Dr. Daniel Borja, a transplant surgeon at Northwestern Memorial Hospital, talks about a new technique that preserves livers longer for transplantation.
Interview conducted by Ivanhoe Broadcast News in 2023.
How common are liver transplants, and what are some of the barriers of the transplants that the patients are facing?
Borja: They are quite common in United States. With roughly about 9,000 a year, 9,500 in the whole country. And the main boundary of the main limitation is the number of donors. We don’t have enough donors for everybody that needs an organ.
So we’ve all heard that waiting list for transplants are long. But how long are they?
Borja: So it depends on the organ. For some organs people have to wait 5, 10 years. For some other organs, they don’t have to wait as much, but they are seekers. So even if they have to wait one or two years, it’s- it’s a lot of time. And that’s a reason why we need to increase organ availability.
What makes a liver not viable?
Borja: If the donor is sick. If the donor has diseases that affect the function of the organ, perhaps the most common is obesity. If the donor has history of obesity, it can be a liver with fatty liver disease. Another one, for example, is if the donor have any history of hepatitis B, hepatitis C at the time that we go and we look for the organ, they may already have fibrosis scarring. So those are the main reasons. Sometimes the characteristics of the donor, they don’t or maybe to sick to recover the organ, maybe too unstable to recover the organ and we cannot use it.
But now there’s a new treatment that’ll help more livers to be useful for transplant. Can you talk about that?
Borja: Yes, for the past few years, we have been using more machine perfusion instead of having the organ sitting on cold fluids and ice like we have been doing it since the beginning of transplant. Now, we connect these organs to special devices and infuse oxygen, blood, fluids into the organs and they decrease some of the damage associated with the donation, something called ischemia-reperfusion.
How does it work? And what’s the difference between cold and warm measures?
Borja: It’s mainly the temperature. The biggest difference is the temperature that you use to try to improve the function of the organ. So if you do it at cold temperatures, it’s called hypothermic. If you do it at the normal body temperature, it’s called normal thermic. There are also some protocols in which you do it in-between and that’s called sup normal thermic.
How does reperfusion impact the liver?
Borja: So the main effect that it has it decreases ischemia reperfusion at the time that we open the clamps, at the time that we do with transplant. The changes in temperature affect the organ. But if we put them in the machine reperfusion device, we decrease that risk. We improve the ability of the liver to recover from these changes in temperature so that we decrease ischemia reperfusion.
Is there a percentage of livers that this will make more viable?
Borja: Right now, it is very hard to predict. We can just assume certain number. But the reality is that I think that the more we become familiar with this technology, we’re going to start using it more and more and more. We have seen here at Northwestern that livers that we have been hesitant five years ago to do the transplant, now we can use and the way the patient does after transplant is quite good.
Is it FDA approved?
Borja: It depends on the device. There are multiple devices in United States. Some of them have been approved by the FDA. Some others are in the process of being FDA approved. Some others have enrolled enough patients to complete the clinical trials. And FDA is currently reviewing the experience of centers using these technologies to decide whether it is FDA approved or not.
Do you have any names that are FDA approved?
Borja: Yes. I believe there are two devices that the FDA has approved TransMedics and OrganOx. They have been approved. They- those deliver normal thermic perfusion. There’s another device called LifePort that delivers hyperthermic perfusion. They completed the trial and now they are being reviewed by the FDA.
Before this, what was the option for preserving livers?
Borja: We didn’t really have a lot of options. Basically the option is has a surgery and you would send your team and you will try to be very efficient with the timing. Try to minimize the time between the recovery of the organ and the time that you will do the transplant. That was the way that I was taught. That was the way that most transplant surgeons in United States were taught. If you want to be efficient and use a liver transplant try to minimize, the cold ischemia time, the amount of time that the organ is outside of the body. Now with these devices, we can increase that cold ischemia time and we can deliver the organs to other places.
Are you amazed that the livers being used a few years ago couldn’t be used?
Borja: Yes. Personally, that’s one of the things that is driving my interests in research. In all my years in practice, I have seen quite a change in the organs that we’re using. We were not using as many donors with hepatitis C. We were not be using as many donors, considered donors after cardiac wave. The age of the donor has increased. And with these technologies, were using more frequently?
Is there anything I’m leaving out or that’s important or anything that you’ve studied and you wanted to touch on?
Borja: Just that maybe that these technologies are available for most of the people. As long as they are considered transplant candidates and that they need to have a liver transplant. These are technologies that are available for most of them. Sometimes people tend to think, I’m never going to be able to use these devices. These devices are restrictive for people in big institutions or different cities. The reality is that all these devices are becoming available for almost every patient that has cirrhosis and needs to have a liver transplant in United States.
END OF INTERVIEW
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