Organ Transplant Programs Are on the Rise in San Diego

Vicki Lamberton doesn’t need prompting to remember the date on which a Denver doctor diagnosed a rare medical condition that eventually placed her fate in the hands of UC San Diego Medical Center, and a team of specialists that hopes to save her life with a heart-lung transplant.

“Feb. 20, 1986. Two, 20, 86,” said Lamberton, a 35-year-old Denver resident who since has entered the date on countless hospital forms. But Lamberton, the mother of two young boys, is awaiting an even more important date: the day when a heart-lung donor makes her transplant--the first such operation in San Diego County--possible.

“Waiting has always been the problem,” said Dr. Stuart Jamieson, who heads the UCSD transplant team that will perform Lamberton’s operation. Waiting is “a very risky thing to do, but in these cases there is no alternative.”

Lamberton, her husband, Vincent, and their two sons are now living at a relative’s house in Moorpark. “We had a choice of moving straight to San Diego or coming here to live with my sister and arrange for air transportation,” Lamberton said.

She is one of a growing number of people awaiting transplants in San Diego. But the lengthening list is not the result of more people getting sick. Rather, San Diego is undergoing a boom in the number of transplant programs at area hospitals.

UCSD, Sharp Memorial Hospital and Scripps Clinic have recently announced or opened new transplant programs or expanded services provided by existing programs. Those hospitals plan to eventually add new heart, heart-lung, kidney, liver and pancreas transplant programs. Mercy Hospital has placed a proposed heart transplant program on hold until a chief surgeon is located.

Sharp and UCSD now have a total of nine patients on their heart transplant lists. They have three patients awaiting heart-lung transplants and three awaiting single lung transplants. UCSD also has 120 patients awaiting kidney transplants.

There are no liver transplant programs in San Diego, although several hospitals are now contemplating them.

Some critics have argued that the highly specialized and expensive transplant units--a relatively straightforward heart transplant can cost $100,000 or more--will needlessly boost local health care costs by duplicating services available elsewhere. The critics maintain that San Diego’s hospitals, in an era marked by skyrocketing health costs, should dedicate scarce capital to other, more pressing needs.

Questions have also been raised about whether the new programs can match the success rates of the more established surgeons.

Hospital administrators in the past have given a variety of reasons for the addition of expensive transplant programs. Most claim the programs allow them to better serve their patients’ overall health needs. Others have acknowledged that the programs give hospitals a certain status and greater ability to attract top-notch doctors.

Competition among local hospitals that perform major organ transplants moved into a new phase last weekend when UCSD became the second local hospital to perform a heart transplant. Sharp has been transplanting hearts since 1985. UCSD surgeons previously did the transplants through a program based at Sharp.

Jamieson said that at UCSD, the expanding transplant program plays an integral part in the hospital’s role as a teaching institution. The program “fits in with our reputation for handling difficult cases,” he said.

He also noted that the heart transplants are a small part of the total work performed by him and other members of the team. During the past week, for example, Jamieson performed the heart transplant as well as several open-heart surgeries that included a major operation on Roger Revelle, the noted scientist and co-founder of UCSD.

Dr. Ron Adamson, co-director of Sharp’s transplant program, suggested that patients will be better served as the number of transplant centers increases, because physicians must spend a hefty amount of time with patients who need time-consuming postoperative care.

Health care officials defend the increase in transplant programs by saying that San Diego is merely catching up with the growth of such programs elsewhere in the country. “San Diego is the sixth-biggest city in the U.S., and most cities of its size already have two heart transplant programs,” Jamieson said. “Boston and Kansas City each have four.”

“San Diego is actually one of the last major metropolitan areas to undergo this kind of growth,” said James A. Cutler, recently named executive director of the Organ and Tissue Acquisition Center in San Diego, which is charged with locating and transporting donated organs and tissue in San Diego and Imperial counties.

Local transplant programs may make the expensive operations available to “the majority of people who probably can’t afford to manage moving out of town to be near a hospital,” Cutler said.

Typically, health insurance rules and a patient’s doctor determine where transplants are done. Local hospitals accept patients from around the country, and San Diegans are not restricted to programs at local hospitals.

UCSD’s first heart transplant represented a major step in its planned expansion of its existing program, which had been limited to kidneys. Like many hospitals, UCSD also transplants corneas, bone and skin tissue. It also conducts skin grafts and, several years ago, made an ill-fated attempt to perform liver transplants.

UCSD’s heart transplant patient, Gary Troxel, a 25-year-old construction worker from Riverside County, is “well ahead of schedule” in his recovery, Jamieson said late last week. Jamieson moved his transplant team “lock, stock and barrel” from the University of Minnesota. In that program, 93% of the patients have lived at least three years after their transplants.

Jamieson, who completed his first heart transplant on July 4, 1979, described the operation as “pretty routine . . . but it was strange to be doing this operation in an environment (UCSD) where one had not been done before.”

The flurry of media activity that accompanied the UCSD transplant contrasts with the scene at Sharp, where doctors last week completed their 70th heart transplant.

“We no longer hear from the press each time we do an operation,” said Adamson.

Sharp’s heart transplant program has a survival rate beyond the national averages, he said. No one has died on the operating table, he said, and ‘we have . . . a 97% one-year survival rate and an 80% survival rate 4 1/2 years later.”

While heart transplants today are viewed as a relatively common form of therapy, Jamieson and Adamson noted that the next frontier in San Diego--the heart-lung combination--is a more difficult procedure.

“It’s still a very specialized operation,” said Jamieson, who performed his first heart-lung transplant in 1981.

