Friday, April 5, 2013

Depression Treatment Linked to Longer Transplant Survival

An elusive goal, the ability to favorably impact LONG TERM survival following liver transplantation has just been reported for the first time from the University of Pittsburgh in the American Journal of Transplantation. Earlier posts have focused on the emergence of a new Quality of Life Era of transplantation because of our ability to predictably overcome routine EARLY surgical and immunological challenges.  Rogal and collaborators now show that adequate depression treatment with medication(s) within the first year after liver transplantation for alcohol related disease is more strongly linked to the patient's survival at ten years than other risk factors. More strongly linked to survival at ten years than how ill the patient was at the time of transplant. More strongly linked to survival at ten years than the absence or presence of Hepatitis C.

Why is this so significant? Because it represents a factor that we may potentially improve to improve survival! The overall ten year survival rate following liver transplantation with a deceased donor organ is only 54%, far from what we would like it to be. Judging (extrapolating) from the 25% of patients in this study who were depressed but inadequately treated, the ability to intervene more favorably in one-quarter of transplant recipients could significantly impact the overall statistic. And forgetting about statistics for a moment, wouldn't it be wonderful to offer better therapy to each of those inadequately treated patients?

The question is how to accomplish the delivery of adequate care of a complex patient within the current healthcare environment? Transplant teams don't routinely deliver primary care for their patients and depend on local providers to do so. While psycho-social personnel are key team members, they usually focus most on the pre-transplant and early post-transplant issues. These new important data highlight a possible need to expand that emphasis or, at least, to improve the linkage and tracking of what is happening locally - consistent with the Accountable Care Organization model. Not easy to accomplish particularly without additional resources. Clearly, we will have to find a way.

If, as I suspect, the finding that the adequacy of depression treatment also extends to a strong linkage with long term survival following kidney and other transplant types, monitoring of the mental health medications and (perhaps) services will also require improved engagement by those respective transplant teams. Wow, a lot to chew on. But, at least we have a direction in which to go so that we can potentially make outcomes better.

Wednesday, April 3, 2013

ABC Drama Risks Harming Tissue Donation - For Real

Yes, organ and tissue donation are exciting, medically provocative and timely - what more can a Hollywood writer ask for? Perhaps that is why the April 2nd episode of ABC's Body of Proof tore the topic of rabies transmission through transplantation directly from the headlines. Less than three weeks following the first public report of the second U.S. case transmitted through solid organ transplantation and weeks after the season premier of the show, writer Alexi Hawley's hastily written script might well have benefited from better editing and consideration of responsibility to the public.Sure rabies transmission can - and has - occurred through tissue transplantation. But creation of a plot based on  people vanishing from their lives to become victims of a serial tissue "harvester" and the pervasive use of callous, insensitive terminology such as the "dead body" were simply uncalled for.

How can any uninformed layperson who saw this episode's fileted open extremities within the context of a serial murder body snatcher seeking to "harvest tissue" ever be expected to respond favorably to a real opportunity to donate tissues +/or organs? Repeated references to the "dead body" and the "cadaver" only deepened the portrayal of lack of respect for the human beings at the center of the story.

It is time for Hollywood and the entire entertainment industry to harness the power they control to consistently deliver truthful messages about transplantation and donation. Yes, stories such as rabies transmission make for easy fodder. Retelling them in responsible ways will not limit the drama. It will require a bit more energy on the parts of writers and producers. It is well worth the effort, as one never knows who will be waiting next in line to be a recipient of this good will.

Sunday, March 31, 2013

Wedding Affirms Quality of Life for Face Txp Recipient

Yesterday's marriage of face transplant recipient Dallas Wiens and 70% burn victim Jamie Nash in Fort Worth, Texas was a triumph of love, medicine and social support.   Five years after he was burned in the Ridglea Baptist Church when the cherry picker he was using to paint the church touched a high power line, he returned to the same church for his vows with the woman he had met in a burn victims support group in Boston, the site of his face transplant.

Reported by the Boston Globe to be both the nation's first full face transplant, and the world's first without any rejection, in contrast to the recent sensitized patient (this blogger has no inside information), this face transplant marks the solid establishment of the era of Quality of Life Transplantation. Face, hand, uterus, and larynx transplants are performed to make people's lives better, not to directly prolong their survival. This is an enormous step forward from the prior fifty year long era of Life Saving Transplantation in which transplants were not optional - done only to salvage the life of the dying person with the luck to be selected and allocated an organ in time.

How have we gotten here - slipped virtually seamlessly into this new era? Evolutionary improvements in the armamentarium of immunosuppressant medications available to prevent +/or reverse rejection, better selection of donor and recipient through changes in tissue typing techniques, and overall improvements in medical/surgical care coalesce to make success predictably attainable in life saving transplantation. Results are so good today that we have created our own supply and demand crisis. So many people with kidney, liver, heart, lung, intestinal failure are suitable candidates for life saving transplants that we cannot offer them all organs - 18 die per day waiting for transplants in the U.S. alone.

That predictability of successful transplantation has empowered surgeons to brazenly perform these Quality of Life transplants, knowing the control of rejection can probably be achieved for their patients. With careful informed consent, people like Dallas Wiens, who said "I miss the sensation of my face and my sense of smell the most" in 2010 (AP 2010), can now have the life transformations they dream of.  Following the first laryngeal transplant in 2001, transplant surgeon Anthony P. Monaco MD, PhD, who had himself undergone laryngeal removal for cancer seven years earlier, wrote in the New England Journal of Medicine that "if I were 40 year old, I would probably consider undergoing the operation myself. For Dallas, who at age 27 can again eat, drink and smell normally (though he is blind), and his bride Jamie, all stars have aligned. May the quality of their married lives together also be the stuff of dreams, as his transplant has been to date.