BY CONNIE MITCHELL
| ILLUSTRATION BY ABIGAIL GOH
They would fill St. Louis’ Busch Stadium more than twice, take every seat in 261 jumbo jets and fill each bed in Barnes-Jewish Hospital 85 times over. They are the more than 108,000 Americans waiting for an organ transplant. And for too many, a donor organ won’t arrive in time.
According to the national Health Resources and Services Administration, 17 people die each day waiting for an organ transplant. In the first nine months of 2020, just more than 29,000 organ transplants occurred, leaving the vast majority of those in need still hopefully waiting for a kidney, heart, lung, liver, pancreas or other organ.
The physicians, surgeons, nurses, therapists, counselors and technicians working at the Washington University and Barnes-Jewish Transplant Center see hope in the eyes of the people who come to them for help. The Transplant Center, one of the largest in the U.S., offers a second chance at life for those who undergo a successful transplantation. But the specialists working at the center also see people who never receive the transplants they so desperately need.
A look at supply and demand
The gap that exists between the number of available organs and the number of people needing them has engendered innovation. New techniques and treatments are changing the field of organ transplantation. Thanks to these recent developments, a greater number of acceptable organs are being matched to waiting recipients.
More than 90,000 people nationwide need a new kidney, making it by far the most in-demand organ. For most of the people awaiting a kidney transplant, life is a continual round of dialysis that can be exhausting and can often consume at least three days each week. And yet, there are only slightly more than 20,000 kidneys donated each year.
The problem of organ shortages like this can be deceiving, notes William Chapman, MD, FACS, Washington University transplant surgeon at Barnes-Jewish Hospital and chief of transplant surgery at the Transplant Center. “In some ways, we’re victims of our own success,” he says. “We have more donor organs than we’ve ever had before, so there’s the potential to help more people.” But, Chapman adds, “advances in transplant medicine are now allowing us to consider the option of transplantation for more people than we would have a few years ago.” In other words, demand has increased alongside supply.
Thanks in good part to improvements in surgical techniques and recovery protocols, surgeons now are able to perform successful transplants in older, sicker patients—people who might not have qualified for the surgery just a few years ago. And as life expectancy increases across the U.S. population, people in their 70s and 80s are no longer considered too old to benefit from a transplant. In addition, physicians now use new, highly effective anti-rejection treatments and strategies for managing post-transplant issues, which means more patients live longer, healthier lives with their transplanted organs. “We’re doing more challenging transplants, and age is no longer an exclusion,” Chapman says. “That wasn’t the case just a few years ago.”
Given the ever-increasing need for organs, Chapman urges people to consider becoming organ donors. Driver’s licenses offer an opportunity to indicate the desire to donate, he says, noting that it’s also important to have family discussions that leave no doubt about end-of-life wishes. Should a sudden death occur, families can find making on-the-spot decisions about organ donation quite difficult. It can be less stressful to have conversations about donation before an urgent decision must be made.
donor kidneys available each year
people on the wait list for kidney transplant
organ transplant surgeries in the U.S. from January-September 2020
Innovations in kidney transplantation
Diabetes and hypertension, the two most common causes of kidney failure, help drive the high demand for donor kidneys. “These diseases can be more prevalent in obese people,” says Jason Wellen, MD, MBA, Washington University transplant surgeon and surgical director of the kidney and pancreas transplant programs at the Transplant Center. And, he adds, as obesity becomes more prevalent in the community, the Transplant Center sees “more patients with higher BMI (body mass index) numbers” with kidney failure. But obesity can complicate transplant surgery, in some cases making the surgery itself more difficult and incurring greater risk of post-surgery wound infection and organ rejection, among other risks. Not that long ago, many people with obesity might not qualify for transplantation.
Advances in surgical procedures are ameliorating some of these complicating factors. Such procedures include minimally invasive robotic-assisted transplantation, which can offer even more precision than traditional surgery to surgeons and reduced complications, pain and recovery time to patients. The human body’s ability to thrive with one kidney instead of two makes living organ donation possible, an option that has saved many lives. In 2020, Transplant Center surgeons performed 301 kidney transplants at Barnes-Jewish Hospital alone. Of those, 68 used kidneys from living donors.
“You only need one functional kidney to live a completely normal, healthy life, and we probably need to do a better job of helping people understand that,” says Tarek Alhamad, MD, MS, FACP, FASN, Washington University nephrologist at Barnes-Jewish Hospital and medical director of the kidney and pancreas programs at the Transplant Center. In fact, he adds, kidney donation is “one of the safest elective procedures” performed. Now often done as a minimally invasive procedure, it involves a small incision; living donors typically require only one or two nights of observation in the hospital after surgery.
Every year, a handful of people contact the Transplant Center to express interest in donating a kidney to be matched to a person they don’t know. A greater number come forward to assist a relative or friend in need. “We want every patient to have a living donor, if possible,” Wellen says. “Receiving a kidney from a living donor is a recipient’s best chance for lifelong renal health.”
Generally speaking, this is because living donor kidneys are healthier than those coming from deceased donors. At the Transplant Center, a living-donor nephrectomy is often done with a robot-assisted surgical system. “During nephrectomy,” Wellen says, “it is imperative that we remove the kidney with an adequate length of blood vessels and the ureter so that we can adequately reimplant the kidney into the recipient. The robotic system ensures that those structures are well visualized during extraction.” Wellen and Adeel Kahn, MD, MPH, Washington University transplant surgeon at Barnes-Jewish Hospital, established the robotic donor nephrectomy program at the Transplant Center.
