Faculty Bibliography

Because of a shortage of transplantable livers and hearts, the transplant community has had to decide--by who gets an organ--who lives or dies. Despite this shortage, whether one has previously received a transplant is not used as a criterion to distribute organs. The existing allocation system distributes 10% to 20% of available hearts and livers to retransplant patients. This article examines three differences between primary transplantation and retransplantation that may affect the priority that retransplant candidates should receive in vying for organs: (1) the special obligations that transplant teams have not to abandon patients on whom they have already performed a transplant, (2) the fairness of allowing individuals to get multiple transplants while some die awaiting their first, and (3) the difference in efficacy between primary transplantation and retransplantation. Only this last difference holds up to critical analysis. Our moral duty to direct scarce, lifesaving resources to those likely to benefit from them, suggests that, all other things equal, primary transplant candidates should receive priority because their mortality after transplantation is lower. Consistency also demands that previous transplant history be taken into account, as we already allocate organs according to ABO blood group matching, a factor that affects transplant outcome approximately the same amount as a previous transplantation. We therefore conclude that the system should be revised so that primary transplant candidates have a better chance of receiving organs than retransplant candidates.

A retrospective study of all adults receiving BMT over a 13 year period at a large transplant center was performed to determine overall survival and prognostic indicators of poor outcome among patients receiving mechanical ventilation (MV). Of 653 adult BMT patients, 191 (29%) received MV after transplant. Of these 191, 161 (84%) died on the ventilator or within hours of extubation; 18 (10%) survived 1 week after extubation and 6 (3%) survived 6 months. Survival was not predicted by type of graft, use of total body irradiation (TBI) or reason for intubation. The patient's age and the timing of intubation were predictive of survival. Of patients > or = 40 years, 98% died within a week of extubation and all died within 30 days. Similarly, of those intubated within 90 days of transplant, 94% died within a week of extubation and all died by day 100. These results suggest that MV is rarely effective in achieving long-term survival in adult BMT recipients, especially older patients and those early in their transplant course. An argument, based on cost/benefit considerations and medical futility, can be developed to withhold MV in certain patient subsets apart from a clinical research trial.

The transplant community has quietly initiated efforts to expand the current pool of cadaver organ donors to include those who are dead by cardiac criteria but cannot be pronounced dead using brain-based criteria. There are many reasons for concern about "policy creep" regarding who is defined as a potential organ donor. These reasons include loss of trust in the transplant community because of confusion over the protocols to be used, blurring the line between life and death, stress on family members, and burdens imposed on health care providers when a long-standing policy regarding who can serve as a cadaver organ donor is unilaterally changed. While these concerns are not sufficient reason for abandoning efforts to broaden existing eligibility standards for cadaver donation, they are sufficient reasons for the transplant community to desist in changing existing standards without widespread professional and public discussion.