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.
In February 2000, Joseph Payne, a retired math professor in Charlottesville, Va., received a well-worn but acceptable kidney at Washington Hospital Center at age 70--from his wife, Ruth, who was 71. His other option was ultimately to go on dialysis three times a week, an expensive and disruptive regimen, while waiting up to four years for an organ from a younger donor.
"My sense was that if there were a transplant possibility, I might not get a prime kidney, which would only have been fair," Payne says. "When you get to be 70, you don't want to take a kidney away from a healthy 30-year-old."
A marginal liver might be one with excess fat from an obese donor. In recent years, experts have learned that although too much fat makes it difficult to store the organ for long, it doesn't necessarily mean the liver will malfunction after transplant, as surgeons once feared.
Even livers with hepatitis are usable, although only in recipients who already have the infectious disease, says Johann Jonsson, director of the abdominal transplant program at Inova Fairfax Hospital in Falls Church, Va. "The liver might not be as good as one from a 20-year-old healthy person," he says, "but it's still a lifesaving operation for someone with hepatitis. Especially in the last five years. We've gotten more aggressive in trying to use livers that previously were not considered."
Defective donor hearts include those that first need a bypass--sometimes more than one--while a marginal pancreas may be slightly scarred, fibrous, fatty or damaged by hypertension drugs called vasopressors. Such a pancreas is acceptable if, before transplant, close inspection shows the that damage isn't too great and that the vasopressors are flushed, says Robert Corry, director of pancreas transplantation at the University of Pittsburgh Medical Center.
Many considerations--including medical urgency, time spent on a waiting list, blood type, organ size and genetic makeup--go into matching a donor and recipient. Determining whether a less-than-ideal organ is suitable for transplant adds another wrinkle to this already complex matter.
It's difficult to gauge the overall success of this surgical approach because transplant circumstances and the different types and status of organs vary so much. So far, researchers comparing the performance of marginal and ideal organs have generally studied only a small number of organs at single transplant centers.
Still, most studies paint a promising picture. In a 1999 paper published in Transplantation, for example, Corry reported no significant difference in the survival of 137 patients about two years after they had received either a marginal or "nonmarginal" pancreas at his center. In the same journal and year, researchers in Madrid wrote that three of four livers from donors in their 80s were performing well seven, 16 and 24 months after transplant.
As the practice of using marginal organs becomes more widespread, it is raising a few ethical flags. For one thing, not all transplant centers or surgeons tell patients beforehand that they will get a marginal organ, says Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania in Philadelphia.
"There are a few programs where you know that older organs and older recipients are being used. But in other cases, if an organ comes from someone who's not quite as healthy or if the organ has been damaged a little bit when taken [from a donor], people just don't discuss it, to put it bluntly," Caplan says.
He attributes the hush-hush attitude partly to surgeons who "relish autonomy" and "don't want their judgment interfered with." Indeed, surgeons have a great deal of discretion in deciding whether a donor organ is usable and appropriate for a given patient, based on their experience and expert judgment.
Sugeng Sukolono, 42, a clothing salesman in Alexandria, Va., says he was "pretty disappointed" to learn after receiving two kidneys at Georgetown University Hospital in September that both organs had come from a donor older than age 50. One of the kidneys later failed and was removed. The remaining kidney, although it's not functioning perfectly, is working well enough that Sukolono has time to ponder his next course of action. He may have to return to dialysis or undergo another transplant.
"Now, it is getting a bit better," he says. "But my energy level isn't as high as it was when I was on dialysis."
Marc Lorber, a surgery professor at Yale University and president of the American Society of Transplant Surgeons, says his peers--at least those in New England--are getting better at telling recipients up front about the stakes. He cites one organ procurement organization that has a separate waiting list for patients who agree to accept a marginal organ.
This arrangement, Lorber explains, not only keeps patients well-informed, but also speeds the transplant process when organs become available because the related issues have been resolved.
Another concern for Caplan is the lack of objective national standards to guide the selection and use of all marginal organs. Practices vary, he says, from one region to another.
And he says no one appears to be tracking outcomes on a large scale so that physicians will know over the years which procedures work best under which circumstances. "[That] should be mandatory when you're pushing the frontier," he says.
Medical centers around the country do send a wide variety of transplant data to the Scientific Registry of Information on Transplant Recipients, maintained by the University Renal Research and Education Assn. in Ann Arbor, Mich. But so far, data in the registry about marginal organs covers only kidneys.
For his part, Lorber says he's convinced that the benefits of using marginal organs outweigh the risks as long as surgeons proceed cautiously and do their absolute best to match donors and recipients. He points out, for example, that transplant teams are paring the amount of time between removal and transplantation of organs, which, especially in the case of less-than-ideal organs, makes success more likely.
But some patients, at least, still have reservations.
Glen Greenwood, a 43-year-old freelance artist, didn't learn that he would get a normal kidney but only a partial pancreas--one that had been damaged by gunshot wounds--until after he had traveled from his home in Midland, Texas, to the University of Texas Medical Branch at Galveston.
A longtime diabetic, Greenwood had seen his health deteriorate by the time he underwent the kidney-pancreas transplant in August 1999. He describes dialysis as "hell--I'd rather be outright dead."
The donated pancreas subsequently failed, so he now takes insulin four times a day as he weighs his options.
Although Greenwood isn't pleased with the transplant outcome, he's also convinced he couldn't have tolerated any more dialysis, which caused chronic nausea and constipation.
"If I had been told it was a partial pancreas, I might have reconsidered," he says. "But I was desperate."
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Organ Transplant Web Sites to Visit
* TransWeb.org: Provides information and resources on organ donation and transplants, including facts and myths, profiles and educational materials. (734) 998-7314 or http://www.transweb.org.
* American Organ Transplant Assn.: Helps recipients raise money for transplants; directs them to appropriate medical centers and arranges transportation. (281) 261-2682 or http://www.a-o-t-a.org.
* Transplant Recipients In-ternational Organization: Provides information and resources on organ donation and transplants. (800) 874-6386 or http://www.trioweb.org.
* National Transplant Society: Promotes organ and tissue donations; maintains an organ repository. (847) 412-0604 or http://www.organdonor.org.
* U.S. Department of Health and Human Services: Provides information and resources on organ donation and transplants. http://www.organdonor.gov.
* United Network for Organ Sharing: Maintains organ-recipient waiting list; collects and disseminates data on transplants; provides resources. (888) 894-6361 or http://www.unos.org.