Last summer, Texas transplant surgeons made a diagnostic mistake and transplanted a kidney from a brain-dead donor they believed died from a crack cocaine overdose into a relatively healthy end-stage-renal disease (permanent kidney failure) patient. Turns out the organ donor had rabies and the transplant recipient—along with the three other organ recipients from that donor—subsequently died of rabies. The doctors looked no further than the donor’s crack habit and never suspected rabies or anything else. “He’d recently smoked crack cocaine. He’d hemorrhaged around the brain. He’d died. That was all we needed to know,” said Dr. Goran Klintmalm, chairman and chief of the Baylor Regional Transplant Institute at Baylor University Medical Center in Gretchen Reynolds’ piece in today’s New York Times magazine.
With 88,000 patients on waiting lists for organs and an average of 18 people on those lists dying every day for lack of organs, should transplant surgeons be using “marginal” or “extended criteria” organs? Organs that would have been considered unusable as recently as ten or fifteen years ago. In the 1990s transplant surgeons started accepting kidneys from donors who had high blood pressure, morbid obesity, strokes, or were drug users. Even donor organs from cadavers with hepatitis C—a contagious disease that destroys the liver—were accepted. And today, according to Klintmalm and other transplant surgeons, “marginal organs are well on their way to being the majority of organs” transplanted in urban areas.
The United Network for Organ Sharing (UNOS)—the private organization that oversees all organ transplants in the US—published its definition of extended criteria organs two years ago: “The UNOS classification, which applies only to kidneys, defines a marginal kidney as one that comes from a deceased person over 60 or one over 50 with two of three characteristics: stroke, hypertension or abnormal kidney function. The definition does not mention smoking, diabetes, hepatitis, alcoholism, obesity or drug use.”
Recent studies indicate that older kidneys—from donors over 50—work neither as well nor as long as younger ones. “In a report presented by UNOS, which adjusted for the health of the recipient, among other things, about a third of extended-criteria kidneys failed within three years. (About 20 percent of non-extended-criteria organs also failed within three years.)”
Under the current system, it’s impossible for transplant patients to make an informed decision because they are told only the age and sex of the donor; the decision to accept or reject a marginal organ lies solely with the transplant surgeon. This is starting to change; some states—like my home state of Minnesota—allow transplant patients to “opt-out” of receiving marginal organs. But it’s a binary, all-or-nothing, choice. Sheldon Zink, director of the program for transplant policy and ethics at the University of Pennsylvania worries about such policies: “I would question anyone’s motivation in refusing an organ from a drug user. They aren’t responding to clinical information, because the available clinical data—the anecdotal reports from doctors—indicates that organs from crack-cocaine users are fine, in general. So they must be responding to preconceptions about that person’s lifestyle. That’s only one small step from declining an organ because the donor is black or Hispanic.” That’s a stretch of logic I find both unsupportable and terribly insulting.
To make a bad situation even worse, there’s no system in place for tracking the results of organs from individual donors. Only raw data concerning deaths and “severe surgical complications” are reported to UNOS. If the recipients of organs from the rabies-infected donor hadn’t all died at the same hospital at about the same time, the rabies infection would likely never have been discovered nor disclosed. A similar case occurred in Germany last February.
The US Centers for Disease Control and Prevention (CDC) would like to have a system for formal disease surveillance in transplant patients, but has no authority to require such compliance from the transplant centers. But the Department of Health and Human Services and state agencies do have the necessary authority to institute such a system. For example, last June, the New York State Department of Health undertook a study to look into the use of marginal organs and to make recommendations about what patients should be told and criteria for transplant candidate organs.
Klintmalm is unrepentant and said he’d handle the situation exactly the same if presented with another opportunity: “We cannot start testing every donor for rabies or any of the other once-in-a-lifetime diseases that might crop up. We don’t have time. It would cost too much. You might as well shut down every transplant center. If another case came in today exactly like that one, a young man who used crack cocaine and died, I would not demand more explanation. Why? We’ll never get the risk of transplants down to zero. It’s stupid to pretend we can. That young man appeared to be a perfect donor. I wish we had more like him.”
Surely Klintmalm isn’t hubristic enough to actually wish for more crack-addict or rabies-infected organ donors. Right?
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