Transplant surgery is the surgical removal of an organ(s), tissue, or blood products from a donor and surgically placing or infusing them into a recipient.
Transplant surgery is a treatment option for diseases or conditions that have not improved with other medical treatments and have led to organ failure or injury. Transplant surgery is generally reserved for people with end-stage disease who have no other options.
The decision to perform transplant surgery is based on the patient's age, general physical condition, diagnosis and stage of the disease. Transplant surgery is not recommended for patients who have liver, lung, or kidney problems; poor leg circulation; cancer; or chronic infections.
The typical cut-off age for a transplant recipient ranges from 40–55 years; however, a person's general health is usually a more important factor. In addition, the percentage of transplant recipients over age 50 has increased since 1996.
On average, 66 people receive transplants every day from either a living or deceased donor. In 2002, about 24,500 transplants were performed in the United States:
- 14,400 kidney transplants
- 5300 liver transplants
- 2200 heart transplants
- 1000 lung transplants
- 900 kidney/pancreas transplants
- 550 pancreas transplants
- 104 intestine transplants
- 31 heart/lung transplants
The national waiting list for most transplanted organs continues to grow every year, even though the number of recipients waiting for a heart transplant has leveled off in recent years, and the waiting list for heart-lung transplants has decreased over the past few years. As of April 2003, there were about 81,000 eligible recipients waiting for an organ transplant in the United States.
Organ donors are classified as living donors or cadaveric (non-living) donors. All donors are carefully screened to make sure there is a suitable blood type match and to prevent any transmissible diseases or other complications.
LIVING DONORS. Living donors may be family members or biologically unrelated to the recipient. From 1992 to 2001, the number of biologically unrelated living donors increased tenfold. Living donors must be physically fit, in good general health, and have no existing disorders such as diabetes, high blood pressure, cancer, kidney disease, or heart disease. About 25% of all the organs transplanted in 2002 came from living donors. Organs that can be donated from living donors include:
- Single kidneys. In 2002, 52% of all kidney transplants came from living donors. There is little risk in living with one kidney because the remaining kidney compensates for and performs the work of both.
- Liver. Living donors can donate segments of the liver because the organ can regenerate and regain full function. The number of living donor liver transplants has doubled since 1999.
- Lung. Living donors can donate lobes of the lung although lung tissue does not regenerate.
- Pancreas. Living donors can donate a portion of the pancreas even though the gland does not regenerate.
Organs donated from living donors eliminate the need to place the recipient on the national waiting list. Transplant surgery can be scheduled at a mutually acceptable time rather than performed under emergency conditions. In addition, the recipient can begin taking immunosuppressant medications two days before the transplant surgery to prevent the risk of rejection. Living donor transplants are often more successful than cadaveric donor transplants because there is a better tissue match between the donor and recipient. The living donor's medical expenses are usually covered by the organ recipient's insurance company, but the amount of coverage may vary.
CADAVERIC OR DECEASED DONORS. Organs from cadaveric donors come from people who have recently died and have willed their organs before death by signing an organ donor card, or are brain-dead. The donor's family must give permission for organ donation at the time of death or diagnosis of brain death. Cadaveric donors may be young adults with traumatic head injuries, or older adults suffering from a stroke. The majority of deceased donors are older than the general population.
ORGAN HARVESTING. Harvesting refers to the process of removing cells or tissues from the donor and preserving them until they are transplanted. If the donor is deceased, the organ or tissues are harvested in a sterile operating room . They are packed carefully for transportation and delivered to the recipient via ambulance, helicopter or airplane. Organs from deceased donors should be transplanted within a few hours of harvesting. After the recipient is notified that an organ has become available, he or she should not eat or drink anything.
When the organ is harvested from a living donor, the recipient's transplant surgery follows immediately after the donor's surgery. The recipient and the donor should not eat or drink anything after midnight the evening before the scheduled operation.
PREOPERATIVE PROCEDURES. After arriving at the hospital, the recipient will have a complete physical and such other tests as a chest x ray , blood tests, and an electrocardiogram (EKG) to evaluate his or her fitness for surgery. If the recipient has an infection or major medical problem, or if the donor organ is found to be unacceptable, the operation will be canceled.
The recipient will be prepared for surgery by having the incision site shaved and cleansed. An intravenous tube (IV) will be placed in the arm to deliver medications and fluids, and a sedative will be given to help the patient relax.
