What to Choose? Deceased Organ Donor or Donation After Cardiac Death (DCD)?

What to Choose? Deceased Organ Donor or Donation After Cardiac Death (DCD)?

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Actually, everybody on an organ transplant waiting list is waiting for a deceased donor. It is the kind or deceased donor that may be different. Just like I talked about it, there is the brain death donor. Remember that a brain dead patient is legally dead even though the heart is still beating. It happens that a potential organ donor does not meet the criteria of brain death despite suffering irreversible major brain injury. The organs cannot be used or planned to be used until the patient is legally dead. This is where Donation after Cardiac Death (DCD) comes into play. It has been done for the first time in the 1950’s but has routinely been explored as an option since the early 90’s.

Here is how DCD works. You have a patient, a potential organ donor, who has extensive brain injury. The family is talking about life support withdrawal (removing breathing machine that keeps patients alive) but the patient did not meet the criteria of brain death. The family can now be approached by a well trained organ procurement organization representative to discuss organ donation. If the family consents to DCD donation, medical management continues to keep the patient alive so the organs can be matched with transplant candidate. Once organ transplant recipients are matched with the donor’s organs, which can take several hours to achieve, the most crucial part of the whole process begins. Depending on policies in different regions of the United States, the patient is now brought to the operating room or can stay in the intensive care unit.

The life support is then withdrawn (breathing tube removed, medication stopped) and medical staff is standing by waiting for the heart to stop. Once that happens and they need to wait 5 minutes before they can do anything else. The heart needs to be stopped with no blood pressure for 5 minutes. A physician unrelated to the organ donation process declares the patient dead along with the official date and time. After those 5 minutes and patient is pronounced, they are rushing to resuscitate the donor and to put him back on the breathing machine. During all that time, transplant teams have been standing by at the hospital ready to recover the organs.

What happens if the patient does not die? Usually guidelines are strict and if the patient has not passed within the timeframe allowed, 1 or 2 hours depending on policy, the patient is sent back to the nursing floor and the transplant process aborts. Everybody goes home empty-handed.

For someone to receive an organ from a DCD donor, they need to be specially consented for donation after cardiac death. It may not be every transplant center that is comfortable with that so some may not be offering the option to their patients. Basically the patient waiting for organ transplant consenting for donation after cardiac death is giving himself more chance to get a transplant since it increases the donor pool. For the last few years, there was an average of 3 to 5% of donation coming from DCD donor. That number seems to be increasing every year. Some regions are more aggressive at pursuing DCD donor where others are more passive.


New Heart Transplant Device Use to Deliver Warm (Heart) Organ

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A new device being tested at UCLA Medical Center in California is use to deliver heart ready for transplant. Traditionally organs are delivered on ice from the organ donor site to the recipient hospital. As soon as the heart is removed from the body it is put on ice in a cooler and has to be used within 4 hours. The heart is then on pause and race against time starts so the heart spends as little time as possible without blood flow and oxygen.

When UCLA surgeon, Dr Abbas Ardehali, did a heart transplant on one of their patient lately, he did not remove the heart from ice; he removed it from an experimental device where the heart keeps pumping blood in a near physiological state and is also being oxygenated. We once had the first beating heart bypass surgery and now we have the first beating heart transplant surgery!

This is great news for future heart transplant recipient if the device becomes FDA approved. Its name is The Organ Care System (OCS) and has been developed by TransMedics out of Andover, MA in the USA. This company has also commercialized OCS for lungs perfusion that is used in Europe at this time and in clinical trials in the US at major transplant centers.

These two devices, if they perform as intended will be a major breakthrough for organ transplantation. They allow for the organ to remain outside of the body longer with minimal ischemic (lack of oxygen) injury. Potentially more organ could be recovered and more rejection could be prevented since more time for testing is available. Another benefit would allow for more heart transplant surgery to be performed during daytime or at least more normal hours.

So keep watching, you may see an Organ Care System device in a transplant center near you very soon!

New medication to prevent CMV for organ transplant recipient?

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Let’s come back to Letermovir. It has also obtained the status of Orphan Drug in the European Union (EU). That status is reserved for drugs used to treat rare disease that affects a minority of the population. The drug company is given tax breaks and marketing exclusivity for 7 years in the US and 10 years in EU. This is an incentive that was created by the governments to incite drug companies to develop medicine against rare disease. CMV is known to affect less than 200,000 people in the US, most of them being organ transplant patients.

Valcyte has been on the market for 10 years and Letermovir seems to be the most serious alternative to date. With clinical trials underway we should know soon if this drug has a bright future in helping organ transplant recipients.

