The first 100 liver transplants at UCLA

A clinical program in liver transplantation was begun at UCLA in 1984 after a period of laboratory investigation. The first 100 orthotopic liver transplants (OLT) were performed in 83 patients (43 adults and 40 children) between February 1, 1984 and November 1, 1986. Donors and recipients were matched only for size and ABO blood group compatibility, with OLT performed across blood groups in 28 patients. Standard operative techniques were used, including venous-venous bypass in adults. Arterial reconstruction was performed using an aortic Carrel patch or "branch patch" in 65% of cases and by end-to-end or aortic conduit techniques in the remainder. The hepatic artery thrombosis rate was 5%. Biliary reconstruction was choledochocholedochostomy in 67 OLT and Roux-en-Y choledochojejunostomy in 33 (complication rate of 24% and 24%, respectively). Average lengths and ranges of donor liver ischemia, operating time, and blood replacement were 4 hours (range: 1-10 hours), 7.6 hours (range: 4-15 hours), and 17 units packed cells (range: 2-220 units). Immunosuppressive regimen was cyclosporine-steroid combination, with monoclonal anti-T-cell antibody (OKT3) used for refractory rejection. All patients had one or more complications: pulmonary (78%), infectious (51%), renal dialysis (25%), neurologic (22%). All patients had at least one episode of acute rejection, and 3.6% had chronic rejection. Retransplantation was needed in nine patients once and in four patients twice. The overall retransplant survival rate was 54%, and two of four patients who received a second retransplant are alive. Sixty-three of the 83 patients (76%) are alive (adults 72%, children 80%). The 1- and 2-year actuarial survival rate is 73% (adults 68%, children 78%). Thirty-eight of 43 patients (88%) who had transplantation in the past year are alive. Of 14 perioperative variables assessed as predictors of early mortality, only postoperative dialysis (p less than 0.0005) and presence of severe rejection (p less than 0.01) had statistical significance. Seventy per cent of adults returned to work, and 84% of children had normal or accelerated growth. A new program in liver transplantation provides a dramatic option in patient care and an academic stimulus to the entire medical center.

Current state of heart transplantation

Heart transplantation has now been accepted as a proven therapy for terminal heart disease by the medical profession and the Government, and in the USA by insurance companies. Major improvements have been achieved in donor and recipient selection and management, organ preservation, immunosuppressive techniques, and the prophylaxis, diagnosis and treatment of infectious complications. The successful introduction of cyclosporin A to clinical heart transplantation in December 1980 at Stanford University heralded a dramatic expansion in the application of heart transplantation, resulting from improved patient survival, a reduction in serious morbidity, a shorter hospital stay and reduced cost.

Experience of a Canadian multi-organ transplant service

Organ transplantation has become the treatment of choice for selected patients with end-stage failure of the heart, liver or kidneys. The expanding role for organ transplantation, however, has led to a corresponding increase in the complexity of patient management. In response to these changes, University Hospital, London, Ont., has established an interdisciplinary multi-organ transplant service (MOTS). MOTS coordinates donor organ procurement and patient management. Donor organs have been retrieved from as far south as Dalton, Georgia, as far west as Calgary and as far east as Halifax. As of Dec. 31, 1985, 485 transplants had been performed, including 387 kidney transplants, 51 heart transplants, 3 heart/lung transplants, 43 liver transplants (in adults and children) and 1 pancreas transplant. With current immunosuppressive protocols MOTS projects 1-year patient survival rates of 95% after kidney transplantation, 88% after heart transplantation and 81% after liver transplantation. Patient rehabilitation has been excellent.

Impact of organ transplant program on the Clinical Chemistry Laboratory at the University of Pittsburgh

The success of cyclosporine in immunosuppressive therapy in organ transplantation suggests that such existing programs may expand in scope, and new programs may be initiated at institutions that currently do not have them. Significant clinical laboratory support and the allocation of laboratory resources are necessary to sustain an organ transplant program. At the University of Pittsburgh, the number of transplant-related clinical chemistry procedures (primarily cyclosporine and liver and renal function tests) increased from 1.4% of the total chemistry tests in 1979-1980 to 21% of the total in 1983-1984. There was a concomitant increase in cost for transplant chemistry tests as follows: $47,000 in the fiscal year 1979-1980 to $1,250,000 in the fiscal year 1983-1984. Measurement of blood cyclosporine levels alone can consume a large fraction of a total laboratory budget; from being a negligible expense at the end of March 1983, it escalated to almost $300,000 by October 1984. Our experience in this regard indicates that it is difficult to gauge the magnitude of necessary laboratory resource commitment to such a program a priori with any degree of certainty. In this context, the capacity to be flexible in assigning laboratory resources appears critical.