TRANSPLANT SURGERY. After the patient has been brought to the operating room, the anesthesiologist will administer a general anesthetic. A central venous catheter may be placed in a vein in the patient's arm or groin. A breathing tube will be placed in the patient's throat. The breathing tube is attached to a mechanical ventilator that expands the lungs during surgery.
The patient will then be connected to a heart-lung bypass machine, also called a cardiopulmonary bypass pump, which takes over for the heart and lungs during the surgery. The heart-lung machine removes carbon dioxide from the blood and replaces it with oxygen. A tube is inserted into the patient's aorta to carry the oxygenated blood from the bypass machine back to the heart for circulation to the body. A nasogastric tube is placed to drain stomach secretions, and a urinary catheter is inserted to drain urine during the surgery.
The surgeon carefully removes the diseased organ and replaces it with the donor organ. The blood vessels of the donated organ are connected to the patient's blood vessels, allowing blood to flow through the new organ.
Several tests are performed before the transplant surgery to make sure that the patient is eligible to receive the organ and to identify and treat any problems ahead of time. The more common pre-transplant tests include:
- tissue typing
- blood tests
- chest x ray
- pulmonary function tests
- computed tomography (CT) scan
- heart function tests (electrocardiogram, echocardiogram, and cardiac catheterization)
- bone densitometry test
The pre-transplant evaluation usually includes a dietary and social work assessment. In addition, the patient must undergo a complete dental examination to reduce the risk of infection from bacteria in the mouth.
Organ transplantation is an expensive procedure. Insurance companies and health maintenance organizations (HMOs) may not cover all costs. Many insurance companies require precertification letters of medical necessity. As soon as transplantation is discussed as a treatment option, the patient should contact his or her insurance provider as soon as possible to determine what costs will be covered.
Patient education and lifestyle changes
Before undergoing transplant surgery, the transplant team will ensure that the patient understands the potential benefits and risks of the procedure. In addition, a team of health care providers will review the patient's social history and psychological test results to ensure that he or she is able to comply with the regimen that is needed after transplant surgery. An organ transplant requires major lifestyle changes, including dietary adjustments, complex drug treatments and frequent examinations. The patient must be committed to making these changes in order to become a candidate for transplant. Most transplant centers have extensive patient education programs.
Smoking cessation is an important consideration for patients who use tobacco. Many transplant programs require the patient to be a nonsmoker for a certain amount of time (usually six months) before he or she is eligible to participate in the pre-transplant screening evaluation. The patient must also be committed to avoid tobacco products after the transplant.
Patients are legally required to sign an informed consent form prior to transplant surgery. Informed consent signifies that the patient is a knowledgeable participant in making healthcare decisions. The doctor will discuss all of the following with the patient before he or she signs the form: the nature of the surgery; reasonable alternatives to the surgery; and the risks, benefits, and uncertainties of each option. Informed consent also requires the doctor to make sure that the patient understands the information that has been given.
Finding a donor
After the patient has completed the pre-transplant evaluation and has been approved for transplant surgery, the next step is locating a donor. Organs from cadaveric donors are located through a computerized national waiting list maintained by the United Network for Organ Sharing (UNOS) to assure equal access to and fair distribution of organs. When a deceased organ donor is identified, a transplant coordinator from an organ procurement organization enters the donor's data in the UNOS computer. The computer then generates a list of potential recipients. This list is called a match run. Factors affecting a potential organ recipient's ranking on the match run list include: tissue match, blood type, size of the organ, length of time on the waiting list, immune status, and the geographical distance between the recipient and donor. For some transplants, such as heart, liver, and intestinal segments, the degree of medical urgency is also taken into consideration.
The organ is offered to the transplant team of the first person on the ranked waiting list. The recipient must be healthy enough to undergo surgery, available, and willing to receive the organ transplant immediately. The matching process involves cross matching, performing an antibody screen and a host of other tests.
Donor searching can be a long and stressful process. A supportive network of friends and family is important to help the patient cope during this time. The health care provider or social worker can also put the patient in touch with support groups for transplant patients.
Contact and travel arrangements
The patient must be ready to go to the hospital as soon as possible after being notified that an organ is available. A suitcase should be kept packed at all times. Transportation arrangements should be made ahead of time. If the recipient lives more than a 90-minute drive from the transplant center, the transplant coordinator will help make transportation arrangements for the recipient and one friend or family member.
Because harvested organs cannot be preserved for more than a few hours, the transplant team must be able to contact the patient at all times. Some transplant programs offer a pager rental service, to be used only for receiving "the call" from the transplant center. The patient should clear travel plans with the transplant coordinator before taking any trips.
