COVER

THE TRANSPLANT REVOLUTION

CHRIS WOOD November 23 1987
COVER

THE TRANSPLANT REVOLUTION

CHRIS WOOD November 23 1987

THE TRANSPLANT REVOLUTION

COVER

The tiny figure on the operating table was hardly visible beneath swathes of sterile cotton. Plastic tape holding respirator tubes masked the infant’s snub nose and distorted her Cupid’s-bow mouth. With infinite care, surgeon John Najarian probed the gaping wound in 11month-old Jamie Fiske’s abdomen. Forceps delicately lifted the vein that attached Jamie’s disabled liver to her body, exposing the vessel to Najarian’s surgical scissors. Moments later his gloved hand pulled Jamie’s malfunctioning organ from her body. Within minutes another took its place: the healthy liver of a 10-monthold Utah boy, Jess Bellon, who had died several days earlier from injuries received in an automobile accident. Finally, Najarian’s deft fingers wove sutures into the connections between Jess’s liver and Jamie’s body, completing the organ transplant. That dramatic 5V2-hour operation took place in Minneapolis five years ago this month. Next week Jamie, now an energetic, independent Bridgewater, Mass., kindergarten student, will celebrate her sixth birthday.

Birthday: She would never have

reached that birthday, nor probably even her first, without her new liver. “Jamie is a typical six-year-old,” her father, Charles Fiske, told Maclean's. “The transplant does not play a big part in her life now.” For surgeon Najarían, however, the six candles on next week’s cake, and the birthday card Jamie will receive from Jess Bellon’s parents, will have a special meaning. Said Najarían: “Five years represents a very important milestone. If she can go five years, she

can go the distance.” It is a season of such milestones. Next month transplant specialists will mark the 20th anniversary of the world’s first human heart transplant, by South African doctor Christiaan Barnard. This month is also the fourth anniversary of the world’s first successful lung transplant, at Toronto General Hospital, as well as the second anniversary of the first successful heart transplant into an infant, at

the Loma Linda University Medical Center in California.

In the two decades since Barnard’s ground-breaking operation, organ transplantation has lost much of its novelty, but none of its drama—or its ability to generate controversy. And since clinical tests earlier this decade at University Hospital in London, Ont., and other centres proved the effectiveness of the powerful antirejection drug cyclosporine, organ transplants have proliferated. Last year’s statistics for Canada alone are staggering: 123 heart

transplants, 857 kidney transplants, 66 liver transplants and nine lung or combination heart-and-lung transplants. Indeed, the procedure is now “routine,” declared Dr. Calvin Stiller, chief of transplantation at University Hospital. “It has moved from experiment to being a therapeutic procedure that people expect to have done.”

At the same time, surgeons continue to test the limits of their skills,

attempting ever more complex transplants. Last month Dr. Thomas Starzl, who in 1963 performed the world’s first liver transplant, achieved another breakthrough when his surgical team at the Children’s Hospital of Pittsburgh gave a threeyear-old Kentucky girl, Tabatha Foster, five new organs. Four days after receiving a new liver, pancreas, small intestine and parts of a new stomach and colon, Tabatha sat up in bed and sang Itsy Bitsy Spider. By last week, two weeks after the operation, she

was in critical but stable condition.

Still, such feats have sparked fresh debates about ethical issues involved in the operations, and some critics argue that the high-tech—and highcost—medical intervention absorbs scarce health dollars that could be better spent on prevention of disease. Last month an Orillia, Ont., baby born without a brain was sustained on a respirator so that her organs could be used in a transplant (page 40). Some observers speculate that the precedent could encourage physicians to seek body parts from mentally disabled children whose lives are endangered. However, as researchers break new ground—including such operations as brain tissue transplants—and employ techniques that until recently were confined to science fiction plots, that ethical debate is unlikely to diminish.

Lungs: But for patients like Thomas Hall—the first recipient to survive a lung implant and return to full health—those concerns pale beside the immediate benefits of replacing a diseased or damaged organ with a healthy, functioning one. The lungs of Hall, a 62-year-old Toronto wholesale hardware manager, were crippled by fibrosis—a scarring condition usually brought on by lack of blood or oxygen—and were barely functioning. “I had been on oxygen 24 hours a day for a year,” Hall recalled. “I couldn’t walk upstairs. I had six to eight months to live.” But one month after he received a new lung, on Nov. 7, 1983, Hall went home from hospital, able for the first time in years to breathe deeply. Hall’s lung capacity is still limited because he has only one new lung—and it is small, having come from a 13-year-old boy who had died in a car accident. “I’m still a 62-year-old man,” Hall added. “I can’t run or walk fast for long periods. But as long as I act my age, I do all right.” Other recipients enjoy more dramatic recoveries. “It is like being reborn,” declared Sudbury

music teacher Allan Joukanen 4V2 years after his May, 1983, heart transplant. Joukanen, 32, exercises regularly and plays drums in a country music band.

