Oriented to Thoracic Transplant
Recipients -- July 1997
WHEN TO TRANSPLANT: RECIPIENT SELECTION FOR TRANSPLANTATION
Kathleen L. Grady, Ph.D., RN, FAAN,
Nursing Director, Rush Heart Failure and Cardiac Transplant Program,
Rush-Presbyterian-St. Luke's Medical Center, Associate Professor,
Rush University College of Medicine,College of Nursing,Chicago,
- There was never yet an uninteresting life. Such a thing is an
impossibility. Inside of the dullest exterior there is a drama, a
comedy, and a tragedy. We, as health care providers, strive to
prevent illness and provide care to sick patients thereby extending
life and promoting quality of life so that patients can play out
their dramas. In providing care to patients with end-stage heart
failure, heart transplantation has successfully moved from the
experimental to the conventional domain of therapy. Actuarial
survival rates are 80% at 1 year, 65 % at 5 years, and 45 % at 10
years. As heart transplant survival rates have improved over the
years, patient selection criteria have expanded to include older
patients, patients with coexistent disease processes, and critically
ill patients awaiting new hearts on conventional and experimental
circulatory assist devices.
- Care-takers of heart transplant programs should expand criteria
for patient selection with the greatest attention to patient
survival, morbidity, quality of life, and the careful use of donor
hearts, a precious and scarce resource. Therefore, the purpose of
this article is to describe the indications for adult heart
transplantation through a careful examination of current selection
criteria and contraindications.
DIAGNOSES OF PATIENTS REQUIRING HEART
- The majority of adult patients who require heart transplantation
have either ischemic cardiomyopathy (47.2%.) or cardiomyopathy of
other etiologies (43.5%). Fewer patients have valvular (4.2%) or
congenital heart disease (1.3%.). Ischemic patients typically have
inoperable coronary artery disease with cardiac dilation and severe
left ventricular dysfunction (LVD). The 2-year survival rate for
ischemic cardiomyopathy patients treated medically has been reported
to be as low as 31%, while the 2-year survival rate for patients
with cardiomyopathies of other etiologies is 50% to 60%.
- The nonischemic dilated cardiomyopathies for which heart
transplantation maybe a therapy are classified as idiopathic,
inflammatory (infectious and noninfectious), toxic, and familial.
The primary physiologic derangement in nonischemic dilated
cardiomyopathy is cardiac dilation with impaired systolic function
of both ventricles. Diastolic dysfunction may also exist in some
patients. Idiopathic dilated cardiomyopathy (wherein a specific
etiology is not found) is the most prevalent form of nonischemic
dilated cardiomyopathy. A specific etiology is found in fewer than
20% of cases. Postviral myocarditis is thought to be a major cause
- but unfortunately, cardiomyopathy is often diagnosed after heart
failure has become chronic, and myocarditis can no longer be
- Heart transplantation has also been performed, although not
commonly, in patients with active inflammatory processes causing
- Transplantation for toxic causes of dilated cardiomyopathy, such
as cardiomyopathy produced by ethanol and chemotherapeutic agents,
is even less common. Patients with alcoholic cardiomyopathy who
abstain from ethanol intake can experience spontaneous improvement
within a few months. Furthermore, issues related to
- compliance may interfere with an alcoholic patient's candidacy
for heart transplantation.
- Lastly, in a recent study, familial dilated cardiomyopathy,
thought to be rare, was documented in 20% of patients with
cardiomyopathy. There were no significant differences in gender (25%
female vs. 53%0 male), age at diagnosis (46.8 years vs. 44.9 years),
left ventricular ejection fraction (LVEF) (29.4% vs. 29,9%), or
echocardiographic findings (left ventricular end diastolic dimension
[LVEDD] = 68.5 mm vs. 68.8 min.) of patients with familial dilated
cardiomyopathy (n =: 2) versus nonfamilial dilated cardiomyopathy (n
= 47). Based on disease severity and lack of contraindications,
these patients are also candidates for heart transplantation.
