Friday, March 22, 2013

Breathing Lung Device Broadens Transplant Options

Four months of life - good life that includes daily walks several miles long without the oxygen tanks of Fernando Padilla's past - are attributed to his double lung donor and the lung support device that kept them breathing once they had been removed from that donor. Performed at UCLA in November 2012, this was the first clinical use of the TransMedics Organ Care System (OCS) transport method for lung support between organ recovery and transplantation UCLA news release . Instead of storing the lungs in cold solution, they are kept warm, functional (breathing Oxygen) and supplied with red blood cells. Incredible.

Do the principles sound familiar? They match those achieved by the Oxford liver transplant group who recently successfully transplanted two livers after keeping them on a  liver support device . Not surprisingly there is also an active trial of a heart in a box support device meeting the same needs in heart transplantation.

This is a watershed moment in transplantation. Incessant deaths of potentially salvageable transplant candidates, failure to dramatically increase the number of available deceased donor organs and regulatory pressures to perform only successful transplants are all powerful drivers. Support devices for kidney perfusion are demonstrated to improve outcomes and permit selection of better quality organs based on perfusion parameters kidney support device .  Research efforts to achieve equivalent support for lung, liver and heart transplantation have all reached the clinical bedside within the past year. All remain in the clinical trial stage with encouraging preliminary results. We appear to have real progress in hand.

Tuesday, March 19, 2013

Should This Kidney Txp Program Close?

Closure of the Miami Valley Hospital Kidney Transplant Program in Dayton, Ohio will alter the face of transplantation in the region - but will it be for the better or not? Whose opinion matters? This is a 43 year old program that has performed more than 900 kidney transplants according to the  Dayton Daily News , and patients have received deceased donor transplants faster there than at surrounding programs, or in the rest of the country. see program specific data reports To insiders, this may reflect better access to good quality organs, in which case the local patients would be disadvantaged with closure of the program. Or, it may mean that transplant surgeons were more aggressive in the types of organs they were willing to use for transplantation. If those organs worked well, the decisions were terrific. If not, then maybe not such good decision making. However, good outcomes also require good follow-up patient care, which takes a transplant "village". And this may not have been readily available at a fairly small center.

Administration officials indicated that finances are driving the decision to close the program, a very plausible explanation since hospitals generate much more income from liver transplantation - not in this institution's repertoire dayton daily news 3/19/13 . That is undoubtedly part, not all of the story. Local patients will now have to seek care at more remote transplant centers but will undoubtedly return to their own providers for follow-up. This is the trend in modern transplantation. Transplant at one center with the majority of subsequent care delivered elsewhere. It may be supervised to a greater or lesser degree by phone by coordinators from the primary transplant center. But a not so well known truth is that many patients will never return back to that transplant center, opting instead to receive what proves to be essentially the same quality follow-up care that may have been responsible at least in part for the closure of their own local center.

Which patients are least likely to return for follow-up at the primary center? The least healthcare literate, oldest and least affluent of course. So, closure of a small, local center favors the typical patients in subtle ways that also contribute to their better outcomes with transplantation. Go figure.

Sunday, March 17, 2013

Is New Liver Support Device The Answer For Liver Transplant Candidates?

Two liver transplants performed in February 2013 at King's College Hospital in England are remarkable because each human liver was temporarily supported ex vivo (outside of a human body) by a new support device liver device report . Both livers were kept alive with blood circulating (perfusing) through them at body temperature for the hours between being recovered from the deceased donor and subsequent transplantation into the waiting patients. Currently, a high proportion of organs available for transplantation are declined because of a high fat content (e.g., fatty liver) that literally congeals with the prevailing storage method in icy cold solution. Avoidance of cold with this new device might permit utilization of more of these available fatty livers - a major step towards saving lives.

Today we commonly utilize kidney perfusion devices that have been shown to improve the outcomes of transplants and to reduce the likelihood of transiently requiring dialysis after the transplant, until the organ recovers. In fact, the most commonly used device, the LifePort kidney support device has been on display at MOMA (the Museum of Modern Art) because it is so beautifully designed. With this and other devices, more kidneys of questionable quality are transplanted. We can both extend the time period between procurement and transplantation, and interpret measurements generated from the pump to determine the kidney's viability. But an equivalent had not been available in liver transplantation.

The bottom line is that we have thus far become aware that the new liver support device from OrganOx appears not to have harmed the two transplant patients or their livers that functioned after being supported with it. The report is that both patients are making excellent progress. Whether or not the potentials for 1) prolongation of transplant time frames and 2) range of usable organs will be fulfilled as well remains to be seen.