Sunday, June 22, 2003

Hospital's cutting edge

By revising standards for donated organs, surgeon breaks record for liver transplants

By Tim Bonfield
The Cincinnati Enquirer

[IMAGE] Andrea Smith, 38, of Springboro had a liver transplant April 2 at University Hospital. Her liver was starting to fail.
(Michael Snyder photo)
| ZOOM |
A new doctor has turned University Hospital into Ohio's most prolific liver transplant program in less than a single year by accepting organs that were rejected by all the other transplant centers in the state.

With half a year to go, University Hospital has performed 49 liver transplants, surpassing an annual record for the center set in 2000 and eclipsing all other centers in the state.

The dramatic increase has occurred because Dr. Steven Rudich, the director of liver transplant services at University Hospital since December 2002, has extended the definition of a transplantable organ. The center now uses "extended criteria donor" organs, including older organs, organs with higher percentages of fat, and others previously considered unacceptable.

"Until recently, Ohio was a net exporter of livers. So we decided to take a more aggressive approach to getting people off the waiting list," Rudich said. "Last year, Ohio sent nearly 50 livers out of state. I realized we could build this program just by taking the livers that were being shipped out for transplant in people in other states."

Through March 31 - the most recent statewide data - University Hospital had performed 20 liver transplants. That's more than double the nine transplants performed during the same period at the renowned Cleveland Clinic, and well above the 12 transplants performed at Ohio's other three adult liver transplant centers combined.

Waiting list

As of Thursday, the number of liver transplants done at University Hospital had climbed to 49 - eclipsing the center's annual record of 41 transplants performed in 2000. Cincinnati's liver transplant program was launched in 1986.

The increased activity has resulted in cutting the local waiting list for liver transplants by nearly two-thirds - from 43 at the beginning of the year to 15 as of Thursday.

"I don't know what a marginal donor is anymore," Rudich said. "In terms of age, the upper limit for a donor used to be 60. But I've used an 84-year-old organ for a 65-year-old lady, and she's doing great," Rudich said.

The recipient in that case was Barb Horton, now 66 and living in Springfield Township. She had been on the waiting list for about a year when a call came to her home on a Friday night, Jan. 10. The surgery was completed Jan. 11.

"They told me the age of the donor," Horton said. "I was shocked at the time, but I said, 'Why not?' A lot of people die on the waiting list."

In fact, an average of 17 people a day nationwide die while on waiting lists for organs, according to the United Network for Organ Sharing. While about 5,000 cadaver organs are donated each year, the waiting list for liver transplants exceeds 17,000.

Horton is not concerned about accepting a liver that was older than her.

"How many people do you hear of dying because their liver just wore out from old age? If it extends my life another 20 years, that would be fantastic," Horton said.

About two-thirds of the organs transplanted in Cincinnati were rejected by other surgeons for use in people higher on the waiting list.

Every organ that is donated in Ohio is first offered to the sickest person on the waiting list who also has the right blood type and the closest tissue match among all the transplant centers in Ohio. The sickest people on waiting lists in Michigan and Indiana also get a first chance at organs donated in Ohio.

Evolving standards

An organ can be rejected for various reasons. The potential recipient might be too sick at the moment to tolerate the surgery. There could be size or age mismatches between donor and patient. Surgeons could have a variety of medical concerns.

Once rejected, the organ procurement center starts calling other transplant doctors to see if they have anyone else on the waiting list who might be a good match.

"We've put out the word that we want to be aggressive, that we will consider ECD organs," Rudich said. "They know to call me."

As recently as five years ago, most transplant centers shied away from accepting livers from donors over 60 years old. Most would reject an organ with more than 30 percent fat content out of fear that the organ would be more likely to fail soon after transplantation - a condition called primary non-function.

Even serving time in jail (a risk factor for hepatitis and AIDS) could cause rejection of a donated liver.

Now, some centers are transplanting 80-year-old livers and others with up to 60 percent fat.

But as yet, there are no widely accepted new standards.

Rudich said his views about liver transplantation were shaped in large part by conversations with Dr. Joe Tector, a transplant surgeon who moved to Indiana University two years ago from the University of Miami, which Rudich describes as one of about 10 aggressive transplant centers nationwide.

"Tector told me, 'Whatever you learned about acceptable risk, put that in the toilet,' " Rudich said.

From improved anti-rejection drugs to faster surgical techniques to gradually increasing understanding of how livers actually work, everything about liver transplantation has evolved since the 1980s, Tector said.

Nationwide, 450 to 550 livers are donated but not transplanted each year, according to the United Network for Organ Sharing.

"Donating a loved one's organs is one of the ultimate acts of altruism. It's done during a time of terrible grief, and nobody knows who gets helped. So it's a shame to lose any donated organ," Rudich said.

Taking a risk

While patients often are thankful just to get the chance at a transplant, University Hospital is taking some risks by using more marginal livers.

"Primary non-function is the biggest concern," said Dr. David Vogt, surgical director of the liver transplant program at the Cleveland Clinic. "Not only does the patient die if you cannot perform an emergency re-transplantation, using a second organ impacts other patients on the waiting list."

Comfort level

Dr. Vogt acknowledges that University Hospital and other centers in other states have successfully transplanted livers that the Cleveland Clinic rejected, but he disputes that his center is overly conservative in accepting organs.

"We all have our own levels of what we're comfortable with. We may not be using quite the same donors as Cincinnati would, but we have clearly expanded our criteria versus five or six years ago," Vogt said.

Rudich says 100 percent of transplants performed this year at University Hospital have survived 90 days, the time frame when primary non-function, post-operative infections and early signs of rejection would be expected to appear.

As for how the revamped program fares on five-year survival rates, it will take nearly five more years to get an answer, Rudich said.


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