Improving Organ Availability for Transplantation

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again, everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, I am extremely pleased to welcome a return guest and a legend in the world of liver surgery and liver transplantation. That's Dr. Charles Miller, who's the Enterprise Director of Cleveland Clinic Transplantation, also a Liver Surgeon in the Department of General Surgery here within DDSI. Charlie, welcome to Butts and Guts.

Dr. Charles Miller: Oh, thanks, Scott. Thank you for that kind introduction.

Dr. Scott Steele: So, as you know, we'd like to start off a little bit with our guests and tell us a little bit about your background, where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Charles Miller: I went to medical school and general surgery and vascular surgery all at Mount Sinai Hospital in New York. And after that I went on staff. And during my residency I'd spent a year doing an unusual year, my third year doing transplantation research and taking care of a very small kidney transplant program. I was the only resident, so it was a really great year and I got interested in transplants.

So, after my vascular surgery fellowship, I stayed on staff as a vascular surgeon and helped the guys in the kidney transplant program, but not a lot. And then about a year later, Mount Sinai decided they wanted to have a multi-organ transplant center, and they asked me to set up and run a liver transplant program, which was ultimately the first in New York. And so, in all of 1986, I spent time at the University of Pittsburgh, learning from the great Thomas Starzl and many of his disciples. We went back to New York, and New York's a complicated place, so we had to wait for 20 months before we could actually start the program. And then, we did the first liver transplant in New York State on September 3rd of 1988 and grew that program there.

And then after about 2004, Dr. Fred Loop, who was the CEO of the Cleveland Clinic, made me an offer I couldn't refuse, and I came to the Cleveland Clinic to build up their liver transplant program here and build up transplantation.

Dr. Scott Steele: Well, we are super glad that you are here. And today, we're going to talk a little bit about improving organ availability for transplantation. Before we dive into that, can you first just give us a little bit, kind of a 50,000-foot-view of what organ transplantation is and why would a patient require one?

Dr. Charles Miller: Patients require transplantation, in general, because they are suffering from end-stage organ failure, usually. One of the organs that we think of, like maybe the heart, is heart failure. The lungs have respiratory failure. Kidneys, the kidneys have failed, they're on dialysis. Those are the ones we could talk about. And so, when they've got towards the end of their spectrum of disease, there's no real alternative except for replacing the organ. And so that is what transplantation is about. And we have many, many thousands of people on the US waiting list, waiting for one organ or another, or sometimes a combination of organs. And that's what transplantation is all about.

Dr. Scott Steele: What are some of the other organs that can be transplanted?

Dr. Charles Miller: Here at The Clinic, we have transplanted some faces, some limbs, and uterus transplantation, which is a fascinating area, where there are a very small number of women that are actually born without a uterus, and they can't carry their own child. And so, it's something that is a strong desire for many, many women to carry their own baby to term. And so, we've done eight uterus transplants and we have five new beautiful children from those transplanted uteruses. And I have to tell you, when you see that, one time I was giving a talk and they said to me, "Oh, did you just come from the OR saving lives?" And I said, "No, I came from the OR, we were making lives."

Dr. Scott Steele: That's absolutely fantastic. Charlie, you talked about a lot of different disease processes that can occur that would have a patient require an organ transplantation. But who qualifies for an organ transplant? And can you go, this is kind of a very, let's pick the liver for example. Just give me a real brief overview about how that transplant procedure is performed.

Dr. Charles Miller: Oh, so qualifying, you have to be able to understand the process, go through it. And I mean, basically, just be somebody that can take a relatively complicated regimen of medications afterwards to be responsible because they're getting a very, very precious and valuable gift. Then they go onto a list and then you get an organ depending on how sick you are. The sicker you are, the more likely you'll get an organ.

The transplant procedure for a liver transplant - it's different than a kidney transplant. A kidney transplantation is when a kidney is put in a different place in the body, down by the groin. It's an extra organ. We call it heterotopic. So, it's put in a different place than the kidneys normally are, and it's just another kidney that actually works very well when the other two have failed.

A liver transplant requires that you take the liver out, save all the vascular and biliary connections in a way that you can put a new liver in, sew it in, and have it take the place of the old liver and function perfectly. And that requires a lot of sewing of the arteries and veins and bile ducts.