- Before ending the discussion of diagnoses requiring heart
transplantation, it is necessary to address repeat transplantation,
which accounted for 2.30% of the population in the most recent
International Society for Heart and Lung Transplantation (ISHLT)
Registry Report. Repeat transplantation offers the only hope of
survival for posttransplant patients with severe myocardial
dysfunction due to primary graft failure, severe acute rejection, or
accelerated coronary artery disease. Unfortunately, Ensley et al
found that 1 year survival was significantly less in patients with
repeat transplantation than in those with primary transplantation
(48% vs. 79%,). Factors found to increase survival following repeat
transplantation included accelerated coronary artery disease as the
cause of allograft failure, second transplant after 1985, a period
of greater than 6 months between transplants, and not having
preoperative mechanical assistance. Evans et al reported that
retransplantation was more costly, than primary transplantation.
Given that 29% of patients die or are removed from the heart waiting
list for a contraindication, retransplantation needs to be carefully
considered in light of an inadequate donor supply, decreased
survival, and associated costs.
EVALUATION FOR HEART TRANSPLANT
- Given a diagnosis of congestive heart failure (CHF) from
an explained or unexplained etiology, it is the responsibility of
heart transplant teams to decide whether a patient needs a heart
transplant. Standard criteria for heart transplantation vary
somewhat from program to program. but generally are based on the
patient's severity of heart disease, adequacy of current therapy,
and potential future therapy: and on the presence of coexistent
conditions and other contraindications that may preclude heart
transplantation. Standard recipient selection criteria are listed in
the box entitled "Standard Criteria for Heart Transplantation."
Typically, patients undergo a wide variety of cardiac and noncardiac
tests to determine need and eligibility for transplantation. The box
entitled "Cardiac Transplant Evaluation" lists the initial
testing that patients undergo in order to determine their candidacy.
Additional tests may be ordered depending on preliminary findings.
- Standard Criteria for Heart Transplantation
- 1. End-stage heart disease not correctable by other medical or
surgical therapy with a poor prognosis
- 2. Age <65 years
- 3. New York Heart Association functional Class III-IV
- 4. Absence of other irreversible end organ damage and infection
- 5. Stable psychosocial status, including absence of current
alcohol or drug abuse
- Severity Of Heart Disease
- One of the greatest challenges in heart transplantation is to
determine if a patient's illness is severe enough to warrant heart
transplantation and if all other conventional therapies have been
exhausted so that heart transplantation is the only option. Over the
years, physicians have attempted to define and refine listing
criteria for heart transplantation. Generally, patients who require
heart transplantation have symptomatic end-stage heart disease and a
poor prognosis for survival beyond one year. Traditionally, cardiac
measures used to evaluate prognosis and candidacy for heart
transplantation have included LVEF, hemodynamic status, presence of
ventricular ectopy, and New York Heart Association (NYHA) functional
class and symptoms. Ejection fractions (EFs) of less than 20% to 25%
(normal EF = 40% to 65%) are common in patients being evaluated for
heart transplantation. Likewise, patients have abnormal hemodynamics
with a decreased cardiac output and index, increased pulmonary
artery and pulmonary capillary wedge pressure, and decreased
systemic pressure. Patients may be stable on oral heart failure
medication or may require intermittent or continuous intravenous
inotropes, including dobutamine and milrinone. Patients at high risk
of mortality require intra-aortic balloon pumping or mechanical
assist devices, such as left or biventricular assist devices or
total artificial hearts.
- Evaluation of symptoms of heart failure is subjective and
difficult to measure. Traditional measurement of symptom severity
has been through use of the NYHA functional classification system.
Patients are categorized according to symptom occurrence with
activity. Class I patients have no activity limitation and no
cardiac symptoms with ordinary activity. Class IV patients have
severe limitation of activity, inability to carry on any activity
without discomfort, and possible cardiac symptoms at rest. Some
studies have shown that heart failure patients with NYHA Class IV
symptoms have a significantly worse prognosis than patients with
NYHA Class II or III symptoms. Grady et al examined symptoms in
heart failure patients awaiting transplantation (n = 175) using the
Heart Transplant symptom Checklist (a 92-item, Likert-scaled
instrument with 0 = not bothered at all to 3 = very bothered). The
most frequent and distressing symptoms were tiredness, difficulty
breathing when doing something, difficulty sleeping, and weakness in
the whole body. The Sickness Impact Profile has also been used to
assess functional disability in heart failure patients. Grady et al
found that less functional disability correlated significantly with
greater life satisfaction in patients awaiting heart
transplantation. Psychosocial tools provide additional, valuable
information in the' understanding of patient perception of heart
failure; however, their use has often been limited to research and
their widespread application may not be practical. Furthermore, one
need only examine individual heart failure patients to understand
that the correlation between objective indicators and subjective
indicators of heart failure is conflicting and low, Indeed, it is
common to see a patient with an LVEF of 15% who has no symptoms and
is working full-time and another patient with an LVEF of 30% who is
gravely ill in the intensive care unit on an intra-aortic balloon
pump. It is. therefore, important for health care providers to
refrain from generalizing from population data to individuals with
- More recent prognostic information about heart failure and when
to transplant has been gained through the measurement of exercise
tolerance and sympathetic nervous system activation. Although
researchers do not agree on the level of oxygen consumption at which
prognosis is poor and heart transplantation should be recommended,
it has been found to be a good predictor of mortality in ambulatory
heart failure patients with severe LVD.
