Transplant cardiologist at the University of Utah Health, Dr. Josef Stehlik talks about saving congestive heart failure patients with donor hearts infected with Hepatitis C.
Interview conducted by Ivanhoe Broadcast News in 2022.
You hear about organ transplants and the list that people wait on for a year and it just gets bigger and bigger because our population keeps getting bigger and bigger. Can you talk about the need?
STEHLIK: Yeah, that is correct. There’s a big gap between the number of patients that are awaiting organs and then the number of organs available every year for transplantation. There’s actually been a fair amount of research looking at increasing the number of organs we can safely use for transplantation.
I know there’s always the battle to get people to sign up to donate their organs.
STEHLIK: That’s correct.
But is it also a battle once the people that are signing up their organs might not be good?
STEHLIK: Yes. Not everybody can donate organs, but what we try to, or the organ procurement organizations that coordinate the logistics to be aware of every possible patient or possible patient will [inaudible 00:01:32]. So the decisions, sometimes it’s not as easy to say somebody is sick or somebody is too old. For different transplants, there’s different criteria for which organs can be used. One of the approaches for every possible donor for us to be aware of, or the organ procurement organizations to be aware that there could be a possibility of donation. The other one is of course, for patients ahead of time to decide to make a gift through signing up. But this process can even happen at the time of donation through their families.
And now there are just research is coming up with ways to take organs that may not have been viable ten years and make them viable now.
STEHLIK: That is very correct. So, I’ll mention some of those approaches. So, one of them, unfortunately really severe seeing a lot of drug overdose deaths in the United States that’s linked to the opioid epidemic and other problems. Within this unfortunate amount of time, you have actually figured out how to use safely many of the organs of patients who died of drug overdose. In the past, we had concerns regarding the safety of those organs, but research has actually shown us that many of these organs will work for many years or even decades after transplantation.
How do you do that? How do you make something that is there certain drugs like you can’t use a fentanyl drug overdose, but you can use and opioid drug overdose?
STEHLIK: It doesn’t go down to a specific drug, but it goes down to very carefully assessing the health of the organ that is being used. One is health of the organ, is the organ going to be working well? And another assessment is there also a risk of possibly infectious disease transmission. And as you know, we have very good testing now for infectious disease so that we minimize that risk. But another great development has been in hepatitis C. So hepatitis C organs in the past, we wouldn’t use because we knew the outcome of these organs would be less than optimal. However, in the past few years, there have been new medications develop the are curative for hepatitis C. Antiviral medications that will eliminate the virus. So even if the donor has not received this treatment before death, we can actually transplant the organ and while the virus will be transmitted to the recipient in a timely fashion, will provide treatment for hepatitis C and eliminate the virus fully within the first weeks after heart or other solid organ transplantation.
Can you cure the hepatitis C?
STEHLIK: Yes, we cure hepatitis C.
Are there any other diseases like that that maybe on the near future that would be able to be used like the organs?
STEHLIK: Yes of course, everybody has high hopes for treating HIV. So hopefully HIV you can treat prior to organ donation. But mentioning HIV in the past, HIV in the recipient’s was a contraindication for transplantation. But because medications for HIV have advanced a lot as well, now has opened doors for patients who have lived with HIV maybe for many, many years and now need heart or other organ transplantation to also receive organs, and we’ve done that at the University of Utah.
Are there any other ways that you’re able to take organs that were available before and use them now?
STEHLIK: Yeah. Really expanding use is taking place in donors who don’t die of brain death. Traditionally we use donation after brain death, and brain death criteria has been established back in the ’60s and really those donors are considered deceased. But you might know that many patients don’t die of brain death. They might have catastrophic injury or illness, and they are on life support. They will not survive without life support. And then they make a decision or the family or the patient to withdraw life support and the patient will pass of the traditional circulatory death when the heart stops. And in the past, these donors have not been necessary considered for donation. But many of these donors have expressed a wish to donate organs. So what has been expanding is donation, which we call donation after circulatory determination of death. And that is in these patients that die of circulatory death. You then proceed with organ procurement and organ donation for transplantation.
Why wouldn’t they be eligible before?
STEHLIK: So, before there was concern that in the process of death, there we’ll be damage to the organs. Was something that we called warm ischemic time. And the organs could not come back to life in a sufficiently healthy way. But what has changed now that for many organs we actually have perfusion machines. We call it [inaudible 00:06:39]perfusion, taking the organs out, putting them on a perfusion machine, assessing their health, and then transplanting the organs. And the pioneers in this approach of DID donations have been the abdominal organs, kidneys and liver. About more and more organs in the chest, lungs and the heart are being used in this fashion as well.
And you’re also able then to also preserve the organs a little bit longer than you had been in the past, right?
STEHLIK: That’s a very astute question. So especially in heart transplantation, we are limited by the amount of time between taking the organ out of the donors body and transplanting them. In general less than four hours, and beyond four hours we face some challenges. And the hope actually is that with organ perfusion outside of the body, it will be already extending this time to many more hours down to four hours we’ve traditionally limited to.
Do you have a specific hour time?
STEHLIK: Yes. So currently, I think most are between four and eight hours, but research is being done and the idea is that you can extend to 24 hours even for the heart, which will actually allow better matching of organs to patients who need them. Right now we’re limited to about 500 miles. You can imagine if you have 24 hours, the whole country, it’s a possibility for transferring the organ to the patients who need them the most or where it’s the best immunological match to allow the best outcome after transplantation.
Do you have an idea?
STEHLIK: Yes. Well, I can tell you that in kidney transplantation, DCD donation is now 25-35 percent of transplantation. So that already tells you that the expansion has been by at least a third. There’s a bold plan to double heart transplantation with the use of innovative techniques for organ procurement in the next, we’ll see how many years. But I think the aspirational goal is that every patient who needs organ transplant receives an organ transplant, and this is one step towards that goal.
Are there any other things on the pipeline that you’re really excited about when it comes to organ transplantation?
STEHLIK: Well, one thing you might have heard is xenotransplantation and it is a transplant of organs from genetically modified pigs into humans. Heart xenotransplant and perform to the University of Maryland into a human. And there’s an experimental phases of kidney xenotransplantation. So, we still have a fair amount of research to do in that area. But that could be an approach if it can be worked out so that it’s safe and durable, that could provide opportunity too many patients as well.
Is there anything we are missing?
STEHLIK: The one thing we could mention maybe also we’re seeing more and more patients as medical treatments are improving. Some patients live with their conditions longer before anything organ transplant, which is great. But we also end up seeing patients who have multi-organ dysfunction with just one organ and that increases the need to consider transplant of more than one organ. We have been seeing lately more heart and kidney transplants, heart and liver transplants. And I’ve chaired the University of Utah a couple months ago. We’ve done our second heart, liver, kidney transplants, so triple organ transplant, which is a very unique approach to triple organ disease and provides an opportunity for patients who really have multi-organ failure to return to active lifestyle.
Did this person go from critically ill to now healthy?
STEHLIK: That’s right. Our first patient was done two years ago. He’s actually a veteran from Phoenix, Arizona who was referred to our program and he was discharged two years ago and he has not been readmitted. So he lives a very active lifestyle and he actually took it upon himself to pass it along and to teach people about organ failure, transplantation, how to stay healthy, how to become healthy after an illness. One thing maybe to mention is that organ transplantation, our goal is not only to save patients lives, but to provide good quality of life with the transplanted organ. So a real focus is to provide patients ability to live active lifestyle, return to work or return to family life.
END OF INTERVIEW
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