Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, December 25, 1994 TAG: 9412290072
SECTION: HORIZON PAGE: G4 EDITION: HOLIDAY
SOURCE: JOHN BARBOUR ASSOCIATED PRESS
DATELINE: LENGTH: Long
Forty years after the first successful organ transplant, more and more the dead are coming to the rescue of the living.
Each year more than 300,000 parts of muscle and bone, donated by or from the dead, are transplanted into living Americans battered by accident or the wear and tear of time. Plus some 44,000 corneas. Plus more than a dozen other tissues.
And each year 18,000 organs - hearts, livers, lungs, kidneys and pancreatic tissue - are sewn into Americans whose own organs have failed.
Sadly the need for organs is almost twice that number. Many die each year waiting for organs, and many normal people die and take their otherwise healthy organs with them to the grave or the crematorium.
Since the first kidney transplant in 1954, great strides have been made to lengthen the survivability of both organs and recipients.
One kidney recipient operated on at the University of Colorado in 1963 has survived almost 32 years. A pancreas recipient who got his transplant at the University of Minnesota in 1978 has survived more than 16 years.
A heart transplanted in 1974 at Stanford University still beats after more than 20 years. A pair of lungs transplanted at the University of Mississippi in 1987 still breathes after more than seven years. And a liver transplanted at the University of Colorado in 1970 still functions after almost 25 years.
For a variety of reasons, not everyone who wants an organ can get one, even when it is available.
Urologist Bruce Lucas, who does mostly kidney transplants at the University of Kentucky, recently had a patient, a man in his 60s, who came in as a kidney transplant candidate. He was evaluated and it was determined that his heart had problems which could not be corrected medically or surgically.
``It just appeared that the risks were too great,'' says Lucas, president-elect of the United Network for Organ Sharing, ``and I had to tell him that. I said, `You've got the right attitude, but you've got the wrong heart.'
``My guess is he'll live a few months, but if we transplanted him, my guess is he would almost certainly would have died there on the table or in the first few weeks.''
It is a risky business. But for some the risk is worth it for both the candidate and the doctor.
One of the most ravaging diseases people encounter is diabetes. It attacks the heart, the kidneys, the blood vessels, virtually the entire body. When a diabetic's or anyone's kidneys fail, they can fall back on dialysis to filter out toxins from their blood, a job the kidneys normally do. But that is an uncomfortable, limiting solution. Everyone in that category is a candidate for a kidney transplant.
The ideal solution is a kidney from a close member of the family, since those tissues are most compatible, less likely to have a severe immune reaction in which the recipient's body produces antibodies against the donor's kidney in an effort to shuck it off as it would a disease.
Twice in the past few years babies have been born to American parents with the express purpose, in part, to provide compatible bone marrow to another member of the family suffering from surely fatal leukemia. In the latest case, Jill and Randy Schwartz of Cleveland decided to have another child to save the life of 5-year-old Christy. Bone marrow was harvested from the newborn's umbilical cord and frozen, awaiting a transplant scheduled for January.
Few people realize that organ recipients must continue to take immune depressants like Cyclosporin for the rest of their lives to protect the transplant that keeps them alive. Some tire of this, because of various side-effects, and opt out, a fatal decision. A teen-ager in Florida went to court to force a hospital to cease his treatment.
For a diabetic, the basic disease that disabled the kidneys is still in place when the new kidney is brought into play. That complicates decision-making in a situation where there are more candidates for transplants than there are available organs.
``The problem is,'' Lucas says, ``diabetics don't do nearly as well as nondiabetics over the long term, and the same thing can be said for persons with severe heart disease or other serious problems. It's a gray area.
``The longer you spend in the field, the more patients you see, I think the clearer one's mind is on which case is a good idea to pursue and which is not. I can't define it.
``For myself, some of the patients I've gotten the greatest satisfaction from are diabetics. We've got several now who've been 15 to 20 years with their kidney transplants, raised children from the age of 3 or 4 who are now of college age.''
For the vast majority of transplants, those involving muscular and bone tissue, the immune reaction seldom or only slightly comes into play. And there is less of a tissue shortage, since one donor serves many.
``Heart valves might to some extent be in short supply,'' says Jim Weixel, consultant for the American Association of Tissue Banks. And in the event of catastrophic accidents, where there are a lot of fire victims, there could be a temporary shortage of cadaver skin. The skin transplants are used to help the body retain fluids and prevent infection in the early weeks after injury until the patient's own skin grows back, usually a matter of weeks.
``Now, there are new techniques that plastic surgeons have developed in recent years,'' Weixel says. ``It's just incredible what they can do in saving patients who have third- and second-degree burns over a lot more than 50 percent to 60 percent of their bodies.''