- The usefulness of markers of sympathetic nervous system
activation gained the attention of researchers in the mid-1980s.
Levine et al described increased plasma norepinephrine levels and
plasma renin levels in a population of stable heart failure
patients. Corn et al subsequently reported significant differences
in heart failure patient survival based on plasma norepinephrine
levels. The usefulness of markers of sympathetic nervous system
activation has been supported by other researchers.
- In addition, criteria for heart transplantation differ somewhat
for ischemic versus nonischemic dilated cardiomyopathy patients
based on etiologic differences. There are no specific criteria to
accurately predict whether an ischemic cardiomyopathy patient will
benefit most from revascularization or heart transplantation.
- Regarding nonischemic cardiomyopathy, a number of patients
listed for heart transplantation will spontaneously improve and can
be removed from the transplant list. As many as 50% of patients who
have idiopathic dilated cardiomyopathy with a new onset in symptoms
may experience an improvement in EF within 6 months and no longer
require transplantation. Therefore. it is important to monitor these
patients and repeat tests (such as radionuclide ventriculography and
metabolic treadmills) based on history, physical examination, and
reported symptoms in order to determine if improvement has occurred.
- It is apparent that cardiovascular assessment for heart
transplantation begins with a thorough history and physical
examination, followed by many tests in order to gather sufficient
information to make a decision about listing. Even then. changes in
a patient's condition can occur (including spontaneous improvement
or deterioration) that may either remove the patient from the list
or increase his or her priority status for a new heart. In a
comparative study, Stevenson et al reported that the 1 year
actuarial survival of 214 candidates for heart transplantation was
lower than that of 88 outpatients who received a transplant (67c/c
vs. 88%, P= 0.009). This finding is congruent with clinical
practice. However, these researchers further examined the
outpatients who survived the next 12 months without transplant (n =
94) and determined that their survival was 83%. The results of this
study have implications for candidate selection, They support higher
priority to critically ill inpatients awaiting transplantation but
suggest that patients who wait more than 6 months should be
reevaluated regarding their continued need for transplantation,
rather than receiving a higher priority based on accumulation of
time on the waiting list.
- Contraindications To Heart Transplantation
- Contraindications to heart transplantation are relative or
absolute. Over the years, modifications have been made to these
contraindications that have expanded the waiting list for
transplant. The contraindications listed in the box entitled
"Contraindications to Heart Transplantation" are discussed
relative to the recent literature.
- One of the more obvious changes in selection criteria for heart
transplantation has been the increase in the upper age limit from
approximately 50 years in the 1970s to >65 years in the 1980s and
1990s. This increase in the upper age limit is supported by several
studies that have shown no difference in survival and the
posttransplant incidence of rejection and infection between older
patients versus a younger cohort. Furthermore, there were no
differences m initial hospital length of stay after transplant and
older patients have been successfully rehabilitated. However,
steroid-induced diabetes and osteoporosis occurred significantly
more frequently in older patients.