Dr. Scott Steele: Charlie, when you are on the other end of it, we do have a living donor program, and I encourage all of our listeners out there to go back and listen to that one. How can someone donate an organ? How can they volunteer? How do they even get involved in that pathway? And then what does it take are their requirements after they've enrolled in the pathway that they either say, "Yes, you can," or "No, you can't?"

Dr. Charles Miller: I would say, usually, when a person comes that needs a transplant, they're told of two options. Waiting for a deceased donor, which would require a long wait. Or if they have somebody, a family or a friend or somebody from church, who would be willing to donate, it's a wonderful option. And to try to reach out and find somebody that would like to donate either one kidney or a portion of their liver, those are the two that we do, Scott.

And both are very safe for the donor. There are occasional problems, but very rarely. And the donors get a great deal of satisfaction from giving this gift to a friend or a family member. Or, one we're actually doing today is an anonymous person who does not actually know the recipient, giving a small portion of their liver to a baby. They just want to be generous.

Dr. Scott Steele: That is unbelievable. It's common to hear a lot about what we're talking about today, and that's organ availability. And so, we talk and hear about these organs wait lists. So, are there enough transplantable organs available for those in need, or what is the degree of deficit?

Dr. Charles Miller: Well, that's a really good question. And I say it because there's a shortage. It's not clear that it could ever be enough, so you have to make the queue ordered so you take the sickest first, and you match them up correctly.

The second thing is knowing what a good organ is. And one of the things we are very vested in here is trying to maximize utilization of every organ from a deceased donor. For instance, we now have, in liver and lung, oxygenated profusion machines, where we can take those livers and/or lungs and put them on a machine and not only resuscitate them in some ways, but we can assess how they're functioning on the machine. And so, it's the first really objective way of assessing organs in how well they might work in the recipient. Up until very recently, it was just the opinion, the subjective opinion, of an experienced transplant surgeon, whether or not it was a good organ. Now, we have something we can actually measure. When you can measure something, you learn a lot and you get better.

And so, in the last year, Scott, this is an amazing number - we've gone from doing a liver transplant every 1.8 days to doing one once every 1.3 days. Now, that's a 40 percent increase because we're much more confident. We are using many more organs that may have actually been discarded because of lack of understanding about whether or not it was good and erring on the side of safety. Now, we're being safe and efficient.

Dr. Scott Steele: So, truth or myth? one single organ donor can save up to eight lives.

Dr. Charles Miller: Oh, I think it's very true. So, let's count. One heart, two lungs. Possibly two pieces of liver, you can split a liver. That's five. Two kidneys, that's seven. A pancreas, an intestine, which I didn't talk about, but that's an amazing thing. That's eight or nine. A uterus, 10. And possibly a limb. So, I think you're over 10.

Dr. Scott Steele: That's incredible. Let's switch gears now. Tell us a little bit about organ perfusion, and how does that factor into increasing organ availability?

Dr. Charles Miller: Well, that's what I was talking about, pumping the livers, organ perfusion. And what we're doing right now, you can profuse it with modern technology, is that it seems that you have to oxygenate the perfuse to make the liver or the lungs actually stay for long periods of time and be good and actually improve.

So, whether or not it's blood, whether or not it's warm or cold, are still areas of research we are heavily vested in. We've just recruited a great new surgeon from Europe who has a strong interest in this. And we intend to understand the physiology of this, perfect the art of perfusion, and we will be able to resuscitate more and more organs, make organs much more available for all these patients waiting. They won't have to wait as long, and they're going to get a better organ.

Dr. Scott Steele: When we talk about perfusion, are there certain organs that can be perfused and others that can't really?

Dr. Charles Miller: No, actually I think they could all be. They're all vascularized organs, so all you have to do is perfuse the arterial circuit of any organ. And they're doing some heart transplants now, so that's another. Kidneys have been perfused for many years in an old-fashioned without oxygen, and probably they would be even better preserved with oxygen. But that's a coming technology. And whether you could do it… we are just starting to look carefully about perfusing pancreases and intestines. You can do anything, and I think it would work very well. It's just that the needs were so great in liver and lung that that's where it developed - the clinical need.