The Transplant Center maintains a rigorous qualification process for those wanting to become living donors. The aim is to ensure every potential living donor is healthy enough to participate in the program. Wellen notes that about 1,200 people were screened for living kidney donation at the Transplant Center in 2019; one in 16 was cleared to donate. Because of this qualification process, Wellen says, “if someone is approved for living donation, we’re extremely confident of a complete return to normal function in a very short period of time.”
Candidates for kidney transplant use various methods to discuss their need for living donors. Many use social media to discuss their illness; others enlist the help of a “champion,” someone who agrees to reach out to potential donors on behalf of the recipient. But what happens if a recipient finds a willing donor only to discover the kidney is not compatible? There are ways to overcome this problem, Alhamad says.
“For example, if a recipient and donor have different blood types, new treatments allow the previously incompatible organ to be used,” he notes. In such cases, recipients receive preoperative medications and blood plasma treatments to prepare for the new organ; the resulting transplants are as successful as blood-type compatible transplants.
Another option, called paired-kidney exchange, can benefit multiple recipients. Here’s how it works: “If a patient finds a living donor, but the kidney isn’t a match, we can look at both in-house and national kidney exchanges,” Wellen says. “In many cases, the donor organ will match another recipient. And that recipient may have a potential donor who matches someone else in need. So we create chains of living donors and end up with the ability to offer transplantation to multiple people.”
Innovations in liver transplantation
Donating a kidney to someone in need is a fairly straightforward endeavor. But for the more than 12,000 people waiting for a donor liver, receiving an organ from a living donor is a more complicated proposition. In 2019 in the U.S., 8,896 people underwent liver transplantation; only 524 of those surgeries used living donor organs.
At the Transplant Center, all 114 liver transplants performed in 2019 used livers from deceased donors, although there is an effort underway to begin a living donor liver program, says Maria Majella Doyle, MD, MBA, FRCS (I), Washington University transplant surgeon at Barnes-Jewish Hospital and surgical director of the liver transplant program at the Transplant Center.
“In theory, living organ donation is a great option, and it works well for kidneys,” she says. “But it’s easier to remove a kidney than it is to remove half or more of a liver from a living donor. There are more risks for the donor, and the surgery itself is a much more complex procedure.”
The decision to donate a portion of one’s liver isn’t an easy one, Doyle says, but it is a viable option. The donation surgery can take four to six hours, the risk of complications is greater than a donor nephrectomy and recovery includes a four-to-five-night hospital stay. Doyle says it’s unlikely that more than half of all future liver transplantations will use living donor organs.
Chapman adds that, like the increase in kidney transplant candidates, a growing number of people are in need of liver transplantation. “We have a health crisis related to obesity; diabetes and fatty liver disease are increasing the number of people with liver failure. Right now, the number of people needing liver transplantation surpasses the number of suitable donor organs.”
Given this imbalance, physicians are working to devise new ways to solve the problem. One option is the use of “orphan livers.”
“About 10% of livers recovered from deceased donors and intended for transplant are initially declined by transplant centers,” explains Chapman, noting that all harvested livers are carefully vetted to ensure they are suitable for transplant. These rejected organs are called orphan livers.
Recently, however, researchers are looking at ways to make some orphan livers viable for transplantation. For example, in a small clinical trial, Chapman and colleagues at the Transplant Center will look at the viability of matching orphan livers with recipients who might not otherwise receive a donor organ. Chapman says: “These organs wouldn’t be used otherwise, and the patients we select would go without a transplant. They need each other.”
To prepare orphan livers for transplantation, the study will use a technique called normothermic machine perfusion, or NMP. During this process, an orphan liver is perfused with oxygen and a blood-based solution in much the same way that living donor kidneys are kept healthy and viable before transplant. While the organ is undergoing perfusion, physicians can assess whether the liver will function properly when transplanted.
“We’ve seen extremely good outcomes using NMP in trials conducted in Europe and in preliminary studies in the U.S., and we expect to validate those results with this trial,” Chapman says. “We need to look closely at all organs for their potential for transplantation.”
Improving the viability of donor lungs
“We use several technologies to help increase the number of available donor lungs,” says Daniel Kreisel, MD, PhD, Washington University thoracic surgeon at Barnes-Jewish Hospital and surgical director of the lung transplant program at the Transplant Center. Overall, transplant centers have become more liberal in evaluating and clearing donor lungs for use in transplants. For example, Kreisel says, “in recent years we’ve been able to review CT scans of potential donor lungs before procurement, which makes it much easier to determine if the lungs will perform well after transplant. In the past, without the close assessment a CT scan provides, many of those lungs would have been rejected.”
Another path to viability
Recently, transplant specialists have been able to make better use of organs from donors with hepatitis C, a viral liver infection. “We had been using hepatitis C-infected organs before now, but only for transplantation into patients who also were infected with the disease,” says Jeffrey Crippin, MD, Washington University liver specialist at Barnes-Jewish Hospital and the Transplant Center’s medical director.
But now people with hepatitis C benefit from highly effective new drug treatments that essentially deliver a cure or remission. And the medication’s more than 95% efficacy and small risk of adverse side effects allow physicians to treat transplant recipients for hepatitis C following surgery. In other words, the hepatitis C-infected donor organ can be used, and the recipient can be treated for the illness after the transplant.
“The new medications for treating hepatitis C have been a true game-changer for liver transplantation,” Crippin says. “And for many patients, the relatively small risk that the drugs won’t clear the virus outweighs the much greater risk of death without an available organ for transplant.”
Crippin offers a message his colleagues at the Transplant Center share: “We want our patients and their families to know that the field of transplantation is constantly in search of solutions to the shortage of donor organs. Transplant teams across the country and here at Barnes-Jewish Hospital will always do what’s deemed to be in the best interest of the patient, and we will give our patients every opportunity possible for a long and healthy life.”