- Contraindications to Heart Transplantation
- Metastatic cancer
- Severe primary pulmonary, hepatic, or renal disease
- Irreversible neurologic or neuromuscular disorder
- Acquired immunodeficiency disorder
- Insulin dependent diabetes (with end-organ damage)
- Active drug or alcohol abuse
- Age >65 years
- Pulmonary hypertension
- Systemic disease process
- Active peptic ulcer disease, active diverticulitis
- Recent pulmonary embolism
- Active infection
- Severe peripheral or cerebral vascular disease
- Morbid obesity
- Cardiac Transplant Evaluation
- Ventricular Function
- Radionuclide ventriculography with left ventricular ejection
fraction (LVEF} and right ventricular ejection fraction on (RVEF}
- Right heart catheterization
- M-Mode and two-dimensional echocardiogram/Doppler echocardiogram
- 24-hour Holter monitor
- Metabolic treadmill exercise test (Naughton protocol)
- 12-lead electrocardiogram
- Noncardiac Organ System
- Chest radiograph
- Pulmonary function testing
- 24-hour urine for protein and creatinine clearance
- Pneumovax vaccine
- Tetanus and diphtheria toxoid, adult
- Skin test anergy battery
- Tuberculin purified protein derivative (PDD }
- Social work consult
- Nutritional assessment by dietitian
- Ophthalmology consult (if >45 years or diabetic)
- Gynecology consult for women
- Carotid Doppler study in patients with coronary artery disease
or who are >40 years
- Lipid profile
- In Human immunodeficiency virus (HIV) antibody test (AIDS
- Rapid plasma reagin (RPR) test (syphilis screening)
- Hepatitis B surface antibody and antigen and Hepatitis C
- Plasma catecholamines
- Glycosylated hemoglobin
- Lower extremity Doppler tests (armlankle pressures) in patients
with coronary artery disease or who are >40 years
- Dental consult, panorex of mandible
- Digital rectal exam (if @@ years); stool for occult blood (if
- Sigmoidoscopy (if >50 years and has not had test in last 3 to
- *Schedule visit with cardiovascular surgery
- *Schedule visit with an anesthesiologist
- *Blood titer: cytomegalovirus, Epstein Barr virus, toxoplasmosis
- Donor Matching
- Blood type
- Human leukocyte antigen (HLA) antibody screen, (also called %
panel reactive antibodies)
- HLA A B C and DR typing
- *Should be completed immediately prior to listing
- In response to the concern for a limited donor supply, some
programs have used older donor hearts (>40 yrs) for older
candidates. Luciani et al compared patients over the age of 55 who
received donors who were <40 years (n = 37) with donors who were
>40 years (n = 18). There were no differences in survival at I
year (88% vs. 84%) and 4 years (81% vs. 80%) in patients who
received older versus younger donors. Also, the incidence of acute
rejection and allograft arteriopathy were similar in the two groups.
- Heroux et al reported on heart transplantation in 12 patients 65
years or older versus 57 patients aged 55 to 64 years. Although
there was no difference in survival between the two groups, older
patients had a higher number of hospital days during the first
posttransplant year, experienced more infection and less rejection,
and were more functionally limited than younger patients. The
results of these studies suggest the need for careful screening of
patients aged 65 years or older for age related comorbidites.
- One of the earliest contraindications to human heart
transplantation studied was pulmonary hypertension, Excessively
elevated pulmonary pressures in the early postoperative period were
shown to cause donor right heart failure. Because pulmonary
hypertension is often present in patients with chronic CHF, programs
perform right heart catheterization to assess the existence, extent,
and reversibility of pulmonary hypertension as part of the
evaluation for heart transplantation. As waiting times before
transplant have lengthened to an average of 6 months for almost one
half of the listed candidates, clinicians have recognized the need
to repeat their assessment of pulmonary pressures every 3 to 6
months, depending upon the extent of pulmonary hypertension.
- Patients with systemic disease processes typically are excluded
from consideration for heart transplantation, although physicians
argue in favor of listing patients in some situations, Obvious
absolute contraindications to transplantation include metastatic
cancer; severe primary pulmonary, hepatic, or renal dysfunction;
irreversible neurologic or neuromuscular disorders; or acquired
immunodeficiency syndrome. Patients with systemic lupus
erythematosus, amyloidosis, sarcoidosis, scleroderma, familial
hyperlipidemia, and previous stroke are being referred to heart
transplant centers for evaluation. Physicians argue that
transplantation will improve a patient's prognosis in these
- Coexistent conditions that may be exacerbated by the process of
transplantation and immunosuppression have also been
contraindications to heart transplantation. Conditions that require
resolution before transplantation include active peptic ulcer
disease, active diverticulitis, a recent pulmonary embolus, and
active infection. Each of these conditions can result in sepsis and
be devastating in the early postoperative period. Patients with
peptic ulcer disease can also bleed and/or perforate, Severe
peripheral or cerebral vascular are also relative contraindications
to heart transplantation. The presence of pretransplant obesity has
been recently shown to be an independent predictor of mortality
after heart transplant.
