Five years ago, 37 people had a death sentence commuted to a chance for life.

Surgeons at Erlanger hospital's Kidney Transplant Center performed 37 transplants in 2004, giving new organs to patients who almost certainly would have died without them.

Last year, the center did only nine transplants, the fewest among the eight adult transplant centers in Tennessee, according to statistics from the Organ Procurement and Transplantation Network, under the U.S. Department of Health and Human Services.

Erlanger's 75 percent drop in kidney transplants since 2005 highlights complex ethical and professional challenges small transplant centers face in working with some of the sickest patients in medicine, while dealing with increasing government scrutiny of their success rates.

Dr. Daniel Fisher, the surgeon who helped create Erlanger's transplant program in 1989, said the center finds itself in a self-perpetuating cycle that is proving hard to reverse.

The center's small size hinders its ability to compete with bigger centers that benefit from patient referrals from hospitals and insurance companies that perceive larger centers to be higher quality.

"If we're only doing 15 kidneys a year and Vanderbilt's doing 150 kidneys a year ... in theory some insurance company could say, 'We'd rather have all these transplants done at Vanderbilt because the patients are going to get a better job,'" Dr. Fisher said after the transplant center's 20th anniversary celebration this month. But volume does not necessarily correlate with quality, and small centers also provide crucial access for patients who can't afford to travel to a large regional center, he said.

UNOS spokesman Joel Newman said the agency's quality campaign is focused on improving quality, not punishing or shutting down programs.

Though UNOS does not have authority to close down a program, it could put hospitals on probation, label a program as a member "not in good standing" or recommend to the U.S. Department of Health and Human Services that it close a program, Mr. Newman said.

Erlanger's program has never received any of those rebukes, he said.

ETHICAL DILEMMA

On top of pressure to meet the expectations of government regulators, doctors also face the ethical dilemma of how best to allocate a scarce resource: viable donor kidneys.

While it can seem cruel and callous, specialists must decide which patients have the best chance for success after the transplant.

"If a kidney is put in the wrong patient and the kidney dies ... then we've wasted that kidney for another patient that might have done great," Dr. Fisher said. "You're kind of damned if you do sometimes and you're damned if you don't."

Nationally, more than 80,000 people are waiting for a kidney transplant but only about 15,000 transplants are performed annually.

Specialists are compelled to prioritize patients who are most likely to have a successful outcome, Dr. Fisher said.

Only about half of the estimated 800 dialysis patients in Chattanooga are healthy enough for the kidney transplant waiting list, and many of the region's healthier patients end up referred to larger centers like Vanderbilt's.

Vanderbilt has 661 people on its kidney transplant waiting list, while Erlanger has about 70, hospital officials said.

"We all basically compete for the organ donor pool," said Ed Vavala, administrator of Vanderbilt's multiorgan transplant program. "The larger the list of patients a transplant program has the greater opportunity one of those patients is going to match up with a deceased donor in the state of Tennessee."

Focus on Numbers

Nationally, federal agencies overseeing the nation's organ transplant programs also are emphasizing the importance of kidney centers' performing a minimum number of transplants each year.

Under new rules from the Centers for Medicare and Medicaid, a center must perform at least 10 transplants a year. Anything less could be a red flag, Dr. Franklin.

CMS will visit Erlanger before the end of the year to look at the number of transplants performed in the last 12 months. Erlanger has done 13 transplants since October 2008, so it will have complied with the guideline, said Jackie Ross-Smith, transplant manager.

If federal agencies eventually make a move to consolidate smaller programs into larger centers, "those (centers) that are doing fewer will be culled out," Dr. Franklin said.

Though no formal efforts have been made to cut off federal funding for smaller centers, local specialists say they are working to ensure Erlanger won't be targeted for cuts.

"We know we're a small program, but we know we're a great program," said Lynn Whisman, chief nursing executive at Erlanger. "Erlanger has no intention of looking at closing the program down or worrying too much about our low numbers, as long as our quality outcomes are good."

If the center were to close, Hixson resident and transplant recipient Robin Miller said it would place an enormous burden on patients who would be forced to travel to regional centers hours away, possibly without the support of their family. At age 21 she was the first person to receive a transplant at Erlanger in 1989.

"We need it here," said Ms. Miller, who is now 41 and is again on dialysis. "You've got Erlanger right here. ... Why should we have to go all the way to Nashville? Your family can't come down; you're there all alone."

The hospital and its trustees remain steadfast in their support of the transplant program, said Dr. Charles Longer, chairman of the hospital's board of trustees.

"I do think it's an important program that we should keep," he said. "The quality of the people we have involved in transplant here is competitive with anyone. I think it's a very valuable and necessary activity to support the community."