“Survival rates are not as good as heart (transplants), but we’re getting better all the time,” Adamson said.

In a strategic move last fall designed to bolster its transplant prowess, Sharp announced a joint venture with Scripps Clinic & Research Foundation. The two hospitals have agreed to work together to improve Sharp’s heart-lung and lung transplant capability. In December, Sharp identified its first candidate for a heart-lung transplant, Adamson said.

The hospital is in “final negotiations” with a surgeon who will conduct kidney transplants, he said. That would place Sharp in competition with UCSD.

Sharp’s agreement with Scripps also calls for the development of a liver transplant program at Scripps’ Green Hospital. Both Sharp and UCSD abandoned liver transplant programs several years ago after running into difficulties. The UCSD liver program is “on hold,” according to a UCSD spokeswoman.

Judging from experience, getting a new program on track in San Diego can be difficult. Mercy, for example, recently put its heart transplant program on hold after its newly hired director encountered contractual problems with his previous employer. Last year, a proposed heart and lung transplant program at Scripps Clinic suffered a setback when federal administrators determined that the surgeon hired to do the operations lacked the proper credentials.

It can also take time for a program to mature. Sharp initially announced its intention to create a heart-lung transplant program in 1988, but is still awaiting an appropriate donor to make the first operation a reality.

Nationwide, there are 223 kidney transplant programs, 147 heart programs, 79 liver programs, 74 pancreas programs, 70 heart-lung programs and 55 lung programs. A year ago, there were 199 kidney programs, 112 heart, 49 liver, 23 pancreas, 35 heart-lung and 12 lung.

At the end of January, nearly 250 people nationwide were awaiting heart-lung transplants; about 1,400 needed heart transplants; 844 were awaiting liver donations; 101 required new lungs; 320 required pancreas transplants, and 16,315 needed kidneys.

Nationwide, transplant teams with patients who need immediate care are frustrated by a lack of donors. Last year, for the first time, the number of heart transplants performed in the United States fell from the previous year’s total, Jamieson said.

“The reason is not because the number of centers is down--the total continues to grow--but (donations) have plateaued out at about 2,000 in the U.S,” he said.

“There’s no doubt that you’ve got to get the organs or the programs can’t grow,” said Doug Heiney, membership affairs manager for the United Network for Organ Sharing, a Washington-based company that oversees nationwide distribution of donated organs. “It’s a ‘chicken-and-egg’ situation. If there are no organs to supply to the transplant center, you’re doomed to failure right from the start.”

In San Diego, donation rates historically have been below the national average, in part because local hospitals were not emphasizing donor recruitment. But during 1989, when the county’s hospitals placed a renewed emphasis on organ recovery, donation rates rose to meet the national average, Cutler said. San Diego’s transplant community believes that, with additional education programs, the local donation rate could exceed the national donation rate during 1990.

East Coast organ procurement officials credit Cutler with playing an integral role in building an efficient organ procurement program for the Washington Regional Transplant Consortium, which distributes organs to six kidney and five heart transplant programs.

In addition to strengthening San Diego’s procurement efforts, OTAC will begin crafting the rules that will govern the local transplant community.

Typically, national regulations determine how donated organs are distributed. But the local OTAC organization can help tailor rules that are more in keeping with San Diego’s special needs, Cutler said.

He intends to bolster San Diego’s procurement effort by making better use of a California law that requires hospital personnel to seek donated organs from the relatives of someone who dies. Cutler believes that many doctors and nurses have not been properly trained to undertake that delicate duty.

“The law shouldn’t force you to do something you’re uncomfortable with,” Cutler said. “That’s what we’re here for. We’ll do the asking.”

However, OTAC’s six staff members are ill-prepared to “go out and educate San Diego County’s 2.5 million residents” about the need for organ donations, Cutler said. For the moment, OTAC is focusing on training the doctors and nurses who typically are on duty when donors are near death.

Even transplant teams recognize that organ procurement “is a tough job,” Adamson said. “Even knowing what I know, it would be a tragic (decision to make). . . . I’m certain I would give permission, and I have a donor card myself, but it still would not be very easy.”

“Most people simply don’t understand how much good organ recovery does,” he said.

The number of recipients generated by one donor can be staggering: According to OTAC, the donor who contributed the heart to UCSD’s first such transplant patient also contributed organs that eventually will end up in as many as 35 different people.

The donors’ two corneas went to individual patients, as did the two kidneys. Skin was donated to five burn victims, and bone and tissue that is being stored will eventually be used to treat as many as 25 other people.

As difficult as it to find suitable hearts for transplants, it is even more difficult to find hearts and lungs that can be used in combination, Adamson said. Those transplants are doubly difficult because “there are two clocks ticking,” he said.

“Our recipients can get real sick, and they face a high mortality rate without transplants . . . but we also have the problem of donors . . . because there are only so many hours between the (donor’s death) and the time when lungs will go bad.”

“We can’t get many heart-lung” donations, Adamson said. “Because there are so many heart recipients waiting, it’s just become very, very hard.”

Because of that severe shortage, UCSD’s transplant team is also considering a single lung transplant for Lamberton, an operation that would relieve some of the stress on her heart. “You have to take what you can get,” Jamieson said. “We can’t always wait for a perfect situation.”

Lamberton, the mother of boys ages 5 and 8, is aware that heart-lung donors are hard to find.

“I know that a person has to die for me to get a transplant,” she said. “The more people I can come in contact with, or who read a story about me, helps. It helps other people, too.”