Michigan Increases its Organ Donor Pool by a Simple Action

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If I was asked that question 10-15 years ago the answer would have been different than today. It was safe to say that most transplant center did not do any transplantation on patients older than 60 years old. These days you have a chance to become an organ recipient as old as 70 years and even a little more depending on the hospital you choose.

Just by asking its residents at government branch offices, Michigan has increased its number of registration on the donor registry by 25% month over month. The increase was seen comparing June 2010 and this year. Secretary of State Ruth Johnson attributes this jump because of her new policy of simply asking people when they show up in a government office. The State of Michigan was almost dead last in the country for its participation on the donor registry. It sure took the initiative to become one of the top states! The best way to promote organ transplantation is to encourage more people to become potential organ donor.

First Lung Transplant in US Using Ex Vivo Perfusion

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The University Of Maryland Medical Center was the first center in the US to perform a lung transplant using ex-vivo perfusion. The procedure is used to make the lungs more suitable for organ transplantation. Only 15-20% of all donors end up giving their lungs due to several factors. This is a very low number compared to kidneys and liver who are used a lot more.

The lungs are very susceptible to their environment especially in a context of a brain dead patient. Those patients have a breathing tube in the throat which increases the risk of pneumonia. Since they are lying down and not moving some gastric content can potentially go in the lungs (this is called aspiration) and cause some infection. Lungs can also fill up with fluid due to previous attempt of resuscitation. Since lung transplant recipients are the most susceptible for complication after surgery, the transplant pulmonologist are pickier.

STEEN Solution with Xvivo Perfusion

This new technology comes from a company named Vitrolife from Sweden. They created the STEEN solution to perfuse the lungs outside of the body just like this picture.

Lung transplant

The perfusion solution replaces the blood is made from human serum albumin, dextran (prevent white cells to react) and some electrolyte solution. The red color seen above is due to the addition of 15% of red blood cells to allow gas exchange (oxygen and Carbone dioxide) in the lungs. This process is done on lungs that otherwise would have been rejected for lung transplantation based on current guidelines and are given a second chance to improve. The doctors can also do a bronchoscopy to look at the lungs from inside or to open up a closed lobe. The whole thing is kept at 37 degrees Celsius which is the normal body temperature.

What about the Future?

The ultimate goal is to have more lungs available for organ transplant and save more people. If this new technology proves to be successful maybe all lungs may eventually be fine-tuned using the Xvivo perfusion. It seems that it could potentially reduce the number and the acuity of lung rejection thus increasing the survival for lung transplant recipient.

 Want to learn more about organ transplantation:

Voice Box Transplantation: Be Heard Again

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The more I read the news about organ transplant the more I am amazed at what scientists are

trying to do. After face transplant, arm transplant, uterine transplant now we have voice box transplant. This has to be a very complicated surgery where nerves have to be connected together. A group of Doctors in UK is planning to perform the first surgery of this kind in that country but it will be the third in the world. Professor Martin Birchall, from University College London (UCL), will lead a team carrying out the procedure on a man or woman whose voice box has been damaged by cancer or accident according to the Telegraph report.

What is a Laryngectomy?

A laryngectomy is the surgical removal of the larynx (voice box). The patient who had a laryngectomy done will need to breathe through an opening in their neck called a stoma (tracheostomy). In order to be able to make some sound or to communicate 3 options are available. A prosthesis can be installed by a surgeon to simulate a larynx. The two other methods are the use of an electrolarynx where a device is applied against the throat and produces sounds similar to a robot. Lastly, the patient can learn to talk with his esophagus but this is a difficult technique to master.

What are the Causes for Laryngectomy?

Throat cancer is the leading cause of laryngectomy. This form of cancer has usually a high incidence in smokers but non-smoker can too have throat cancer. Trauma, such as car accident can also necessitate this life saving surgery. It is a life-saving surgery because patients in need of that surgery run the risk of having their larynx close on them and not able to breathe anymore. Around 3,000 laryngectomies are performed annually in the US.
Larynx Transplant Implications

Loss of a larynx removes many things that make us quintessentially human, through loss of speech, swallowing and altered appearance,” Prof Birchall said in the Telegraph. The goal of this uncommon organ transplant is not a life-saving one like for kidney or liver transplant; it is more about quality of life. The patient has to weigh the risks and benefits of having to be on immunosuppressant for the rest of his or her life. Some questions are left unanswered. What happens if the body rejects the new transplant? Does it need to be removed or is a tracheostomy needed again? Those are questions that a candidate to this surgery should ask his surgeon. I guess some people are ready for anything when it comes to being “normal” again. What’s next now?