- Insulin-dependent diabetes used to be an absolute
contraindication to transplant due to concerns about increased
difficulty controlling blood sugar with steroid therapy and
increased risk of infection and vascular complications. However,
recent studies have demonstrated no difference in survival and
posttransplant complications- (including rejection, infection, renal
dysfunction, and coronary artery disease) in diabetic and
- Heart transplantation has also been successfully performed in
patients with prior cancer without evidence of recurrence, Patients
with lymphomas, sarcomas, and carcinomas (n = 11 } with clearly
identified disease-free intervals were transplanted by the
University of Pittsburgh team. All 11 patients were alive and active
without tumor recurrence for a follow-up time of from 4 to 41 months
(mean = 18 months). The team recommended a mini mum disease free
interval of I year after completion of cancer therapy, with
modifications based on the type of tumor and urgent need for
- Psychosocial criteria have been clinically identified but not
well researched as contraindications to heart transplantation,
Patients are evaluated by social workers, psychologists, and or
psychiatrists in order to identity whether there are any
psychosocial contraindications to transplant. Generally. patients
who are acceptable candidates are motivated and compliant and have
good support systems. Psychosocial criteria that may predict a poor
postoperative outcome include previous noncompliance (especially
regarding medical care, dependencies (alcohol and drugs), lack of
adequate support system, personality disorder, history of
psychiatric disorders. organic brain disorders, or mental
- The literature is equivocal, however, about the importance of
psychosocial criteria regarding listing patients for heart
transplantation and posttransplant outcome. Patients have been
denied transplantation because of serious psychiatric problems,
primarily antisocial personality disorder, substance abuse, or
intellectual impairment. Researchers have also reported that some
patients with psychiatric problems pretransplant continue to have
problems after surgery, while other patients have no problems. While
preoperative psychological distress was not found to influence
medical outcome (morbidity and mortality) after heart
transplantation in one study, patients with psychiatric problems or
noncompliance had a greater need for hospital readmission
posttransplant in another study. In addition, second-year costs
related to transplantation were higher in patients with psychiatric
or compliance problems. Bunzel and Wollenek identified the following
psychosocial predictors of surgical success-supportive partner, few
demands for emotional communication, self-control, ability to deal
with stress, and low aggression level. Additional research is needed
to identify and refine psychosocial criteria for heart
- Heart transplantation is an effective therapy for patients with
end-stage CHF due to known or unknown causes. There is a limited
donor supply of hearts available to transplant, and waiting times
for transplantation are increasing. Therefore, heart transplant
teams must carefully consider and weigh all physiologic and
psychosocial factors to make a clinical decision that is best for
the patient (regarding survival and quality of life) and the best
societal use of a scarce resource. Furthermore, additional research
is necessary to examine preoperative physiologic and psychosocial
predictors of morbidity, mortality, and quality of life as outcomes
after heart transplantation. As health care financing comes under
scrutiny, the need to allocate hearts equitably and yet provide the
most benefit to patients is even more imperative.
- J Cardiovasc Nursing 1996; 10(2):58-70
- Abridged by D. Marshall
DID BILLIONS BUY A HEART? - Amway founder DeVos overcame
- 71-year-old billionaire gets new heart in London operation
- by Patricia Anstett - Detroit Freepress Staff Writer 6/4/97
- Did money buy Richard DeVOS a heart? DeVos, the 71-year-old
founder of Amway Corp. and one of the country's richest men, was
recovering Tuesday at a London hospital from a heart transplant
operation Monday, according to a statement released by his family
Tuesday. DeVos waited five months for his new heart - half the
average time a person in Michigan waits for a heart transplant.
- DeVos owns the Orlando Magic basketball team. Last fall, Forbes
magazine listed DeVos as the 23rd richest American, estimating his
wealth at $3.2 billion..
- He went to London after checking out his US options and
concluding that "his chance of qualifying for a heart
transplant in the United States was about zero," said a close
associate. The associate asked not to be named, citing the DeVos
family' s preference for privacy in the last year as word grew that
DeVos was seeking out medical centers worldwide that specialized in
- "Money didn't buy him a heart in America," the
- DeVos had assembled a medical team, headed by his Grand Rapids
cardiologist, Dr. Luis Tomaris, to check out options for a heart
transplant, here and abroad. "The strong conclusion was that
London was his best chance," the associate said. Tomaris was
out of the country and unavailable Tuesday for comment. The Amway
Corp., which DeVos cofounded in 1959 with Jay Van Andel as a
household cleaning-products firm, would not disclose the name of the
medical center where DeVos had his operation.