Blood donation and conservation
Some transplant centers allow patients to donate their own blood before surgery, which is known as autologous donation. Autologous blood is the safest blood for transfusion , since there is no risk of disease transmission. Preoperative donation is an option for patients receiving an organ from a living donor, since the surgery can be scheduled in advance. In autologous donation, the patient donates blood once a week for one to three weeks before surgery. The blood is separated and the blood components needed are reinfused during the operation.
In addition to preoperative donation, there are several techniques for minimizing the patient's blood loss during surgery:
- Intraoperative blood collection: the blood lost during surgery is processed, and the red blood cells are reinfused during or immediately after surgery.
- Immediate preoperative hemodilution: the patient donates blood immediately before surgery to decrease the loss of red blood cells during the operation. The patient is then given fluids to restore the volume of the blood.
- Postoperative blood collection: blood lost from the incision following surgery is collected and reinfused after the surgical site has been closed.
A transplant recipient can expect to spend three to four weeks in the hospital after surgery. Immediately following the operation, the patient is transferred to an intensive care unit (ICU) for close monitoring of his or her vital signs . When the patient's condition is stable, he or she is transferred to a hospital room, usually in a specialized transplant unit. The IV in the patient's arm, the urinary catheter, and a dressing over the incision remain in place for several days. A chest tube may be placed to drain excess fluids. Special stockings may be placed on the patient's legs to prevent blood clots in the deep veins of the legs. A breathing aid called an incentive spirometer is used to help keep the pa tient's lungs clear and active after surgery.
Medications to relieve pain will be given every three to four hours, or through a device known as a PCA (patient-controlled anesthesia). The PCA is a small pump that delivers a dose of medication into the IV when the patient pushes a button. The transplant recipient will also be given immunosuppressive medications to prevent the risk of organ rejection. These medications are typically taken by the recipient for the rest of his or her life.
A two to four-week waiting period is necessary before the transplant team can evaluate the success of the procedure. Visitors are limited during this time to minimize the risk of infection. The patient will be given intravenous antibiotic, antiviral and antifungal medications, as well as blood and platelet transfusions to help fight off infection and prevent excessive bleeding. Blood tests are performed daily to monitor the patient's kidney and liver function as well as his or her nutritional status. Other tests are performed as needed.
After leaving the hospital, the transplant recipient will be monitored through home or outpatient visits for as long as a year. Medication adjustments are often necessary, but barring complications, the recipient can return to normal activities about 6–8 months after the transplant.
Proper outpatient care includes:
- taking medications exactly as prescribed
- attending all scheduled follow-up visits
- contacting the transplant team at the first signs of infection or organ rejection
- having blood drawn regularly
- following dietary and exercise recommendations
- avoiding rough contact sports and heavy lifting
- taking precautions against infection
- avoiding pregnancy for at least a year
Short-term risks following an organ transplant include pneumonia and other infectious diseases; excessive bleeding; and liver disorders caused by blocked blood vessels. In addition, the new organ may be rejected, which means that the patient's immune system is attacking the new organ. Characteristic signs of rejection include fever, rash, diarrhea, liver problems, and a compromised immune system. Transplant recipients are given immunosuppressive medications to minimize the risk of rejection. In most cases, the patient will take these medications for the rest of his or her life.
Long-term risks include an elevated risk of cancer, particularly skin cancer. An estimated 6–8% of transplant patients develop cancer over their lifetime as compared to less than 1% in the general population.
In a successful organ transplant, the patient returns to a more nearly normal lifestyle with increased strength and stamina.
Morbidity and mortality rates
Mortality figures for transplant surgery include recipients who die before a match with a suitable donor can be found. About 17 patients die every day in the United States waiting for a transplant. In 2001, over 6000 patients died because the organ they needed was not donated in time.
The Scientific Registry of Transplant Recipients gives the first-year survival rates for transplant surgery as follows:
- 97% of pancreas transplant recipients
- 95% of kidney transplant and kidney/pancreas recipients
- 90% of autologous bone marrow transplant patients
- 86% of liver transplant patients
- 85% of heart transplant patients
- 77% of lung transplant patients
- 70% of allogeneic bone marrow transplant patients Three-year survival rates are as follows:
- about 91% for kidney transplant patients
- about 87% for pancreas and kidney/pancreas transplant patients
- about 80% for liver transplant patients
- about 79% for heart transplant patients
- about 59% for lung transplant patients
Available alternatives to transplant surgery depend upon the individual patient's diagnosis and severity of illness. Some patients may be eligible to participate in clinical trials, which are research programs that evaluate a new medical treatment, drug or device. Information on current clinical trials is available from the National Institutes of Health (NIH) clinical trials web site: http://www.clinicaltrials.gov or by calling the NIH at (888) FIND-NLM [(888) 346-3656] or (301) 594-5983.
