by Anita Browning
Did you know that your decision to become an organ donor can affect up to 50 people? In addition to your bones, eyes, tendons and other tissues, your organs can be used to save lives. Here at Children’s, the Transplant Center is one of our premier programs. It’s where some of our co-workers, like transplant surgeon Dr. Patrick Healey, give seriously ill kids “new” organs — and new life.
Dr. Patrick Healey
I spent some time with Dr. Healey, who was kind enough to answer some questions about transplantation.
What kinds of transplants do we do here at Children’s?
We do kidney, liver, intestine and heart transplants, as well as multi-organ combinations of liver-kidney and liver-intestine. The kidney, liver and intestine transplants are done by our transplant program and the heart transplants are done by the Heart Center.
Of the solid organ transplants that you do, which are the most common?
We have done 15 to 18 kidney transplants and 15 to 18 liver transplants per year, and in 2007 we did our first three intestine transplants — two of those were liver-intestine transplants. We used to do more kidneys but now, as the liver program has grown, we do just as many liver transplants. For the liver patients, approximately two-thirds of recipients are under age 5, so they really need the pediatric expertise we have here at Children’s. The majority of the kidney patients are adolescents, many of whom have had chronic kidney disease and related issues with growth and development, so they also actually do better in a pediatric center.
What conditions lead to a child needing one of these transplants?
The majority of pediatric transplant patients have congenital anomalies — conditions that are present at birth — that result in abnormal development of their organ function. Examples include urinary tract problems, which can lead to kidney failure, or a condition called biliary atresia, which can lead to liver failure. These conditions are very different from the most common reasons for adult transplants, which include hypertension (high blood pressure) and diabetes leading to kidney failure, and hepatitis leading to liver failure.
Don’t kids get diabetes, too?
Yes, they do, but diabetes management has come a long way. An adult may have been diagnosed with juvenile onset diabetes, but chances are good that it will be 15 to 20 years before they will need a transplant. There are so many techniques now that have been developed to keep the disease from devastating the organs as quickly as it used to.
When a child needs an organ transplant, where do the healthy organs come from?
The organs can come from living donors or deceased donors. Living donors are often related to the recipient, but not always. Deceased donors have generally suffered a fatal brain injury, but their organs are still functioning well. These patients have an absence of brain function, meet criteria for brain death, are legally deceased, but are maintained on mechanical support to maintain organ function for the purpose of donation. Nationally, the organ donation and transplantation activity is administered by UNOS — United Network for Organ Sharing. Children’s is part of the largest organ sharing region in the U.S. — our region includes six states: Washington, Oregon, Alaska, Montana, Idaho and Hawaii. Several members of our transplant team have UNOS appointments.
Can children be living donors and donate organs to a sibling or relative, for example?
No. Living donors currently need to be able to decide and consent to donation voluntarily and without coercion. There are too many ethical and legal considerations in the case of a minor who can’t consent for himself or herself.
So then, can children receive adult organs?
Yes. Of course, it’s better for smaller patients to receive smaller organs, but an adult liver, for example, can be cut down to a single lobe to optimize its size for the pediatric recipient, or a living donor can give part of their liver. The liver regenerates, so in the healthy adult donor, it will grow back to its original volume within around six weeks. In fact, we cut down about 40% of the livers we receive for our patients. While we can’t reduce the size of an adult kidney for transplantation into a small child, we have developed specific techniques and management for these situations and the outcomes are excellent.
Is there a waiting list for kids who need organs?
There is one waiting list for everyone — both children and adult patients awaiting transplants. Donor organs are allocated to patients waiting on the list according to urgency of need, and fairness to the whole group waiting. Of the 98,000 people on the waiting list, approximately 2,000 are children less than 18 years old. Children do get first priority on that list in certain circumstances, such as kidneys from young donors less than 35 years old, and livers from young donors less than age 11.
How many of the transplants you do at Children’s are urgent?
Roughly 15 to 20% of the liver transplants done at Children’s are in the most urgent groups, Status 1A or 1B.
In general, how long do those patients have to wait for an organ?
Overall wait times are about eight months for liver transplant, and over a year for kidney transplant and intestine transplant. Urgent liver patients may get a transplant within a few days of listing or after several weeks — there is no good way to know when a donor organ will be available.
What kinds of things need to “match” when you are finding organs for a particular patient?
We generally match the blood type, and the size. Blood types of recipient and donor need to be identical or compatible, although we can do an ABO-incompatible transplant in an emergency situation. Kidney and heart patients also have a crossmatch test to make sure that the recipient immune system will not immediately reject the donor organ. The health history of the donor, and the function of the donor organ also need to be good. A living donor undergoes a thorough evaluation at the University of Washington (UW) to determine suitability and safety of donation.
Are relatives always a good match to donate to each other?
Usually but not necessarily. As we all get our DNA from our parents, the child will have a 50% match with each parent. Siblings, however, can range from identical to totally unmatched, so we always have to do the same tests no matter who the organ comes from.
If they are not receiving an organ from a family member, do recipients know who their donor is?
In the case of the deceased donor, the identity of the donor is not known to the recipient at the time of the transplant. If the donor family is interested in learning about or meeting the recipient at some later point in time, they initiate the process. This is coordinated by LifeCenter Northwest, our regional Organ Procurement Organization.
How long does a transplant operation take?
A kidney transplant takes four to five hours and a liver transplant takes between 6 and 12 hours. The living donor operation takes place at UW and the transplant operation at Children’s happens almost simultaneously, so that the organ is out of circulation for no more than two to three hours.
Wow! How does that work?
It takes good coordination and communication between the two surgical teams, one here at Children’s with the recipient and the other at the UW with the donor. The goal is to keep the organ out of circulation as briefly as possible. We talk on the phone with the UW’s surgeons probably four to five times throughout the operation.
Amazing. How long before you know if the new organ will do its job?
For a kidney transplant, we may see some urine output before the end of the transplant operation, but it usually takes five to six days for the function to get to normal, and about two weeks to 18 days for liver function to improve after a liver transplant.
How long does a transplant patient continue coming back to Children’s for follow-up care?
Typically we follow patients after transplant until adulthood when they transition to an adult transplant program for their continued follow-up. During this follow-up, we monitor the organ function, check for infection or other complications of a weakened immune system and closely track growth and nutrition.
The long-term management of transplant patients and the connection that develops between our team and the patient and family feels a lot like the relationship a primary care physician has with his or her patients.
We also have dedicated transplant coordinators and nurse practitioners who follow each patient throughout their transplant experience. The support they provide, along with the work of pharmacists, child life specialists, social workers and dieticians on the transplant team, has been instrumental in the success of our transplant program here at Children’s.
It’s great to see the quality of life improving for these kids. Part of the reason I became a transplant surgeon was because of this chance to provide continuous care to my patients, and to see them thrive and move on in their lives, after such extreme illness.