- Doctors had told DeVos that his heart was pumping at less than
20 percent of its capacity, the associate said. The vibrant,
positive man who once visited 16 cities in a week spent much of the
last year in bed, exhausted, the associate said.
- DeVos has had two heart bypass operations - factors that also
made him a less-than-optimal candidate for a heart transplant.
- The DeVos family has given large sums of money, to the American
Heart Association, said the associate, and "his 'spiritualism
and passion for life inspires many" - factors that may have
convinced British doctors to believe he was a good candidate.
- DeVos' age was perhaps the major stumbling block. Many centers
won't accept patients 60 or older, fearing they will die in the
first year of the operation or suffer serious complications.
Nationwide, only 6 percent of the US patients to receive heart
transplants were 65 or older in 1995, according to the United
Network for Organ Sharing, a nonprofit organization. Fifty-two
percent of the heart recipients were aged 50-64.
- "It is unusual for a 71-year old man 'to be placed on the
heart transplant list in the United States," said Dr. Keith
Aaronson, associate professor of internal medicine at the University
of Michigan Medical Center.
- Non-US citizens are eligible for US organs, but UNOS, the
monitoring agency, limits a center's procedures for nonresidents to
no more than 5 percent.
- In the United States, money only gets people so far. They can be
listed at more than one US transplant program per region, but must
be evaluated by each program. Transplant surgery costs $122,601,
according to one 1994 study. But costs may be double that if a
person is hospitalized prior to surgery.
- Wealthy people may travel around .he country looking for centers
to take them, Aaronson said. "That's the extent, in the US,
that money would do anything for you. But you can't buy a heart. If
you try and corrupt the system, you'd have to corrupt a whole lot of
- Abroad, patients face other problems: similar shortages of
hearts, refusal of insurance plans to pay for are and varying
standards of care. Two-thirds of all transplants world wide are
performed in the United States.
- Dr. Robert Higgins, a transplant surgeon at Detroit's Henry Ford
Hospital, said age is increasingly a factor in candidate selection
because congestive heart failure - a disease in which the heart
fails to pump at full capacity - primarily affects people over 60
and there are few good options. ' He estimated that only one of
Ford's 15 heart transplant patients last year was 60 or older.
- But only 2,342 people got heart transplants in the United States
last year, compared to nearly three times the number waiting for
- In Michigan, 72 people were waiting for a heart as of May 1,
according to Gift of Life. The state's organ procurement agency.
Last year, the average wait was 317 days, though one person waited
just one day and another waited nearly 2,000.
- Amway Cofounder Says He Feels Great
- Grand Rapids - Amway Corp., co-founder Richard DeVos, who also
owns the NBA's Orlando Magic, said he was cheerful and enthusiastic
after getting a heart transplant earlier this month. "1 don't
know how many of you guys are believers, but you've got to believe
in miracles," DeVos, 71, said from the London hotel where he
returned last week. "We just have to praise God for that."
- He got his heart from a woman, who needed a lung transplant but
a whose heart was healthy. so Doctors preferred to give the woman a
combined lung-heart transplant to increase her medical chances,
DeVos told The Grand Rapids Press in an article published Friday.
- "That's why we can say, I'm doing well and so is the
donor," DeVos said.
- DeVos will remain in London for a critical three-month period in
which his doctors will watch for signs of rejection, his family said
in a statement released Friday. So tar, four biopsies have shown no
sign of rejection.
- Contributed by Dr. Don Marshall, Kalamazoo The Associated
Press contributed to this report.
- For information on donating organs, call the Gift of Life at
1-8004824881, anytime. For transplant information and statistics,
the United Network for Organ Sharing has a Web site at www.unos.org
- Editorial comment: In truth, does not this situation present
the designated recipient situation on behalf of the donor with the
strong potential for remuneration in some form ?
