The state of Pennsylvania voted a law for tax credit for employers who allow workers become organ donor. This is very interesting that states are getting involved at that level to promote organ donation. The only problem is only 3 companies used the credit last year. Not sure if it is by ignoranceor there was just very few living donor. Let’s hope it is well publicized and more people will enjoy that benefits.
This is a very touchy subject here in America. It seems that nobody wants to address the issue. The physicians are still hesitant to consult palliative care. It could be because it represents failure of modern medicine for some. Privately, a lot of people are in favor of euthanasia, or assisted suicide, for chronically ill people. How often have you heard, If one day I am in this or that condition please pull the plug. In some countries, especially in Europe, euthanasia is legal, not without creating controversy thought. One specific country has found a way to make it more compassionate. In Belgium where euthanasia is legal, they use organs from the chronically ill that are deemed good quality for transplantation. Of course, they don’t do that with cancer patients. In a span of three years, from January 2007 to December 2009 they were able to recover 4 lungs suitable for lung transplant according to Dirk van Raemdonck and colleagues. During that span they also recovered kidneys and livers who were good enough for organ transplants.
Obviously, everything happens in a control environment and it works the same way as donation after cardiac death. The patient wishing for euthanasia, who has a non-malignant disorder, is given the drugs by a physician. Once the heart stops beating, the patient is pronounced on cardiopulmonary criteria by three independent physicians. Then the patient is brought to the OR where they start the surgery to recover the organs.
Even if euthanasia would become legal here in this country, I don’t expect many potential organ donor since those patients, for the most part, have been sick for years and their organs may not be good. But, it is something to keep in mind for the future and will certainly require a comprehensive ethical debate. Not sure we are ready for that here.
Some transplantation leaders in the US are starting to push for a compensation system to increase the number of kidney living donation. This is a very ethical debate where both sides of the argument have good points. With a waiting list approaching 90,000 patients hoping to receive a kidney transplant some argue that it is time to implement a compensation system to increase the number of living donation.
For the past 10 years the number of persons waiting for a kidney transplant almost doubled and the actual number of transplantation remained about the same. It has for consequence to dramatically increase the wait time for kidney transplant. Some regions of the US have wait time closing in on 10 years for kidney transplant. Living kidney donation is already legal but is on a voluntary basis and federal laws prohibit any kind of compensation. With treatment of dialysis running in the $70,000 per year per patient some claim money will be saved by transplanting patient faster with the help of a compensation system. Opponents to this system are afraid that people would become kidney donor with the intention of making a quick buck and not thinking about the risks and benefits of the operation. It also could be an easy way out of debt for some but with unknown long term consequences on finances. Experts against the compensation system also see that as an opportunity for rich to exploit poor and potentially making the system unfair where wealthy patient would bypass patients with less means. In response to this argument the pro-compensation people say that compensation should not be under the form of money but more like free education or other perks like that.
I expect this debate to pick up steam within the next few months as more people are dying everyday while waiting but it will take years before something changes. There are too many variables and questions that need to be answered. What would be the legal age to receive compensation for an organ? Who pays for the compensation? The recipient? The government? The Transplant Center itself? Who will cover the cost of complications for the kidney donors? What should be the total compensation package in $$? Should it be money or other form? Should deceased donor family be also compensated? Would it open the door to a black market for organs in the US? There are countless of questions that need to be addressed and answered in order to have a fair compensation system in this country. I think it could be possible to have a compensation system fair and equitable as long as the right people are including in the debate. But, it is going to be a long debate and until then the waiting list will keep growing.
An interesting study came out at the American Transplant Congress conference held last month in Philadelphia, Pa. Patients who were chronic opioid (pain medicine) user had a lower graft survival and higher mortality rate after kidney transplant. The study was performed at the University of Michigan with the 1064 patients who received kidney transplant between 2004 and 2008. Of that number, about 10% self-reported as being chronic opioid user (COU) before transplant. Pretransplant chronic opioid use is associated with worse patient survival at 1, 3, and 5 years claims Dr Barrentes who is a clinical transplant fellow at Michigan. The study was done at their own hospital with their own patients and they reported more graft failure and more death with patients who had a history of pain medicine abuse before transplant. The most used pain medicines were hydrocodone, propoxyphene, oxycodone and tramadol.
At 3 and 5 years after transplant, the death rate chronic opioid user was about twice as much as the one from the non-chronic opioid user. Respectively it was 18% vs 7.5% at 3 years and 21% vs 12% at 5 years. This is a pretty significant difference. The study did not identify the reasons behind the increase number in deaths but was pointing at the fact that patients with chronic pain may have morbidities like diabetes or any vascular conditions causing pain that affects graft and patient survival. Dr Barrentes was suggesting that a better screening could be done before transplant in order to be able to provide more support from social workers or psychologists after the kidney transplant.
