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on the patient’s level of bilirubin, which indicates liver function; creatinine, which indicates kidney function; and a clotting test, which reflects the liver’s ability to produce the proteins that make blood coagulate. A patient’s MELD score is highly predictive of his or her chance of dying from advanced liver disease in the next twelve weeks. For that reason, liver transplantation centers use this score to determine which patients will get priority on waiting lists for donor organs. A patient’s rank on a waiting list could have profound implications for survival. There are about seventeen thousand candidates slated for liver transplantation in the United States, but only five thousand transplants are performed each year. Many people die while waiting for a liver.

“When I saw the surgeon who directed the transplantation program—he was clearly very experienced—he told me, ‘You know, at this point there is no way except transplantation.’ That’s when I started thinking really seriously about what I’m going to do. Where am I going to do the transplant? Which surgeon?” The more Omar read about liver transplantation, the more he saw how complex the procedure was, in part because it demanded very specific techniques with regard to harvesting the donated organ, transporting it to the recipient’s medical center, and then transplanting successfully. Beyond the operation were choices the doctors would make that required highly specialized knowledge about which treatments to prevent the recipient’s immune system from rejecting the foreign liver and how to combat infections not only from typical microbes like bacteria, but from so-called opportunistic pathogens like fungi and viruses that take root in tissues because of the patient’s reduced immune defense.

Omar realized that regardless of how much research he did about liver transplantation, he and Ayesha would have to rely on his doctors to make critical decisions about his treatment. These decisions would involve not only technical aspects of the transplant, but how much to do should life-threatening complications occur.

Most centers begin listing patients for liver transplant when their MELD score reaches 10 or higher. But the MELD score at which a patient will actually receive a liver varies by region and medical center. A study done in 2007 by liver transplant researchers at the University of Pittsburgh, one of the major hospitals in the country performing this procedure, found that those centers with a high volume of transplants, one hundred or more per year, tend to transplant patients with lower MELD scores and have shorter waiting times than transplant centers that perform the procedure on smaller numbers of patients. The reasons for these differences weren’t clear. The researchers speculated that high-volume centers might be willing to use organs that had been turned down by other transplant teams, shortening the waiting time. They also theorized that smaller centers that do fewer transplants might have personnel shortages for performing the procedure urgently, which might lengthen the waiting time for patients.

Omar learned that, indeed, different medical centers had different waiting times for patients in need of a liver transplant. He told us that he was also looking for data on the success rates of different surgical teams. “You know, I’m a scientist, I have a background in numbers. I realized that you can’t just look at the reported outcomes alone. If there is a center that takes a lot of high-risk patients who have very high MELD scores and transplants them, then you expect that their figures might be worse than the success rate at a very conservative center which doesn’t take high-risk patients, only good candidates with lower MELD scores.”

Omar was still working full-time in his lab, trying to finish several experiments to be included in his grant proposal, which was due in just a few weeks. Shortly after noon, he closed his computer and went to grab a sandwich in the cafeteria. Waiting in line, he saw the surgeon who had evaluated him for transplantation.