Solid Organ Transplantation: Looking Back … And Ahead
This article is reprinted from the Fall 2012 issue of Skylight.
Twenty years after the first transplant of a kidney at Dartmouth-Hitchcock Medical Center, the Solid Organ Transplantation Program is at the cutting edge of treatment, research, and policymaking in the field.
"We're the only center in the state of New Hampshire providing transplant care for patients with end-stage organ failure," says David A. Axelrod, MD, MBA, Section Chief of Transplant Surgery since 2005. "This is critical for patients, as well as for trainees across medical disciplines. Transplantation sits at the nexus of research, clinical strategy, and policy development. It's allowing us to move from a one-size-fits-all model to a more humane, tailored, personalized-medicine approach, while lowering the cost of caring for patients with end-stage organ failure." Kidney transplants, for example, are safer and more cost effective over the long term than dialysis. Solid organ transplantation is one of the greatest gifts of modern medicine. Just ask Larry Russ, a 46-year old plumber from Bradford, VT. After decades of managing his diabetes, he is now free of the disease, thanks to his new pancreas transplanted by D-H surgeon Christopher Simpkins, MD, in February of 2012.
"They're right onto everything," says Russ. "They have a nutritionist, transplantation coordinators, a social worker, a financial person—all working with the surgeons. All right there."
Since Axelrod began the pancreas transplant program in 2005, Dartmouth-Hitchcock has developed into the busiest pancreas-transplant center in New England, he says. The program performs 10 to15 pancreas transplants a year for patients with complications from diabetes. Axelrod and his team collaborate closely with experts from endocrinology and nephrology to provide the best possible care for D-H patients. D-H now is the third-largest kidney transplant program in New England.
Back in the early 1990s, Mary Hitchcock Memorial Hospital was administering dialysis to 10-15 kidney patients annually who were candidates for transplantation but had to be referred elsewhere for their transplants. "Now," adds the transplant program's medical director, Michael Chobanian, MD, "we're doing between 50 and 60 (kidney transplants) a year."
The very first organ transplant at DHMC occurred in 1992, when surgeons transplanted a kidney to a 51-year-old Burlington, VT, woman from her brother.
"We probably spent three months getting ready for it," longtime transplant coordinator Cathy Pratt, RN, CTCC, recalls. At that point, the program consisted of Pratt, a pharmacist, a social worker, and Horace Henriques, MD, who performed that initial transplant, she recalls.
In 1997, Chobanian arrived from the University of Wisconsin. A pediatric nephrologist and physician of transplant medicine, Chobanian began an innovative program to wean patients from three immunosuppression medications to one, which meant fewer side effects. This therapy remains rare nationwide, thus drawing patients to the D-H transplant program.
Working with then-Chairman of Surgery, Richard Dow, MD, Chobanian oversaw expansion of the transplant program by recruiting highly skilled surgeons who could broaden and deepen the scope of services the department offered.
Miles to Go
Solid organ transplantation was once a risky procedure with uncertain outcomes. Now, it is the most effective treatment for advanced, life-threatening organ diseases. Still, there are miles to go to improve transplantation care and access.
Currently 4,600 people in New England are waiting for a solid organ transplant and only a small fraction will ever receive one. Hundreds more will never make it onto a waiting list. The reasons are multifold: there are not enough organs available; some patients have hardto- match blood types and immune profiles; and many patients lack the financial resources and social support to go through with a transplant. For example, the total cost of medications needed after a transplant range from $5,000 to $15,000 per year for as long as a recipient lives with the donated organ. Many people in Northern New England simply cannot afford that, even if they are insured by Medicare—which covers immune-suppression medication for only three years after a solid organ transplant.
"Organ transplantation is the greatest gift—the gift of life."
Dr. Richard Freeman, chair of the Department of Surgery and a transplant surgeon, envisions a future where no D-H patient is denied access to a life-saving transplant because of socioeconomic barriers. Freeman hopes to grow the transplant section's family and patient support fund through philanthropy and, one day, would like the section to have its own bed-and-breakfast style house, where patients and their families can stay during the pre- and post-operative periods that don't require hospitalization but do involve multiple appointments and specialized tests at DHMC.
"Organ transplantation is the greatest gift—the gift of life," says Freeman. If his vision is realized, that's a gift that any D-H patient in need of a transplant will have a fair chance at receiving.
