LHSC's Multi-Organ Transplant Program: a rich history of innovation, bold future ahead
Forty years ago, Dr. Cal Stiller and a team of researchers with the multi-organ transplant program at University Hospital were one of the first centres in the world to conduct a clinical trial using new anti-rejection medication cyclosporine.
Just 14 months after the cyclosporine trials began, physicians found a significant decrease in organ rejection. The success in kidney transplants jumped from 50 per cent to 80 per cent survival one year after surgery.
With cyclosporine many more transplant recipients survived and thrived.
Fast forward to 2019 and LHSC has celebrated its 6,000th transplant.
The landscape of organ transplantation has changed significantly. Surgeons are now able to transplant some organs or partial organs from living donors. The definition of death and donation has evolved. And, research is leading to a future where organ donation may become obsolete.
Where we are now
The past years have seen the continuation of significant advancements in transplantation including organs from a living donor.
The ability to transplant kidneys and partial livers from living donors has led to an increase in the number of transplants at LHSC.
“The laparoscopic retrieval of kidney donor organs has been a tremendous benefit for living donors. We are able to remove kidneys from living donors through a small incision,” says Dr. Anthony Jevnikar, Co-director of the LHSC Multi-Organ Transplant Program. “It is an altruistic decision to donate a kidney. In the past it sometimes took longer for the donor than the recipient to get back on their feet after surgery, so the laparoscopic process has provided for an easier healing process.”
There was a time when living donors had to be family members who were an appropriate match to donate a kidney or partial liver. But this is no longer a restriction.
Canadian Blood Services offers a Kidney Paired Donation Program for potential donors who are not compatible with the intended recipient, says explains Corinne Weernink , a longtime transplant donor coordinator with LHSC and now the quality and safety specialist with the transplant team.
The national program provides individuals an opportunity to become a living donor and donate a kidney to someone in need and, in doing so, provide transplant candidates an increased opportunity to receive a transplant.
“Five years ago our living donor kidney program had about 20 transplants. Last year we had more than 40 living donor transplants,” says Weernink.
Before donating, the potential donor must undergo an assessment, which usually takes about three to six months for all the test results to become available.
Because there is the potential risk of disease transmission from the donor to the recipient, the assessment includes a detailed questionnaire, medical history, physical exam and blood tests.
Potential donors need to meet with the Living Donation Team including a donation coordinator, social worker, surgeon and nephrologist. The team wants to ensure that the living donor's own health is protected.
The process is similar for living donors giving a portion of their liver for transplant but includes more rigorous testing. The best candidates for living liver donation are family members and close personal friends of the recipient. Anonymous living donors may also be considered.
Living donors should meet these criteria:
- be in excellent physical and psychological health
- be between the ages of 18-55 years old
- have a compatible blood type with the recipient
- come forward to donate voluntarily
- be a healthy weight and about the same physical size (or larger)
- have no history of long-term (chronic) illness such as cancer, diabetes, heart disease
The potential donor will undergo a series of complex tests to ensure that the liver is working well. These include an ultrasound, echocardiogram, stress test, and different types of scans to determine the liver's size and shape as well as the condition of the bile ducts.
Throughout the process potential donors are informed about the risks and can choose to decline at any point before surgery.
For some patients, receiving a new organ transplant has to wait because they are just too sick to undergo transplant surgery.
Patients waiting for a new heart may need a device that can help support them until they are well enough for surgery.
Short-term ventricular assist devices (VADs) can be a temporary ‘bridge’ to maintain the heart and improve the function of other organs.
“The device is used in two different scenarios. First, it may be used as a bridge to transplant or secondly, as a destination, an external support for the heart,” says Weernink.
These bridge devices enable patients to recover and wait until a donated heart become available. And while some have received a heart transplant, others have recovered enough to no longer need a transplant.
With more than 700 transplants over the past 30-plus year, LHSC has performed among the highest number of heart transplants in Canada.
Forward thinking, future thinking
At a Canadian National Transplant Research workshop, Dr. Jevnikar recalls a donor mother and recipient son talking about their experience.
After their talk, they were asked what they thought should be done to improve transplantation. The mother suggested that clinicians and researchers figure out what caused the disease in the first place in order to avoid transplantation altogether.
“That was a great moment that turned on lights for many. Patients spend a lot of time thinking about their condition obviously, and often provide us with forward thinking …future thinking on how we might make transplantation better,” says Dr. Jevnikar.
This kind of forward thinking is apparent in the recent ability to use the organs of donors with hepatitis C.
“If someone with hepatitis C received a liver transplant, they’d often end up with hepatitis C recurring in the liver. Now we have very effective anti-viral drugs that patients can take for hepatitis C that can cure those patients. Amazing to see how this has changed the face of liver transplantation. ” says Dr. Patrick Luke, Co-director of the Multi Organ Transplant Program.
“This has also opened up an opportunity for us to use donor organs with hepatitis C for transplant as the recipient can receive a lifesaving and excellent organ and then can have the hepatitis C eradicated. LHSC was among the first in Canada to do this with kidneys, and it has certainly increased the number of donor organs.”
Giving patients the best chance of living with a new organ is also about providing the best functioning organ. Eliminating the impact of storage time between donation and transplantation is an important component of that.
“With new preservation techniques we can transfer organs such as liver, heart and kidney, to transplant centres in other parts of the country. However, there are limitations in terms of time between donation and transplantation,” says Dr. Luke.
Researchers at Lawson Health Research Institute in London are at the forefront of studying different molecules to protect organs during the storage period, adding molecules to the preservation solution to prolong organ storage without risk of tissue injury. For details on this groundbreaking research see the Summer 2018 edition of Inside LHSC.
Other research ahead will address ways to influence the body’s immune system so that there is less likelihood of organ rejection. While cyclosporine and similar drugs are highly effective in reducing acute rejection in the short term, there can be potential adverse side effects over the long term.
“We are looking at clinical research strategies where patients are temporarily on anti-rejection drugs, and then weaned off. We are currently looking at the best approach to apply this research to patients,” says Dr. Jevnikar. “We recognize that patients are the real pioneers in achieving what we do in transplantation. It is their bravery and trust in us that keeps advancements in patient care going.”
Another area of research in the coming years, one that could revolutionize the entire focus of transplantation, will be the repair and regeneration of organs.
However far into the future this seems, Dr. Jevnikar predicts that in 40 years or so the word transplantation will go into disuse.
“So when we explain to our great great grandchildren why we did organ transplants, we’ll say we didn’t have any other options at the time,” says Dr. Jevnikar. “Instead we’ll be rehabilitating and refurbishing damaged organs, or perhaps even creating new organs, so they’ll work in patients in need.”
“We have always thought beyond transplantation. Our goal is to cure patients and transplantation is the tool we have at hand now. In the future I hope we will be able to do better than transplantation.”