more livers for their candidates. However, the transplant community should not forget that the development and respectability of the modern surgery has been based on the improvement of the postoperative results. As a matter of a fact, the only option, in our opinion, to overcome this problem without compromising postoperative outcome, is to work on alternatives to improve organ quality, such as it has been done successfully in the field of lung transplantation [5].

  • C. R. P. Kruel* and A. Chedid

  • Service of Digestive Surgery, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.

  • *Corresponding author: Cleber Rosito Pinto Kruel,


The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.