The system could be the one to blame for these patients addicted to pain medicines. Sometimes it is just easier for a physician to sign the prescription for narcotics than trying to understand why a patient is hurting. This will not change overnight thought.
With the advance of medicine and better understanding of everything related to transplantation, more patients live longer than ever after transplantation these days. Drugs are better, patient management is more efficient and over the years more and more people have received an organ transplant. The main problem with patients living longer is they may eventually need a kidney transplant. Their native kidneys have been relentlessly exposed to drugs that are hard on them. The transplant drugs, especially prograf and cyclosporine are nephrotoxics and can cause chronic kidney disease in the long run.
For some post transplant patients, a kidney transplant is the only alternative to dialysis. Some may ask themselves if it is worth it and if their prognosis will be good. There are some data available but they are kind of limited because the overall number of kidney transplant after any other transplant is not that elevated. Here is what I found as far as number of transplant on a yearly basis from 1998 to 2007. These include living and deceased donors with an average of 16,000 kidney transplants every year:
Those 350 patients include all previous heart, liver, lung, pancreas, intestine transplants who end up having a kidney transplant on a yearly basis. This is a very small pool of transplant recipients to have accurate statistics on. The good is that the survival rate one year after kidney transplant is pretty similar to the first timer. The survival rate is at about 95-96%. Of course there are plenty of variables like age, diagnosis, race, type of kidney (living or deceased donor).
We only see a small dip in the graft (organ) survival and it is only about the graft like it says. What that means is the new kidney may have failed or stopped working after transplant but it does not say if patient is alive or dead. That is most likely due to rejection. When an organ like a kidney fails, more than likely the patient is still alive. A heart, lung or liver that fails is a lot worst because those organs are a lot more important than a kidney and a kidney can be replaced by dialysis. There is no temporary replacement for the other organs. It is retransplant or death unfortunately.So let’s come back to graft survival for kidney transplant. The graft survival is about 2-3 percent lower when the kidney transplant follows any other organ transplant no matter how many years later. We are talking about 94% instead of 96% after one year, so this is a very small difference.
Based on those statistics kidney transplant seems to be a good alternative after any other organ transplant. The challenge is to find a donor since the average wait time is 2-4 years. This is a long time on dialysis! That does not include the 3-4 months the evaluation period takes. The alternative is to have a family member or friend willing to be a Someone can live with one kidney without any problem.
Patients that have received a lung transplant know too well what a bronchoscopy is. For the ones on the waiting list who never had one; don’t worry you will get to know. A bronchoscopy is usually done by a pulmonologist (lung doctor) and consist a small camera at the end of a long probe narrow enough to fit through the airway. It can be inserted through the nose or mouth and also through the breathing tube is the patient is still on the breathing machine (ventilator). That camera is inserted all the way down in both lungs while the patient lightly sedated. The patient usually receives what some hospitals called conscious sedation. That basically means that you are awake enough to breath and gag but sleepy enough to think what’s happening is only a bad dream.
There are mainly 2 reasons doctors will do bronchoscopies after lung transplant. The first reason is for diagnostic purposes where the physician may or may not suspect something wrong but needs to find out. A bronchoscopy is done at scheduled intervals after the transplant to see if the body is rejecting the new lungs.A rejection is a sign that the body is not accepting the organ and is trying to get rid of it just like it was a bacteria. It needs immediate medical treatment once diagnosed. Biopsies will be taken from several different locations in the lungs to look for possible rejection. A biopsy consists of removing a tiny bit of lung tissue and to send it to the lab under the microscope. Usually the doctor will repeat that 6 to 8 times at each bronchoscopy depending on how the patient tolerate it and how much it bleeds. It takes about 24 hours to know if the lung biopsy showed a rejection or not.
Another diagnostic reason to do a bronch is when a patient shows some signs of lung infection and a culture needs to be performed. By performing a culture, the pulmonologist will be able to identify the bug (bacteria, virus or fungi) that has invaded the new lung and treat it accordingly. Unfortunately, a lot of lung transplant patients are infected with “superbugs” that require powerful antibiotics because they have adapted and become resistant to the weaker ones like Cipro or Levaquin.
The other purpose of a bronchoscopy has therapeutic intentions. Inother words it means to treat a condition found in the lungs where the patient is experiencing lung transplant complications. The main ones that we see are accumulation of thick mucus that will sometimes occlude part of the lung. The doctor will use the scope and go in and wash it out real good. The real term used for the occlusion is a mucus plug. Usually a patient feels 100% better once that issue is fixed.