When cadaver skin is rejected, doctors turn to grafting the burn victim's own skin. And now they are experimenting with growing a patient's own skin in vitro.
Cadaver bone is one of the most commonly used transplant substances. It acts as a scaffold for the patient's own bone-building processes. Sometimes whole bone, cleansed of the marrow, is used and sometimes only powdered bone, treated to remove the calcium, is used, often for jaw regrowth after periodontal disease.
Cadaver ligaments and other sinew help mend the knee joints and vulnerable flexion points in everyone from sports figures to the elderly.
Cadavers are selected just as carefully as are organ donors, but with these tissue transplants the pace is more leisurely. Organ transplants are done under emergency procedures.
All donors are checked for a history of hepatitis, HIV, any sexual disease, and dementing disorder such as Alzheimer's where the cause is unknown but might be contagious. Bodies are checked for tattoos and needle marks, anything that might betray the lifestyle of the would-be donor.
Then acceptable tissue is checked for compatibility with the waiting patient.
There are new efforts to increase the number of organ donors, but there is an ambivalence over the practice in the United States. That's one reason why so much interest focused on the family of Nicholas Green when his parents donated their 7-year-old son's kidneys, pancreas, liver and heart after he was mortally wounded while vacationing in southern Italy.
``Most of the public opinion polls show that 90 percent to 95 percent of Americans have positive feelings about transplantation,'' Lucas says. ``They want to have transplants available, either for themselves or their families or friends.''
But 20 percent to 25 percent say they definitely would not donate their own organs, nor would they allow members of their families to donate. Another 20 percent say they would give donation serious consideration.
That leaves ``a big gap of almost 50 percent who want transplants available but aren't sure of their commitment to being a donor,'' Lucas says.
So how do you get would-be donors off the dime?
One of the problems, Lucas says, ``is we have a flawed donor card. It was basically a good idea back when almost every state put some form of donor card on the drivers' licenses. And the flaw is it only gives people the choice to be a donor.
``What I think we should have been doing 20 to 25 years ago was to push the concept that everyone needs to make a decision on what to do at the time of death in terms of the disposition of their body, particularly the transplantable organs and tissues.
``So if we had pushed a donor card that everyone would sign and it would give everyone the choice of either being a donor, restricting the donation of organs and tissues, or not being a donor, or sitting on the fence and saying let someone else make that decision when I die, then everybody would be confronting this question.''
As it is, Lucas says, people have just pushed the question aside. There just doesn't seem to be any urgency to think about it. And because of that they usually don't discuss their wishes with their families.
That opens another barrier to organ donation, the consent of the family of the deceased. In spite of donor cards, they must give their consent.
``This very important decision, this potentially life-saving decision, that could benefit several people, has to be made in the worst possible setting,'' Lucas says. ``You're asking for organ donation of a person whose husband or wife or other close relative has just died, usually very suddenly and unexpectedly. They're emotionally distraught and don't want to deal with anything. ...
``So it is not surprising that the consent rate is as low as it is. In Kentucky where I work, every year it ranges from 50 percent to 70 percent lack of consent.''
``That's a problem that has yet to be solved,'' says Dr. Margaret Allen, a surgeon at the University of Washington and president of the United Network of Organ Sharing. ``There have been a lot of suggested solutions for that. ... It's possible but uncommon that the individual who dies would have signed a donor card, but the family would be strongly against it.
``On the other hand is the more common situation, where a lot of people haven't thought about whether they want to be a donor or not. They don't make their wishes known.''
That enables UNOS to obtain more organs than they would have otherwise received relying on donor cards alone, Allen says.
Among the options available to swell the ranks of donors are changes in state legislation which would mandate some decision by citizens, changes in law that would make sure that donor cards are honored, but more basic is a realistic attitude toward organ sharing.
Organ seekers are becoming much more sophisticated in their methods. Now specially trained people, rather than a busy doctor, are sent to grieving families to obtain their permission to obtain organs.
And for those fearing mutilation, specially trained people who take tissues such as bone are under stringent rules to respect the body as if it were living and to rebuild any areas of the body from which major excisions are taken.
For the transplant people, the decision of who gets an organ and who does not is a painful one.
``For a lot of these questions there is no right or wrong,'' Allen says. ``In organ donation we've gotten very good at rationing health care. So we try to balance medical equity with justice.''
Behind all the reasoning is the fact that for every organ transplanted, two desperately ill people are waiting, and a new name is added to the list every 20 minutes. And each day eight people die because they could wait no longer.
by CNB