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Organ Transplantation: Modern Triumphs and Tribulations

Innovations in Medical Education: Spinning a Web in Simulation

Current & Choice: Filling the Pipeline

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Organ Transplantation: Modern Triumphs - and Tribulations

Leading the way: Surgeons at Stanford University Medical Center performing the first combined heart / lung transplant, in 1981.

In 1954, Ronald Herrick made history when he became the first person to give the gift of life by donating one of his kidneys to his twin brother, Richard, who had chronic kidney failure. Performed by Joseph E. Murray, M.D., at Brigham and Women's Hospital in Boston, the pioneering operation was the first successful organ transplant ever performed, and Richard Herrick went on to live a normal, active life.

Over the next three decades, other organs besides the kidney became transplantable, saving innumerable lives. In the United States, the first successful kidney/pancreas transplant in 1966 was followed by the first liver transplant in 1967, the first heart transplant in 1968, and the first successful heart-lung transplant in 1981.

Today these transplants are performed so often and the survival rates are so high, they are considered routine. According to the United Network for Organ Sharing (UNOS), in 2002, there were nearly 25,000 organ transplants from approximately 13,000 living and deceased donors. But for each person who receives a transplant, two more are added to the waiting list. More than 80,000 people in the United States are currently awaiting lifesaving organ transplants. Last year, 6,000 of those people died waiting.

"Since the biggest problem in the field of transplantation has been organ shortage, advances have been structured around addressing that problem with innovative surgery or alternative solutions," says Milan Kinkhabwala, MD, associate professor of surgery at Cornell University Weill Medical College and surgical director of the Liver and Pancreas Transplant Program at New York Presbyterian Hospital, a program he helped found in 1998.

Dr. Kinkhabwala says that New York Presbyterian Hospital performs 300 to 400 organ transplants a year, mainly of the liver, pancreas, kidney, heart, and lungs. He was responsible for introducing pancreas transplantation in the hospital in 1996. Today, he says, scientists at the hospital are exploring the possibility of injecting insulin-producing islet cells into patients awaiting a pancreas, making transplants unnecessary.

One way of expanding the donor pool for patients in need of livers is a "split liver" procedure the hospital utilizes, in which the liver of a deceased donor is split and allotted to two recipients. "Another one of our focuses has been living donor transplantation," explains Dr. Kinkhabwala. "The idea that you can take part of a liver from a living adult and give it to someone else is a technique that did not exist ten years ago."

Alternative techniques

Abbas Ardehali, MD, assistant professor of surgery and director of the UCLA Lung Transplant Program, says he believes that short of "a legislative change in the philosophy of organ donation," alternative techniques to traditional transplant surgery must be found to save the lives of those who die waiting for lifesaving organs.

He says that artificial devices that can substitute for the liver, heart, or lungs are one possible solution, although they may be decades away. In his own specialty, Dr. Ardehali has pioneered a technique through which he is implanting in patients lungs that were previously deemed "damaged" and unacceptable for transplant.

Dr. Ardehali explains that the waiting time for lung transplantation in the U.S. is longer than for other organs - from one-and-a-half to two years. The reason is that only 15 to 20 percent of organ donors of the heart, kidney, or liver are also lung donors. This is because trauma to the chest is often a factor in death, and pulmonary functioning is not usually attended to in brain-dead donors. So Dr. Ardehali and his colleagues set out to find a way to utilize these "less-than-perfect" lungs by attempting to heal them after they are transplanted into a recipient.

"After we are finished with the surgical part of the procedure - the implantation of the new lungs into the recipient - we utilize a special solution that is added to the recipient's blood to improve the recovery of the new lung," explains Dr. Ardehali. "The solution consists of amino acids and nutrients that will help the lung repair itself."

Dr. Ardehali and his colleagues have been using this method for the past three years. "It has resulted in an expansion of the donor pool to the point that we are willing to accept lungs that other programs don't feel comfortable with," he says. "In fact, of the 27 lung transplants we did last year, about 22 to 24 of them were lungs that were turned down by other programs and would have gone unused. Our proof that our technique is working is that these patients are alive and their lungs are working well."

The UCLA Alternate Recipient Heart Transplant Program, founded in 1992 by Hillel Laks, MD, works on the same principle. Dr. Laks takes damaged hearts that would not otherwise be used and transplants them into patients who are not listed as organ recipients, usually due to their age.

