New look at old procedure offering hope

By Paul Mayne
October 02, 2013

DCDPaul Mayne, Western News
Dr. Roberto Hernandez-Alejandro and his colleagues at Western's Schulich School of Medicine & Dentistry is hopeful reassessing a particular method of organ donation leads to more organs available for patients.

Revisiting the idea of how and when organs can be donated has given 50 individuals in London new life – literally – thanks to Dr. Roberto Hernandez-Alejandro and his colleagues.

The Schulich School of Medicine & Dentistry professor, and renowned liver surgeon, is hopeful reassessing a particular method of organ donation leads to more organs available for patients.

“This is a potential strategy to address the organ shortage in Canada and the rest of the world,” Hernandez-Alejandro said. “It will also be an option for organ donation the general public should be aware of.”

For any procedure, the problem centred on time.

If organs are transplanted after the heart stops, the procedure is called ‘donation after cardiac death’ (DCD). However, organ damage occurs rapidly once the heart stops, and so decades ago it became difficult to use livers, kidneys or lungs, and impossible to use hearts. Doctors simply didn’t have enough time to remove, transport and transplant the organs successfully.

To combat that, most hospitals set out criteria for ‘donation after brain death’ (DBD) in the late 1960s. This method became the standard for heart, lung, liver, kidney, pancreas and intestine transplants. This gave doctors more time to transplant the organs.

“If a patient has brain death, we can consider them dead, even if the heart is beating. They are potential donors,” Hernandez-Alejandro said. “The benefit is the organs are well perfused; they have good blood supply and good oxygenation, and that’s the main thing. The outcomes of organ transplantation started improving and were very good.

“At that moment, there was a huge revolution and advances in immunosuppression, a very important part that makes the organs have less rejections. So, the successful outcomes became even higher.”

Unfortunately, as time has progressed, more people were in need of transplants than were available via DBD. While the waiting list was months a generation ago, the wait today can stretch into years. In London today, 15-20 per cent of individuals on the waiting list for liver transplants will die waiting for an organ, or be removed from the list because they have become too sick for a transplant.

To bridge that gap between organ supply and demand, Hernandez-Alejandro revisited DCD as an option.

“If you look at the rate across Canada, the rate of donors hasn’t been increasing, but those waiting continue to grow. We needed to explore other options, one being DCD,” he said. “Patients were not donating because we knew these organs didn’t have good blood supply or good oxygenation and were not going to work as well as brain-dead donors.”

But Hernandez-Alejandro said medical technology has made huge strides.

“We have better surgeons, better preservation solutions, better research; so, we started looking at how much time we have between the patient’s (cardiac) arrest and the moment we start flushing the organs,” he said.

The liver has been the focus of Hernandez-Alejandro’s interest.

“The liver is more complex because it doesn’t tolerate too much,” he said. “If, unfortunately, we have a trauma patient in their 20s or 30s, and it has a warm ischemia time of 35 minutes, that might be an excellent organ that will save the life of a patient.”

In 2006, along with Dr. Bill Wall, Hernandez-Alejandro completed the first DCD liver transplant in Canada, a procedure performed in London. Since, the number of similar liver transplants has grown to 50, along with approximately 70 DCD kidney transplants.

“We know if we’re careful in our selection of DCD donors, we can have very good outcomes, comparable to that of DBD,” he said, noting 12 per cent of liver transplants in London are now DCD. “Today, the five-year follow-up with DCD patients shows an 80 per cent survival rate, the same as DBD.

“We have better knowledge of the organs, better immunosuppression, better preservation solution, better coordination; we have learned a lot in these 50 cases.”

Going forward, Hernandez-Alejandro has taken a leadership role in DCD in London, which includes multiple speaking engagements across the country. He is hopeful continued research into the idea of DCD can cut that waiting list even more.























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