Complementary and alternative (CAM) therapies
Complementary therapies can be used along with standard treatments to help alleviate the patient's pain; strengthen muscles; and decrease depression, anxiety and stress. Before trying a complementary treatment, however, patients should check with their doctors to make sure that it will not interfere with standard therapy or cause harm. Alternative approaches that have helped transplant recipients maintain a positive mental attitude both before and after surgery include meditation, biofeedback, and various relaxation techniques. Massage therapy, music therapy, aromatherapy, and hydrotherapy are other types of treatment that can offer patients some pleasant sensory experiences as well as relieve pain. Acupuncture has been shown in a number of NIH-sponsored studies to be effective in relieving nausea and headache as well as chronic muscle and joint pain. Some insurance carriers cover the cost of acupuncture treatments.
"Transplantation." Section 12, Chapter 149 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
American Council on Transplantation. P.O. Box 1709, Alexandria, VA 22313. (800) ACT-GIVE (800-228-4483).
Children's Organ Transplant Association, Inc. 2501 COTA Drive, Bloomington, IN 47403. (800) 366-2682. http://www.cota.org .
Coalition on Donation. 700 North 4th Street, Richmond, VA 23219. (804)782-4920. E-mail: coalition@shareyourlife. org. http://www.shareyourlife.org .
Division of Organ Transplantation, Health Resources and Services Administration (HRSA). 5600 Fishers Lane, Rm. 14-45, Rockville, MD 20857. 301-443-3376. comments @hrsa.gov. http://www.hrsa.gov .
National Foundation for Transplants. 1102 Brookfield, Suite 200, Memphis, TN 38110. (800) 489-3863 or (901) 684-1697. http://www.transplants.org
National Heart, Lung and Blood Institute (NHLBI) Information Center. P. O. Box 30105, Bethesda, MD 20824-0105. (301) 251-2222. http://www.nhlbi.nih.gov .
National Organ and Tissue Donation Initiative. http://www.organdonor.gov/ . Provides information and resources on organ donation and transplantation issues.
National Transplant Assistance Fund 3475 West Chester Pike, Suite 230, Newtown Square, PA 19073. (800) 642-8399 or (610) 353-1616. http://www.transplantfund.org/
Partnership for Organ Donation. Two Oliver Street, Boston, MA 02109. (617) 482-5746. E-Mail: info@organdona tion.org. http://www.organdonation.org/
Transplant Foundation. 8002 Discovery Drive, Suite 310 Richmond, VA 23229. (804) 285-5115. E-Mail: email@example.com.
Transplant Recipients International Organization. International Headquarters: 2117 L Street NW, Suite 353, Washington, DC 20037. (800) TRIO-386. E-Mail: firstname.lastname@example.org. http://www.trioweb.org .
United Network for Organ Sharing (UNOS). 700 North 4th Street, Richmond, VA 23219. (800) 24-DONOR (800-243-6667). http://www.unos.org . Provides general information on transplants, current statistics and listings of transplant centers.
CenterSpan. http://www.centerspan.org . Features Transplant News Network, an on-line broadcasting service that publishes monthly news reports on recent developments in transplant medicine.
Scientific Registry of Transplant Recipients. http://www.ustransplant.org .
TransWeb. http://www.transweb.org .
Angela M. Costello
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
A transplant surgeon, along with a multidisciplinary team of transplant specialists, should perform the transplant surgery. Transplant surgeons are usually board-certified by the American Board of Surgery, as well as certified by the medical specialty board or boards related to the type of organ transplant performed. Members of transplant teams include infectious disease specialists, pharmacologists, psychiatrists, advanced care registered nurses and transplant coordinators in addition to the surgeons and anesthesiologists.
Organ transplants are performed in special transplant centers, which should be members of the United Network for Organ Sharing (UNOS) as well as state-level accreditation organizations.
QUESTIONS TO ASK THE DOCTOR
- Who performs the transplant surgery? How many other transplant surgeries has this surgeon performed?
- Where will my organ come from?
- What is the typical waiting period before a donor is found?
- Will my insurance provider cover the expenses of my transplant?
- What types of precautions must I follow before and after my transplant?
- What are the signs of infection and rejection, and what types of symptoms should I report to my doctor?
- When will I find out if the transplant was successful?