Mismatched living, related donor renal transplantation: a prospective, randomized study

A prospective, randomized study of 49 mismatched living, related donor renal transplants was undertaken to compare the effect of donor-specific transfusions (DST) combined with conventional immunosuppressive therapy (azathioprine, prednisone, and antilymphoblast globulin) to cyclosporine and prednisone with and without use of prior DST. The results demonstrated that cyclosporine and prednisone without DST have equal patient and graft survival rates after transplantation and an equal incidence of infectious complications and rejection episodes when compared with recipients who received DST and conventional therapy. Patients who received DST and subsequent cyclosporine had poor graft survival rates with more rejection episodes and infectious complications. Hospitalization and the relative cost of transplantation were decreased when recipients received cyclosporine without prior DST. It is concluded that cyclosporine allows easier access to transplantation, is more cost effective in the initial posttransplant period, and does not subject the recipient to the risk of donor sensitization as is seen with DST recipients given conventional therapy. The nephrotoxic side effects of cyclosporine have been minimal and renal function remains excellent in the recipients treated with cyclosporine.

Heart transplantation at a private institution: a two year experience

Since October 1982, 45 patients were referred and 15 underwent orthotopic heart transplantations. Eleven patients are presently alive. The donor heart ischemic time averaged 104 minutes for locally procured hearts and 183 minutes for hearts harvested in distant cities. Ninety-three percent of the patients survived the perioperative period. Survival rate at six months was 84%, at one and two years 72% and 52%, respectively. The one year survivors spent 80% of their time out of the hospital. The average cost for the transplant admission was $58,023. Four patients died 11 days, 57 days, 8 and 12 months after the operation. During the first three months there were 0.75 rejection episodes, 1.13 infections and 1.40 other complications per patient. We conclude that heart transplantation can be successfully carried out at a private institution, with excellent survival rates and at reasonable costs. In spite of progress, infection and rejection still account for most of the mortality and morbidity.

Skills and resources needed for liver transplantation

Trained specialists in hepatology, liver and biliary surgery, anesthesiology and pathology must form the core of a team for liver transplantation. The hospital must be a center for organ transplantation to provide the essential infrastructure to manage specific aspects of transplantation. A well-organized blood bank is essential to cope with acute requests for large amounts of donor blood. Because of the extremely high costs, liver transplantation has to be approved medically and politically before it can be considered as a generally accepted modality of treatment.

The social and economic costs of end-stage renal disease. A patient's perspective

The soical and economic effects of end-stage renal disease are enormous. This case history of our experience with dialysis and transplantation details our life with these two modes of treatment. Despite the common notion that Medicare covers most of the expenses, the detailed records of our financial experience show that Medicare paid only 53 per cent of our total costs; the remainder came from a mixture of private and public sources. In seeking alternative financial support, we encountered many problems, including complex and constraining requirements for aid, invasion of privacy, high insurance and bank-interest rates and termination of employment. Even those in middle-income brackets find it difficult to maintain their independence under such circumstances. New legislation extending Medicare coverage of home dialysis and transplantation should help to alleviate these problems in the future.

Pragmatic realities in uremia therapy

The present status and future prospects of uremia therapy in the United States are reviewed. Approximately 3500 renal transplants were done in 1976 as compared to 3700 in 1975. Functional two-year survival of grafts has not changed recently (40 to 45 per cent for cadaver donors; 70 to 75 per cent for siblings), but patient survival with cadaver grafts continues to improve (now 65 per cent at two years). Patients on hemodialysis in facilities are increasing rapidly. Only 13 per cent are on home dialysis, as compared with nearly 40 per cent five years ago. Home patients do at least as well as those in centers (80 per cent two-year survival) and cost 40 per cent less. Physician bias probably explains the trend to center dialysis, but pending legislation may provide new incentives for home treatment. Prospects for technical advances are good, but a greater federal investment in research and development is needed. Dollars saved on the center dialysis could be used for this purpose.

Predicting treatment costs and life expectancy for end-stage renal disease

To estimate the cumulative 10-year direct medical costs and life expectancy associated with different methods of treatment for end-stage renal disease, we assessed predictively three treatment transition options. It is predicted that if 1000 patients shift from facility to home dialysis for each of 10 years, life expectancy of the cohort will not be reduced, but there will be a reduction of $241 million in total costs. The same number shifting from facility dialysis to cadaveric transplantation are predicted to have a $279 to $330 million reduction in total costs but a reduction of 7 to 17 per cent in life expectancy. Shifting from home dialysis to transplantation is predicted to reduce total costs by +103 to $142 million, and life expectancy by 10 to 20 per cent. As new program policies for treatment of end-stage renal disease are developed, their effect on both costs and life expectancy needs to be considered.