A more rare complication after lung transplant is called bronchial stenosis. Stenosis means narrowing. So bronchial stenosis means that the bronchus has become narrow and it is more difficult for the air to go through. That usually happens at the site where the surgeon hooked up together the new lung with the patients™ own bronchus. The scar tissue that forms makes the air passage more narrow. That condition is diagnosed during a bronchoscopy and can be treated by 2 ways that are pretty similar to what a cardiologist will do to clear blockages in a heart. The first step is to use a balloon that is inflated at the narrow spot with the goal to open it up. If it opens up and stays like that, it is good. If it closes back up, then a stent may be deployed to keep it open. Just like in your heart. The difference is it happens in the lung, not in the bloodstream.
These were the main reasons bronchoscopies are done on lung transplant patients. The number one thing that is always suspected early on after transplant regardless if the patient has any symptoms is rejection. This is why bronchoscopies are performed so routinely, to catch them early.
Yesterday, I posted the first 5 main mistakes transplant patients make. Today I will present the remaining 5 mistakes that we observe and could shorten your survival post-transplant.
Every single patients (actually this is good for everybody, including me!) should enrolled in a structured program of physical conditioning, providing that their physician has cleared them to do so. A structured environment is much better since you will have someone pushing in your back to have you take the extra step and to show up… Self-exercising is OK for a minority of people because most of us lack motivation and would quit after 1 week.
How often have I heard the doctor asking a patient the reason why he is taking something and the patient replies: I don’t know, a doctor told me to Better informed patients make healthier patients. Cmon guys, there is no excuse today to be uninformed with all the information we can find on Internet. At least know the purpose of each meds you are taking.
It is OK to eat some fast food once in a while if you really like it but I would suggest that you cook your own food at home along with some raw vegetables. Of course, the vegetables need to be washed real good. It will help with your weight management along with your blood sugar. As transplant patients, you are taking so many medications that you don’t need to eat all that processed food along with their chemicals. Check with your dietitian at your transplant hospital about tips and ideas.
Before transplant, while being evaluated, most patients swear they will be taking care of themselves much better. Unfortunately, once they start feeling great after the surgery, some of them go back to their old habits that led them to require a transplant (obviously it is not all patients who need transplant that fall into that category, some have acquired diseases or were born with it). What I mean is by example: a long time smoker now needing a lung transplant, a fast food eater ending up needing a heart transplant because of too many heart attacks or a high salt intake person who ends up with severe hypertension which cause kidney failure requiring transplant. Believe it or not, some patients restart smoking after lung transplant! A new organ does not treat the causes in most cases, it just relieves symptoms. You have received a new chance in life, it is your turn to take care of it.
This is the correct attitude towards the success of your transplantation. If you feel you have some depression please check with your hospital to see if they offer a support group. Some patients feel some guilt regarding being alive while their donor is dead. It is important to also take care of the mind.
It takes about 2-3 months for an average patient to recover from a solid organ transplantation and be able to say I start feeling great!. The first several weeks after surgery new patients call me, as a transplant coordinator, 2-3 times a week and most of the time it is due to anxiety. After that 3 months threshold, providing everything is good, we barely hear from some of the patients anymore. In a way, it is a good thing because it means they are doing well. When a patient feels great, trouble can find them because they are somehow getting non-compliant to a different degree. Here are the top mistakes that I see on a daily basis that could threaten long term survival.
A lot of patients become invalid during the disease process and remain so after the transplant. They end up with a lot of free time while feeling great and have no project whatsoever. The main activity of the day is what leads us to the next mistake: eating. Please find something to do!! Volunteer, school or work.
Sick patients, especially the ones with breathing problems, tend to lose weight because they burn a lot of energy to survive. Once they get a transplant and feel a 100% better, those pounds starts piling on. I have seen as much as 25 pounds a month!! Extra weight increases blood pressure and blood sugar and decrease long term survival because of all the complications associated with obesity.
Why would I have to keep checking my blood pressure, I feel good? This is a question heard during office visits. Well, because one of your transplant medicines side effects increases your blood pressure. Also carrying those extra pounds will make your BP go up. This is the most common answer I hear from the physicians which is funny because the patients are not expecting someone to frankly tell them they are fat!