Survive: Those success stories are increasingly commonplace at Canada’s 25 transplant centres, in locations from Vancouver to Halifax. Indeed, heart transplants have become one treatment for severe heart disease in patients as old as 60, and 84 per cent of those recipients survive for at least a

year with their new organ. In the same way, liver recipients up to 16 years of age can now look forward to an 80-percent chance of surviving the crucial first year after the operation, while one-year success rates for older recipients are now about 70 per cent. The most uncertain prognoses face patients receiving lungs or both heart and lungs—but even they enjoy better than even odds of a successful graft. And with kidney transplants, first attempted in 1954, 90 per cent of recipients survive the first year. Declared London’s Stiller: “We have far better results than the treatment of 50 per cent of cancers.”

Those advances signify dramatic improvements since South Africa’s Barnard performed the first heart transplant on Dec. 3, 1967. His first patient, 55-year-old Louis Washkansky, died of pneumonia only 18 days after he received the heart of a 24-year-old woman who had died in a traffic accident. Still, Barnard’s feat emboldened surgeons around the world, and they per-

formed 151 more heart transplants during the next two years. But they all failed to bring their recipients back to full health, and only 23 of the patients lived more than a few days after their operations. As a result of that dismal mortality rate, the procedure fell out of favor, and only a few surgeons were still attempting heart transplant operations by the mid-1970s.

But in 1976 a pharmaceutical breakthrough occurred that would reverse that bleak record and inaugurate a

new era of transplant surgery. It happened when Swiss researchers who were examining soil samples in search of new antibiotics found a fungus that produced a powerful immunosuppressant—a substance that blocks the body’s defence mechanisms from rejecting foreign tissue. In 1980 that new discovery—now known as cyclosporine—had received its first clinical trials in London, Ont., where it was found to have an ability to suppress rejection of grafted tissue without impairing the body’s ability to combat other invaders.

Waiting: But the surge of transplants that followed the discovery of cyclosporine has also caused new problems—most notably, an acute shortage of organs for the growing number of patients who need them. At any given time in Canada, there are about 1,000 recipients waiting for a suitable kidney. Another 60 or more are waiting for hearts, while smaller numbers await the next available liver or pancreas. And Anne Lake, executive

co-ordinator of London, Ont.-based Transplant International, an advocacy group that promotes organ donation, argues that such waiting lists understate the real need. According to Lake, the actual number of potential kidney recipients is three times higher. Said Lake: “About 3,000 people could be helped, but they are not put on waiting lists because organs are not available.” Still, there is no scarcity of potential donors. Indeed, while only three per cent of the 200,000 deaths that occur each year in Canada are of people able to provide healthy organs for vitalorgan transplant, just 50 per cent of those would be enough to eliminate waiting lists entirely.

Donors: But simply having an adequate supply of body parts does not guarantee more transplant operations. For one thing, organs deteriorate quickly after death, even when braindead individuals are maintained on life-support systems: lungs must be transplanted within four hours of the donor’s death. As a resuit, distance and time frequently bar many pa^tients from receiving suitable organs from donors in far-off hospitals. And for their part, many physicians say that they hesitate to approach grief-stricken

next of kin in order to ask them to donate their dead relation’s organs— even though recent polls show that 88 per cent of Canadian families would agree to such a request. Indeed, most doctors honor surviving relatives’ decision not to donate their loved ones’ organs—even though the victim of a fatal traffic accident may have previously signed the organ-donation form that accompanies all provincial drivers’ licences. Declared Toronto intensive care specialist Dr. Neil Lazar: “It is an added stress when a physician is sitting in front of a family who is grieving. We don’t receive training in delivering bad news.” However understandable that reluctance to intrude on grief may be, the result, added Lake, is that “90 per cent of donor organs are wasted.”

But a new $20,000 computer system installed at Winnipeg’s Manitoba Data Services could reduce the time lost in matching organs with suitable recipients across the country. The system, which has been operating since Sep-

tember, will eventually link hospitals across Canada. Declared Dr. John Jeffery, the chairman of the Organ Waiting List (OWL) network: “In the past we phoned around the country to find potential recipients. Now, we can have the computer sort the master list on the basis of medical priority.” A similar computerized organ clearinghouse in Virginia also links potential donors and recipients in the United States, and Jeffery predicted that the two networks would soon have access to each other.

Gabriel: Last month doctors in London, Ont., broke new ground in the search for donors when they decided to sustain an infant known as Baby Gabriel on a respirator. In the past, profoundly handicapped infants who were born missing large sections of their brain have been allowed to die naturally—an event that inevitably occurs within hours or, at the most, days, but which may leave their organs too severely damaged for retrieval. But in Baby Gabriel’s case, physicians periodically turned off the machine in order to determine whether she could breathe on her own. And when Gabriel could no longer do so, a physician switched the respirator back on and began preparing to transplant her heart into another infant’s chest. Declared Arthur Schafer, the director of the Centre for Professional and Applied Ethics at the University of Manitoba in Winnipeg: “I think under the circumstances it was legitimate: these are babies with zero prognosis.” Still, Schafer expressed concern that without ethical restraints, physicians might be tempted to use other seriously impaired infants who have uncertain chances of survival as sources for organs.

