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'Marginal' Organs Can Be Another Shot at Life

July 16, 2001|PAUL ENGSTROM | WASHINGTON POST

After suffering a second heart attack, Eugene Steele faced a do-or-die decision: Accept a heart transplant or wait for congestive heart failure to take its toll. A no-brainer, you'd think--except the only heart available to the retired electronics manager from Oxnard was one from a 63-year-old stroke victim. Steele, then 67, knew his chances of leapfrogging a long list of younger candidates for a more-pristine organ were almost nil.

He didn't hesitate. Before the transplant, doctors at UCLA Medical Center performed a single bypass on the donated heart to improve its function. More than five years later, Steele feels healthy and strong, and his new--or, more accurately, previously used and reconditioned--heart seems to be functioning normally. He recalls that he wasn't too concerned back then about receiving a less-than-perfect organ.

"It didn't bother me at all. I'm pretty realistic," Steele says. "I realized that whatever I got was going to be gravy."

Like Steele, a growing number of transplant patients and their doctors are wagering that receiving an old or even defective kidney, liver, heart or pancreas is a better bet than waiting for an ideal organ that may never become available.

Hoping to help meet the burgeoning demand for transplants, which outstrips supply by more than 3 to 1, surgeons nationwide are implanting donor organs that only a decade ago were deemed too old or damaged or otherwise unusable. Now such organs--called "extended criteria" organs--are routinely transplanted, giving longer life and new hope to recipients, many of whom are seniors.

"If you've got a patient who's already between 60 and 70 years old, waiting five years on dialysis means they're not going to be a very good candidate when their time comes" for a kidney transplant, says Jimmy Light, director of transplant services at Washington Hospital Center. "One way to shorten the wait is to trade off donor quality."

Says James Palleschi, a transplant surgeon and co-founder of the Northern California Kidney Transplant Center in Santa Rosa, "Everybody is pushing the envelope" on donor organs that in the past would have been discarded as unsuitable.

Many physicians, patients and patient advocacy groups are cautiously applauding the approach--because it boosts supply.

"Anything that will expand the donor pool is bound to benefit patients, and therefore is something we would support," says Stewart Van Scoyoc, a lobbyist for the Patient Access to Transplantation Coalition in Washington. Manikkam Suthanthiran, editor of the journal Transplantation, estimates that using marginal organs may reduce demand by roughly 10% to 15%--"not a trivial amount," he says.

But the practice also raises a host of difficult ethical questions. These include: How much of a say do patients have--or should they have--in the decision to transplant a marginal organ? What are the standards for selecting and using such organs? Should those standards differ according to the age of a recipient? For now, there are no fixed answers.

The easing of transplant criteria owes a lot to medical advances within the last two decades. One is the refinement in organ-rejection drugs.

For example, several new immunosuppressants are now available in addition to cyclosporine. Doctors can use precise combinations of these drugs to target specific parts of the immune system in a way that makes the body less likely to reject implanted tissue while exposing the patient to less toxicity.

Better infection management, more experience on the part of surgeons and careful selection of organ donors and recipients have also helped make it possible to relax transplant criteria. Last year, surgeons performed about 22,800 transplants in the United States--nearly 1,200 more than in 1999. But demand has grown at an even faster rate. As of mid-June, nearly 77,000 people were on the national waiting list for an organ, according to the United Network for Organ Sharing (UNOS), a Richmond, Va.-based private, nonprofit group that maintains the list under contract with the federal government. Each day, according to UNOS, an average of 15 of those people die.

Exacerbating the organ shortage has been a decline in recent years of highway deaths, thanks partly to laws requiring seat belts, airbags and motorcycle helmets--and tougher enforcement of drunk driving laws. Fewer such deaths means fewer potential donors.

Kidneys are the most frequently transplanted major organ, followed by livers, hearts and the pancreas. Lung, kidney-pancreas, intestine and heart-lung transplants are performed as well.

What makes an organ marginal varies with the organ.

A less-than-ideal kidney may be one that, because the donor is in his 50s or 60s, can't filter waste products from the blood as well as it once did, or whose vessels have deteriorated over time. Yet the kidney still has enough "tread" to enable an elderly recipient to live out his or her remaining years.

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