Anti-rejection medicines are tough for the kidneys. In order to protect them and avoid a kidney transplant down the road, it is very important to stay well hydrated. The best thing our physicians recommend is water. Just plain water. In most of the other drinks you have caffeine that acts like a diuretic and will dehydrate you or sugar who contributes to weight gain and higher blood sugar. Water is the tastiest drink when someone is thirsty.
Stay on top of things. You should know when you are getting low on supplies and should order new refills at least 2 weeks ahead of time for mail-in pharmacy or 1 week for local drug store. You don’t want to run out on a thanksgiving week-end. Unfortunately, it does happen. These meds are life-saving so please don’t mess with that. Don”t try to blame your coordinator when you are late!
To be continued
The first question that comes into people’s mind when they consider organ transplant is how long they will have to wait. There are so many factors affecting the wait time that it is very hard to say. For lung transplant, the main ones are type of disease, patient”s size and the transplant center itself. Also lung is the organ with the one of lowest wait time in organ transplant. Relatively less people are waiting for lungs versus the number of available organs compare with kidney or liver.
The way lungs are allocated is by a complicated calculation of different data from the patient. The number, or score, that the system gives after putting all the data in is called Lung Allocation Score (LAS). The patients are ranked by LAS score with the highest number being at the top. Those data are entered in the UNOS™ website by the transplant coordinator and they include the amount of oxygen used, some pressure in the heart, saturation, etc. The number one factor that affects the score is the disease. Some disease like idiopathic pulmonary fibrosis (IPF) will be giving more points than chronic pulmonary obstructive disease (COPD). Patients with IPF are clinically sicker than COPD and their condition can get worst as quickly as overnight. COPD is more about quality of life and is a more stable disease while many can live years without lung transplant.
Another very important factor in determining how long someone will have to wait is the size (height and weight) of the organ transplant candidate. A really small or very tall patient will most likely increase the wait time as few donors meet those dimensions. Being too small I think is worst than too tall. A very short adult patient may need lungs from a child or small teen but they will have to compete with pediatric patients who have priority on pediatrics organs. It is very hard to transplant a very small adult but with a little luck it can happen.
One more very important factor that you can’t really find in the books anywhere is how aggressive the lung transplant program is in pursuing lungs that other centers would turn down. Some pulmonologists will turn down lungs that are less than perfect without trying to improve them. It is important to mention that the lungs are the most fragile organs from the donor. Good lungs can turn bad very quickly if the donor is not managed properly. The OPO coordinator has a very important job to do in maintaining the quality of the lungs or to improve them. Lungs are susceptible to fluid overload and infection for the most part. Detailed attention is needed to keep the lungs fit for transplantation. Some transplant centers don’t bother in trying to salvage lungs. It is worth giving it a shot in a context of shortage of organs and it directly results in more lungs available for the more aggressive hospitals. It happened to me more than once after giving a first look at a lung offer from UNOS, I was certain we would decline due to bad quality. With a good physician giving the right orders about medication and making the perfect adjustment on the breathing machine, the lungs got much better and the patient received his lung transplant.
The average wait time for a busy and proactive transplant center is about 3 months spent on the list for lung transplant. Some will have their organ transplant as early as the same week they were put on the list while others will wait on the list for months if not years. It is very unpredictable but in general it will be faster than the other organs like heart, kidney and liver. Also there is some period of the year when we received very few organ offers and none of them are good and other time where it is the opposite. The number of organ offer is pretty much the only thing that we can’t control at the transplant center level. If all the stars are aligned for you, you can get your transplant rather quickly!
Several patients don’t want to be operated on at night for fear that more mistakes happen due to fatigue and stress. If you are a lung or heart transplant patient you don’t have to worry anymore. A study that came out in the Journal of the American Medical Association (AMA) is proving that there is no more risk at night than daytime for organ transplant surgery. It suggests the reason being that the transplant team is used to it and has found ways to cope with lack of sleep and the pressure of doing transplant surgery.
I have seen quite a few surgeons working at night and let me tell you when they are in the operating room, it does not matter what time it is, the time stop and they just perform. Trust me though, if they have to choose between 2 pm and 2am the surgeons would all pick 2pm for obvious reasons.
The study was done over 10 years involving more than 27,000 patients who underwent thoracic organ transplantation (heart or lungs) in the US. There was no difference in term of survival one year after transplant. The only hiccup for night time surgery was a slightly increased incidence of airway dehiscence. This is explained by having an air leak where the news lungs and patient’s bronchus are stapled together. It can happen because a staple failed, wound healing delay, etc and usually requires going back to the operating room.
The bottom line is when a thoracic surgeon signs up for organ transplant surgery; they expect to be working at anytime of the day or night. They are mentally prepared for it and just do what needs to be done.