"[Dr. Dow] realized that we were working very hard, that it was a worthwhile endeavor," Chobanian recalls. Dr. Axelrod was recruited in 2005, and under his direction, the D-H team has performed 60 whole-organ pancreas transplants and 18 combined kidney/pancreas transplants. He also expanded outpatient transplant services to Manchester, NH, and beyond.
In addition to Axelrod, Chobanian, and Simpkins, the team of transplant providers includes nationally recognized transplant surgeon Richard Freeman, MD, Chair of the Department of Surgery and a member of the board of directors for the United Network for Organ Sharing (UNOS); infectious disease specialist Richard Zuckerman, MD; anesthesiologist Neil Gleason, MD; and cardiologist Salvatore Costa, MD. The staff also includes a group of nurse coordinators, mid-level providers, dietitians, social workers, and transplant administrators—all committed to the care of transplant patients in Northern New England.
The transplant team also is leading the way in improving transplant care locally, nationally, and internationally. Costa recently co-authored a scientific statement for the American Heart Association, outlining the best practices for evaluation of heart disease in patients waiting for kidney or liver transplantation.
Meanwhile, Axelrod and colleagues at the Dartmouth Institute for Health Policy and Clinical Practice (TDI) are examining the outcomes of organ transplants, policies for allocating donor organs—including how to select the best candidates—and variations around the country in the quality and cost of transplants. His work has been published in the Journal of the American Medical Association (JAMA) and the New England Journal of Medicine.
Freeman helped develop and implement the current US allocation system for liver transplants when he was director of the UNOS liver transplant committee. Now he lectures internationally on the topic.
And Zuckerman and Chobanian are collaborating with the D-H immunology department to develop a novel way of assessing the strength of patients' immune systems so doctors can better tailor medication regimens for transplant recipients.
In 2010, the D-H transplant team also participated in the first paired kidney exchange through a national kidney donor matching system. Often an individual may be willing to donate a kidney to a loved one or a friend but are not a good match for that person. The new system, organized by the Organ Procurement and Transplantation Network, matches such willing donorrecipient pairs with other pairs to create a compatible exchange.
As part of the team's efforts to broaden access to new organs to as many patients as possible, Simpkins is collaborating with Dr. Zbigniew Szczepiorkowski, MD, PhD, a transfusion and cellular therapy specialist at D-H, to perform kidney transplants between a donor and a recipient with incompatible blood types. Simpkins brings what Axelrod describes as "unique expertise in this area from his training at Johns Hopkins." Through a post-transplant treatment called plasmaphoresis, conducted in cooperation with the Pheresis Program at DHMC, patients can be safely transplanted across blood group barriers. DHMC is now one of select group of centers nationwide to offer this procedure, giving hope to the hundreds of patients in New England who are waiting for a kidney transplant and have hard-to-match blood types.
Recently, Axelrod and other members of the team began collaborating with D-H gastroenterologist Timothy Gardner, MD, general surgeon Kerrington Smith, MD, and the Massachusetts General Hospital (MGH) on a procedure called islet cell autotransplantation. The procedure is for patients with debilitating pancreatitis whose pain cannot be controlled with medication and requires removing most of the pancreas. The first such procedure at D-H was performed by Axelrod and Smith in May 2012 for a 33-year-old carpenter from Vermont.
While Smith and his team completed the reconstruction portion of the procedure, Axelrod drove the pancreas to MGH, where a special laboratory isolated the cells. Axelrod then returned with the cells, which were infused into the patient's liver, restoring blood-sugar control. Now, several months after the procedure, he remains insulin free and without significant pain. Plans are underway to perform the second procedure of this kind and to ultimately make islet cell auto-transplantation a routine procedure at D-H.
Despite all the efforts of the D-H transplant team to improve access and care, hundreds of patients are still waiting for an organ match—waiting for the chance of a healthier, happier life.
For Larry Russ, the wait for his transplant was worth it.
"Just going on a trip or even on an errand, you're not worrying about having enough insulin for your pump, that kind of thing," Russ says. "You're much freer."
Saving and liberating the lives of such patients is what motivates the D-H team.
"Transplant is a wonderful opportunity to restore a normal life to patients overnight," Axelrod says. "It requires a dedicated team to accomplish this, and I am proud of what Dartmouth has accomplished over the past 20 years."
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