Shocked: Indeed, London’s Stiller said that he had been shocked by a recent proposal he received from a California woman who was the mother of a diabetic girl. According to Stiller, the woman told him that she wanted to become pregnant— and then abort the fetus in order that insulinproducing tissue from the unborn baby’s pancreas could be implanted to replace her daughter’s damaged organ. In addition, Stiller and many other doctors express concern that the growing ease of transplant operations may stimulate the widespread sale of body parts—a practice that is illegal in Canada. And he noted that an underground trade in organs is already operating in

some countries. In Brazil, for one, newspapers sometimes run advertisements offering kidneys for sale. And two years ago many West German doctors reported that they had received brochures offering kidneys from live Third World donors for $80,000 each. Apart from expressing alarm at the

prospect of a black market in organs, some critics question the wisdom of devoting a growing share of the nation’s health budget to transplants— operations which, by their nature, assist relatively few patients. Certainly, organ transplants are expensive. Ac-

cording to U.S. studies, installing a new heart costs about an average $125,000, while a liver transplant operation can reach $170,000. Only kidneys, at $46,000 a transplant, are demonstrably cheaper than the medical alternative: a $40,000-a-year dialysis program. Declared Manitoba’s Schafer: “The lives of some babies are being saved by operations that cost over $100,000. At the same time, thousands of babies are being born prematurely with serious

illnesses, because we haven’t hired enough public health nurses.”

Critics who argue that more attention to other lines of research could reduce the need for organ transplants received timely support last week. Canadian and U.S. regulators ruled that a new drug capable of dissolving blood clots that cause heart attacks could be made available to the public. The drug, tissue plasminogen activator (TPA), is a genetically engineered copy of a substance found naturally in human blood, and it could improve a heart attack victim’s chances of survival by 30 per cent. Still TPA itself will be expensive. Its maker, Genentech Inc. of San Francisco, confirmed last week that the new drug will cost between $2,000 and $3,250 per treatment.

Pioneer: But lung transplant pioneer Joel Cooper, who performed the ground-breaking lung implantation on Thomas Hall, says that he and his colleagues are not about to stop operating. Declared Cooper: “If it can be done, it should be done.” In pursuit of that goal, doctors at the Hubei Medical College in Wuhan, China, reported in October

that they had successfully transplanted a functioning testicle from a man into his 23-year-old son after the younger man lost his own genitals in an accident. The young man, also equipped with a reconstructed penis, is now a father himself; his child, according to geneticists, is his own halfbrother.

As well, scientists at Sweden’s Lunds University and at Cambridge University in the United Kingdom say that healthy brain tissue taken from fetuses may help victims of Parkinson’s disease, a debilitating disease that attacks the nervous system. According to the researchers, such fetal tissue transplants—the first of which may be undertaken next year—may help restore vital functions. Similar fetal transplants, they say, may also offer hope for sufferers of Alzheimer’s disease and multiple sclerosis. And in Sydney, Australian researchers suggest that transplanting healthy immune system cells could help victims of acquired immune deficiency syn-

drome (AIDS) fight the deadly virus.

Toronto’s Cooper also maintains that cross-species transplants between animals and humans hold promise of success—despite one notable failure in 1984. It occurred at Loma Linda centre when an infant known as Baby Fae died less than one month after she received a baboon’s heart. And in London, University Hospital’s Stiller confidently predicts that the stuff of science fiction movies—whole brain transplants —is potentially within technical reach.

Issues: But Cooper acknowledged that such advances will also raise thorny new ethical issues. Declared Cooper: “Can you imagine the animal rights people if you had a colony of primates in the backyard and you’re harvesting hearts?” And Toronto Reform Rabbi Gunther Plaut points to unanswered questions that will become more urgent as more technical barriers fall before the transplant surgeon’s knife. Predicted Plaut: “The question of identity will arise. One of these days, we’re going to have brain transplants. Who is that new person?”

While transplant physicians and ordinary citizens alike may have to ponder those issues one day, the surgeons who are performing current operations say that they enjoy widespread support for their work. In any event, many of the patients who receive new life under their hands say that the experience prompts them to re-examine their goals—and how they will spend their new energies. Declared lung recipient Hall, for one: “I felt I owed somebody something.” As a result, Hall now performs volunteer work for the Canadian Lung Association and is also involved in a campaign to raise money for a new opera house in Mississauga, just west of Toronto.

Gift: In similar fashion, Boston’s Fiskes are showing their gratitude for an operation that will allow their daughter to celebrate her sixth birthday on Nov. 26. They have recently purchased a house within walking distance of four Boston hospitals. They plan to convert it into lodgings for the families of transplant patients—charging them a nominal fee of $11 per night. Said Charles Fiske: “We are doing it because when Jamie was sick, people were very, very good to us.” Clearly, despite arguments over the cost and relative exclusiveness of many transplant operations, the Fiskes and many others support their proliferation—simply because they offer a priceless gift to the recipients: renewed life.

CHRIS WOOD

WILLIAM LOWTHER

RALPH SURETTE

DOUG SMITH