Controversial British voice box transplant given go-ahead

Pigs to Provide Human Organs for Transplantation

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Thanks to a breakthrough in stem cells research, we are getting closer to have pigs be used to grow organs for human transplantation. According to the article in the Telegraph, researchers created rats’ organs in mice by injecting stem cells into their embryo. The same science would be used to grow human organs in pigs. Pigs have an anatomy somewhat close to the one of a human and they are mass produced. One of the major benefit of this new technique is it would potentially reduce the risk of rejection since the organ is created from stem cell from the recipient.

Human blood has already been made in pigs by using the same technique of injecting blood stem cells into pig fetuses. This technique has yet to be used to make organs though but has been successful between rats and mice. Professor Nakauchi, director of the center for stem cell biology and regenerative medicine at the University of Tokyo in Japan, states: “We are now rather confident in generating functional human organs using this approach”.

If this becomes reality one day, many years of research are still ahead, it would mostly benefit the patients waiting for kidney and pancreas transplant. These recipients have one luxury that lung, liver and heart patients don’t have; it is called time. It takes time to grow and organ in pigs, certainly a few months. Those sicker patients can’t wait and would still get the majority if not all the organs from deceased donors. But it would certainly help alleviate a big part of organ shortage since 80% of the 110,000 patients waiting need a new kidney. Let’s hope this becomes reality so more patients can be saved!
Source: Controversial British voice box transplant given go-ahead

Source:Pigs could grow human organs in stem cell breakthrough

Organ Transplants by the Numbers

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Every day we hear in the media and read on the web that so many people are on a waiting list for organ transplants. What do those numbers exactly represent? I will break them down by different organs and compare trends over the last decade so we can see how bad it is or how good it got. The latest data available that I will use are from 2000-2009. I know that we are in 2011 but 2010 almost just finished and it takes time to gather all the statistics.

I will first start with liver transplant:

There were about 16,000 people on the waiting list at the end of

2009 hoping to receive a liver transplant which has been steady for the decade. The number of transplants has increased by about 10 to 15% over that same period of time. A little less than 6,000 patients were lucky enough to receive a new liver in 2009. Just like we will see with kidney transplant, there are much more patients waiting for a liver than there are available organs. This is the reason behind the increase of interest for living donation. There are only a few select transplant centers offering this solution for now. Unfortunately about 2,000 people died while waiting for liver transplantation, which represents about 6 persons a day. This was a slow decrease over ten years though. Liver transplant expected survival rate at 3 years is just above 80% for living donor and slightly below the same mark for deceased donor (traditional donor) and is explained by the fact that living donor recipient are transplanted faster. They are less sick at the time of transplant.

How about kidney transplant?

Kidney is the only organ that has experienced an exponential growth of his waiting list. It went from around 50,000 patients in 2000 to more than 80,000 in 2009. That is a 60% increase over 9 years, which represents about 7% annually. Since the pool of deceased donor has not really increased we can easily understand why living kidney donation has become a popular alternative. Unbelievably, despite this huge increase on the waiting list, there has been about the same number of kidney transplant every year since 2000. The average has been around 14,000 a year (38/day) from 2000 to 2009 with a slight increase towards the decade. About 2,000 people died yearly while waiting. Much less patients, as a percentage, are dying while waiting because dialysis can replace the kidneys for years while someone is waiting for transplantation.

The most interesting statistic is that kidney transplant recipients expected survival rate was different depending if they received the organ form a living or deceased donor. At 3 years after transplant, living donor recipients have a survival rate of 95% while deceased donor enjoyed a survival rate of 88%. The reasons explaining this difference is that living donor recipients get transplanted in months instead of years. They need to be on dialysis for a shorter period of time if at all. Dialysis can take its toll on a body after years of treatment

Let’s talk about lung transplant now:

Lung transplant is the organ that has experience the biggest relative increase in number of transplantation over the decade. It went up by about 50%. In 2000, about 1,000 lung transplant surgeries were performed and in 2009 just above 1,500 took place. In real number it represents 500 more people saved a year. The waiting list dropped significantly during the decade also; it went from a peak of 3,700 patients to just about 2,000 on the list at the end of 2009. About one patient a day dies while waiting (~300/year). Lung transplant recipients have the lowest survival rate at 3 years being at 65%. This is explained by the complexity of managing those patients since the lungs are exposed to the outside world (the air we breathe) and put them at high risk for major infections. Repeated or untreated infection can permanently damage the new lung.

Finally we will breakdown some numbers for heart transplant:

The yearly average number of heart transplant has not really changed during the last 10 years. About 2200 heart transplantations were performed yearly during that time. The main change was seen in the number of patients on the waiting list. This number has fallen over the years for finally slightly going up lately. It went from about 4,000 a year all the way down to 2,700 and now being at about 3,000 candidates waiting for a heart transplant. Better medical management is a reason explaining less patients requiring transplantation. The number of actual heart transplant has been pretty regular hovering around 2,200 surgeries a year which represents 6 per day. There were also less patients dying while waiting which is directly related to the increased use of ventricular assist devices (VAD) also known as mechanical hearts. It keeps patients alive longer and more healthy while waiting for the gift of life. The expected survival rate is also similar to the one of liver transplant patients. About 80% of the heart recipients are still alive 3 years after transplantation.