Dr. Scott Steele: Is the recovery process different when you receive a perfused organ versus a non-perfused organ?

Dr. Charles Miller: Yeah, yeah, that's a really good question, too. We think it is. We think the length of stay for the recipient is shorter. We think recovery is easier because the organs work well. One of the things in liver transplant that has always been a source of consternation for the surgeon is sometimes when you take an organ, you take it out of the cold, you implant it and you turn the blood flow back on, it can cause something called reperfusion syndrome, which you get low blood pressure and tachycardia and hemodynamic instability that makes the anesthesiologist very nervous and makes the surgeons very nervous.

When you pump one of these organs, when you put the blood back through it in the recipient, nothing happens. It's like, boring. It's good. It's a good place to be bored. There's no reperfusion syndrome and the patients are more stable and do better.

Dr. Scott Steele: So, talk a little bit about the risks.

Dr. Charles Miller: I guess the risks are the machine could stop working, but there's somebody sitting there. And so, then you can just turn it back on or fix whatever the circuit is. So, those circuit breaks could be a problem, but we have not seen it.

One of the things we'd like to do is not a risk - we'd like to take the machine with us and put the organ on right after we take it out, but the machines aren't terribly portable. And so, we're working on better versions, more portable. And there's not a risk, but there is a cost to it that we have to understand better how we manage the costs of a whole new technology.

Dr. Scott Steele: And so, are there other ways that we can go about to increase organ availability so patients can get a transplant? We talked a little bit in the past, which we mentioned about the living donor method, but is there anything else?

Dr. Charles Miller: Well, there are technologies that are being developed. Well, first of all, you could theoretically take an organ from an animal, and what I'm talking about here right now, there are clinical trials, it's called xenotransplantation, and what has been done is you genetically engineer pigs to remove certain molecular features of their organs, antigens, that don't allow the human recipient to recognize it as foreign. And they can work. They still undergo severe rejection. It hasn't been done as a clinical trial yet, except it's still in the experimental phase. That's one, and that holds some promise, but how much genetic engineering you have to do and what type of immunosuppression you would need to make it work long-term is far from established and is probably another decade or two away.

Then, there's the possibility of bioengineering organs. This is a very complex area, but it's something that people are working on trying to take a pig liver and wash it out of cells, completely wash it out with detergent, and then repopulate it with human cells and implant that. These are futuristic, but they may well be the future. Right now, we are really focusing on trying to maximize human organs that we can use for humans.

Dr. Scott Steele: Well, that was an incredible, almost sci-fi look into the future regarding some of the advancements on the horizon for organ transplantation perfusion. Now it's time to get to know our guests a little bit better with our quick hitters. Let's start off with a couple of different questions for you, Charlie. So, salt or sweet?

Dr. Charles Miller: Oh, salt.

Dr. Scott Steele: What's your favorite dessert?

Dr. Charles Miller: I think chocolate chip ice cream.

Dr. Scott Steele: Flashback to 2003. When you turned 16, what was your first car?

Dr. Charles Miller: A Buick Special.

Dr. Scott Steele: I don't even know what that is, I'll have to look that one up.

Dr. Charles Miller: With an aluminum engine.

Dr. Scott Steele: Fantastic. And then finally, the trip of a lifetime. If you could go somewhere, where would it be?

Dr. Charles Miller: I think we may do it this summer. We're going to two weddings on two different islands in Italy with my whole family.

Dr. Scott Steele: That's fantastic. So, any final take home message regarding improving organ availability for transplantation?

Dr. Charles Miller: I think the take-home message is get the word out, sign your donor card, go on the registry, and talk to your friends about it, as well. You really can help 12 people in one gift.

Dr. Scott Steele: Absolutely, it is an opportunity to save a life. And so, to learn more about transplant care here at the Cleveland Clinic, please visit our website at my.clevelandclinic.org/transplant. Again, that's my.clevelandclinic.org/transplant. You can also call our Transplant Center at 216-444-2394. That's 216-444-2394. Dr. Miller, thanks so much for joining us here on Butts and Guts.

Dr. Charles Miller: Pleasure, Scott. It was really fun talking to you.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.