A story about Betty

According to an article from ABC News, Betty, who had lost her father to liver disease in 1987, had been diagnosed with fatty liver in the early 2000s. This would progress to cirrhosis and eventually to liver cancer. By 2018, she had been on the list for a liver transplant for several months. There were no other options.¹

Currently, approximately 12,000 people are waiting for life-saving liver transplants.² Almost nine thousand fortunate individuals (8,896 in 2019) receive liver transplants each year, while 20 die each day waiting.^3,4 Overall, there are over 112,000 people waiting for organs of all types.⁵

In a new and very promising turn of events, livers infected with hepatitis C (HCV) are now acceptable for transplantation. What was once considered taboo and unthinkable is now becoming more common thanks to interferon-free, direct acting antiviral (DAA) therapy. DAA treatment, a safe and highly effective treatment which can cure HCV in over 90% of cases, has also decreased the number of people who need a transplant due to HCV-associated disease.^6,7

According to the United Network for Organ Sharing (UNOS), 890 hepatitis C positive donor livers were recovered in 2019.⁸ UNOS is the non-profit, scientific and educational organization created by the United States Department of Health and Human Services (DHHS) that administers the national Organ Procurement and Transplantation Network (OPTN).⁹ The OPTN helps people like Betty get listed for and receive a transplant. 

Dr. James Burton Jr., a hepatologist at UC Health and a Professor of Medicine at the University of Colorado School of Medicine, explained this new option to Betty. Instead of hoping for a perfectly clean liver, he would knowingly transplant an infected liver into her. To save a dying woman, he would likely infect her with hepatitis C. For Betty, this was a not a hard decision. It came down to life or death.¹

This option was OK even though her husband had suffered from hepatitis C in the 1980s, and the disease and treatment had emaciated him. This history caused some trepidation among her loved ones. Because waiting for a clean liver and possibly dying before one became available was the only other option, Betty underwent successful liver transplant surgery in March of 2019. As expected, she contacted the hepatitis C virus. Oral treatment was started just one week after the surgery, and just 12 weeks later, Betty was officially considered cured.¹

In what must be considered a wonderful piece of irony, what had once caused so much suffering to her husband now actually helped save Betty’s life.¹

DAAs made using infected livers for transplantation not only manageable regarding risk of infection but also ethically acceptable in the medical community. In 2018, researchers completed an aptly named study Donate HCV Trial, which confirmed treatment with DAAs prevented the establishment of HCV.¹⁰  Results of the Donate HCV Trial can be found in the New England Journal of Medicine.

HCV infected livers are not the only organs being used to reduce transplant waiting list numbers. Studies involving the use of HCV positive hearts and lungs have also been completed and shown favorable results. One key study was led by Dr. Emily Bethea of Harvard Medical School; study results showed expedited organ transplantation and rapid HCV suppression.^11,12

Using livers and other organs infected with hepatitis C is not the only way numbers on transplant waiting list are decreasing. According to UNOS, successful use of organs from opiate overdose donors has resulted in reducing numbers of people waiting for organ transplants.^13,14 The number of opioid overdose deaths has doubled since 2008, and 2018 marked the first time in 25 years that the transplant waiting list began to decline.^5,14 In 2014 the list peaked at over 124,000; as of January 20, 2020, there are 112,623 people needing a lifesaving organ.⁵

Organs deemed useful for transplantation are rare. They are found in fewer than 1% of deaths in the United States. These deaths are usually caused by catastrophic brain injuries where the victim is declared brain dead but can be kept alive by being placed on a ventilator. These deaths are often result of strokes, cardiovascular events or blunt trauma from accidents.¹³

Drug overdoses can also cause brain death, and two-thirds of total drug overdoses in 2017 were due to opioids.^13,15 Opioid overdose slows respiration to the point that the brain is starved of oxygen. Overdose victims that make it to the hospital are put on ventilators before being pronounced dead. More recently, victims are often younger (ages 25-54), have shorter histories of drug use and are even first-time users.¹³

While the increased availability of life saving organs can be considered the ‘silver lining’ in this tragedy of events, there is hope this trend will not continue. Increasing availability of Narcan and outpatient addiction treatment programs aim to abate the opioid crisis.¹⁵ In the meantime, transplant recipients and their families extend their appreciation to the victims and families for their unselfishness at such a difficult time.

Key Takeaways for the Life Insurance Industry and Life Underwriting

• The number of individuals awaiting organ transplants is decreasing due to increased access to more organs deemed acceptable for transplantation. This could have a significant effect on lowering associated waitlist mortality.
• DAA treatment has reduced the incidence of end-stage liver disease requiring liver transplantation, which could a positive effect on the life insurance industry through reduction in claims associated with HCV-induced liver failure.
• While the effect on mortality has been noted, it remains to be seen if life insurers could increase insurability on transplanted individuals in the future.
• Several recent medical studies involving HCV-infected organs have shown positive results affirming these organs are acceptable for transplantation.
• Advances in the treatment of HCV have not only improved cure rates but have lowered treatment duration.
• The opioid crisis in America continues to be a significant concern to the nation and the insurance industry. A positive consequence to this unfortunate epidemic is increased donor organs. 
  

This article was originally featured in the September 2020 Issue of OTR and is re-printed with permission of ON THE RISK, Journal of the Academy of Life Underwriting (www.ontherisk.com).