As you can see, there is a severe shortage of organs. When including all transplant patients, before or after the surgery, there are good chances that you know one of them. It touches closer to home than we think and please do what you would like others to do for you, be an organ donor!

Source: http://www.ustransplant.org/FastFacts.aspx

Facts about Organ Donation

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Becoming an organ donor is the single best action someone can take to be remembered after passing.  In the United States about 1 person out of 4 is a registered organ donor with their state.  In reality, more people may be willing to sign that card but they don’t do it due to a lack of time, motivation or whatever else.  Even if they do, sometimes they don’t talk about it to their family so when time comes to donate those organs, the family refuses because they are not sure it is the right thing to do.  Signing the organ donation card for your state registry is the first step toward becoming an organ donor.  You also need to talk about it with your family.  Some organ procurement organizations (OPO) have decided not to force family to accept donation after the death of their loved ones even if the signing of the card binds the potential donor legally.  They have chosen not to use confrontation.  So, it is very important that you talk about that with your family so they can honor your wishes.

Organ donation by the numbers.

There are over 110,000 people waiting for an organ (heart transplant, liver transplant, kidney transplant, lung transplant, pancreas transplant, etc.) in this country.  Out of those just about 72,000 are actively listed meaning that the other 38,000 are either too sick at this time (infection or other), do not fully meet criteria (need to lose weight) or have new health issues that just popped up.  Waiting lists are growing faster than patients can be transplanted.  The waiting list went from 18,000 names in 1989 to more than 110,000 today which is more than a 500% increase.  During the same time period the number of organ transplants went from 13,000 to 28,000, a 110% increase only.  The number of donors, including living donors, went from 6,000 in 1989 to

14,000 in 2010, again 110% or so.  The main reason for the increase in donors is the widespread use of living donors especially for kidney transplant.  The number of living donor is almost equal to the number of deceased donors.

Ways to increase number of organ donor

It used to be a time where only pristine donors were used with strict criteria.  A donor in his 50’s was considered pushing it.  Nowadays 65 is the new 50.  It is not uncommon these days to see 60 years old plus organs being used and for the most part they work just as well, for a while anyway.  Transplant physicians are considering using, on a routine basis, organs of donors up to 70 years old in good health.  This is called extended criteria donor.  Lungs from smokers are also used in lung transplantation.  If they were not, you could eliminate about 50-60 percent of the lung transplant surgeries since there would be less lungs available.   All those measure are meant to increase the pool of potential organ donors.

Why become an organ donor?

Because it is the right thing to do.

Once you die you do not need those organs anymore.  If they are still good  to be used, have someone else enjoy them.  Who knows, you may be the one that needs an organ transplant later on in life and wish that more people had signed their card.  Did you know that your family could do a direct donation on your behalf if they happen to know someone that needs an organ transplant?  Even if the recipient is not on top on the list, you can direct the organ to that one person.  Be cool, be an organ donor.

Nora’s Home: The Gift of Life

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Nora was an adorable little girl who enjoyed life more than any other kids of her age. In 1997, she was 7 years old when a tragic accident took her life away.  Her parents consented to organ donation so she could save several critical young lives through organ transplantation. This was her gift of life.  In her honor, her loved ones founded Nora’s Life Gift Foundation in 1998.

According to the website, the Foundation was very active in promoting research for organ failure and organ transplant. The main goal, though, remained charitable contributions. It was in 2001 that the first Nora’s Home opened in Memphis, Tn.  It has provided over 25,000 room nights to organ transplant patients and their caregivers who were from out of town.

In 2006, Noras parents moved to Houston, Tx for a professional opportunity.  Her parents are both physicians at The Methodist Hospital in Houston Texas Medical Center.  Her dad, Dr Osama Gaber is a kidney and pancreas transplant surgeon who is also the Medical director of the Methodist J.C. Walker Transplant Center at The Methodist Hospital.  Her mom, Dr Lilian Gaber, is a transplant pathologist also working at The Methodist Hospital.

The goal of Nora’s Life Gift Foundation is to open the same concept in the Texas Medical Center.  Patients coming from far away for transplant or follow-ups will have less stress by knowing that Nora Home can help them.

Nora’s Home is not opened yet in Houston.  More funds are needed through contributions but at least a property has been secured when an agreement was between the Foundation and The Methodist Hospital in May 2010.

To make a contribution through Nora’s Home website please click the link. Nora’s website