Dr. Laks became the first U.S. cardiac surgeon to perform bypass surgery on a donor heart prior to transplantation when he did a quadruple bypass on a 53-year-old donor heart and transplanted it into a 68-year-old man in 1992. To date, the UCLA transplant team has performed 84 alternate recipient transplants, with survival rates comparable to those of standard recipients.

"Mechanical devices will slowly evolve to the stage where they're as successful as heart transplants. Then we will have more options for all of those patients who don't have donors." - Patrick McCarthy, MD, program director, Cleveland Clinic Heart Transplant Program

Patrick McCarthy, MD, is the program director of the Cleveland Clinic Heart Transplant Program, which recently transplanted its 1,000th heart. The clinic's one-year survival rate is 94 percent. Dr. McCarthy says that advancements in the field of heart transplantation have allowed the clinic to perform transplants on older patients who were previously excluded by an upper age limit.

The clinic has performed nearly 200 heart transplants in patients aged 65 and older, the oldest being 74, Dr. McCarthy says. The majority of research done at the clinic is directed toward finding alternatives to transplantation. Patients whose only hope in the past was a heart transplant are now routinely treated with medicine, bypass, or ventricular operations.

"Mechanical devices will slowly evolve to the stage where they're as successful as heart transplants," says Dr. McCarthy. "Then we will have more options for all of those patients who don't have donors."

Lessons from Jesica

Perhaps due to the tremendous accomplishment in medicine that it represents, transplantation often invites more public scrutiny that many other surgical specialties. "Transplantation at all levels, both in terms of the donor process, recipient outcomes, and individual center statistics, all of these are highly regulated and require reporting to all kinds of federal- and state-level agencies," says Cornell's Dr. Kinkhabwala. "And just like anything else in hospitals, there are many different steps along the path in which a drug, or in this case, an organ, is handled by many different people."

Something went awry in that path earlier this year in a highly publicized case at Duke University Hospital, where 250 to 300 organ transplants are performed a year, when, for the first time, a set of organs was inadvertently given to a recipient with a non-compatible blood type. Despite Herculean efforts to save the recipient, 17-year-old Jesica Santillan, by replacing the incompatible heart and lungs she received with blood-compatible organs, she died on Feb. 22, 2003.

From the time Jesica received her first set of heart and lungs on Feb. 7 until her tragic death two weeks later, William J. Fulkerson, MD, chief executive officer of Duke University Hospital, says his institution was overwhelmed by a "media tsunami." Over that time, in newspapers and on round-the-clock cable television coverage, the entire world came to know the Mexican teenager's name and watched her medical story play out day by day.

Dr. Fulkerson says that an ensuing internal investigation into how such an error could have been made brought to the surface several ways in which Duke - or any medical institution - can prevent such a mishap from occurring again. He says that one of the lessons the hospital has learned is that it, like medicine in general, tends to focus more on measuring and tracking outcomes to evaluate quality and performance and less on the processes that lead to those outcomes.

Consistent processes

"Sometimes when you just look at outcomes, you might not be able to uncover a process that is not as it should be and may produce an error somewhere down the road," explains Dr. Fulkerson. "We must be consistent in our processes, break down our processes to see where weaknesses might exist, put redundancies in place, and institute a systems approach so that individual human error won't lead to a terrible outcome.

"That's what we've done in our transplantation program. We've built in a much more robust check-and-double-check process not only for blood type compatibility but also for other things in the transplant process, including how we enter information about potential recipients who are at Duke into the database that UNOS maintains. So we've put additional safeguards and double-checks into place to ensure that information that we put into the system about our own patients is accurate," Dr. Fulkerson says.

"The idea that mistakes aren't going to happen is fanciful," he adds. "Human beings are fallible. It's a matter of having systems in place that prevent those mistakes from having terrible consequences. The legacy of this tragic event is going to be a much better and much safer transplantation system in the United States. That's what I want Jesica's legacy to be."

It appears that Dr. Fulkerson is getting his wish. Dr. Kinkhabwala says that New York-Presbyterian Hospital has instituted a double-check system by which the blood type of the donor is verified against that of the recipient at the time of transplant.

Likewise, Dr. Ardehali says that Jesica's case has caused UCLA to institute more stringent protocols for the confirmation of the blood types of donors and recipients.

"I think that this is a wake-up call for all of us in the transplant community to devise a strategy that is not 99.99 percent error-proof, but indeed is 100 percent error-proof," Dr. Ardehali says. "I believe this incident has changed protocols at many transplant centers, and I believe the tragedy will substantially decrease the incidence of these types of errors in the future in this country as well as others."

By Barbara A. Gabriel

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