- Tx Bob Vietti of Yates Center, Kansas makes a poignant statement
that pretty well returns the high number of nighttime trips on the
part of many transplant recipients to the proper prospective. As Bob
says, "I've had two heart Tx, Oct.' 83 and May '88. For those
people who have to go to the bathroom several times a night, they
should be thankful. I used to do that, then my kidneys quit. I've
been on dialysis for seven months now.
- Comments were heard from several readers about how they liked
the June cartoon issue. And several is many more than we usually
hear from on any given issue.
- UpBeat did neglect to thank all those readers who have sent in
the cartoons, both used and perhaps still to come, over the past 10
years. Apparently your fellow readers thank you too.
- What was it about seeing a new Bugs Bunny stamp complete with
backup sales of neck ties in my local small town Post Office that
bothered me? Let's see, placement of a money making endeavor for
who, 20th Century Fox, over a solid public service like and putting
out an organ donor stamp?
- What was it about seeing dozens of copies of Tx Claire Silva's
book, "Change of Heart" on display at my local Walden
bookstore that bothered me? Let's see, profiteering using a false
premise that could cause severe ridicule of a solid scientific
procedure benefiting many people in sincere need of it for saving
- Recently spent the day fishing out on the Chesappeake Bay. The
"normal" with me had all kind of trouble with deer fly
bites while yours truly had nothing to do but urge him to get a
transplant of something - anything.
- Tx Jim Nekitas forwards the following important and
scientific document direct from San Diego's Sharp Hospital:
- Top 10 Reasons,Why "Pred-Heads" Should be Thankful for
- l0) Offers men real insight into PMS.
- 9) Enables you to say twice as much in half the time.
- 8) Makes cyclosporine seem easy.
- 7) More affordable than coffee.
- 6) When it sticks to the back of your tongue, taste buds you
never knew existed spring to life.
- 5) Built-in excuse for hogging the whole hour at Support Group.
- 4) You finally have a logical reason for eating that fifth piece
- 3) Your family finally has a logical reason for disowning you.
- 2) With the excuse of bone loss, you'll be able to hang out at
ski resorts in your body cast and be idolized for
- attempting Suicide Mountain.
- And the Number 1 reason why pred-heads are lucky:
- 1) We have inside stock market information.., buy I ,000 shares
of Home Hair Removal Systems.
- By Malcolm Ritter - AP Science Writer 6/9/97
- In 1993, an official with the Centers for Disease Control and
Prevention called a few employees into her office. Then she asked a
question at least one of those employees viewed as silly:
- What was the CDC doing about the risk that animal-to-people
transplants would introduce new germs into the human population,
infecting first the transplant recipient and then spreading to other
- "My first reaction was--nothing," recalled Louisa
Chapman. an expert on animal viruses that infect humans. "Why
should we waste taxpayer time and money on that'?"
- Transplants from animals were so rare and recipients lived so
briefly that it didn't seem a threat to public health, Chapman
- But as she looked into the situation, she changed her mind:
Interest in such "xenotransplants" was heating up. Animals
could not only ease the shortage of kidneys, hearts and livers for
transplantation, but also supply brain tissue for treating diseases
like Parkinson's and pancreatic tissue to treat diabetes.
- These days, Chapman spends most of her time on
- She's not alone. Drug and biotech companies have poured more
than $100 million into xenotransplant research. Scientists report
progress in overcoming rejection of animal organs. and industry
analysts expect anew round of organ experiments in people within
three to five years.
- The heavy betting nowadays is on organs and tissue from pigs,
rather than chimps and baboons as in the past.
- But the concern Chapman heard in that 1993 meeting has not gone
away: Would xenotransplants be a form of Trojan horse, giving new
germs a sneaky entree into the human populalion?
- In March, scientists at the Institute of Cancer Research in
London reported that a virus -- one that might be found even in
healthy pigs - sprang out of pig tissue and infected human cells in
a lab experiment. Then it remerged from human cells in a form that
apparently would slip by the body's defenses.
- That shows the idea of such infection in a pig-to-human
transplant"is more plausible than a fanciful scare story,"
the researchers said.
- Two months earlier, the British government had slapped a
moratorium on xenotransplants, chiefly because too little is known
about the risk of infection.
- And federal regulators in the United States now are refining
draft guidelines to minimize the risk to public health. The
guidelines discuss such things as keeping specialized colonies or
herds of animals and screening them for germs.
- People who get animal organs, cells or tissue should be followed
for Iife for any sign of animal germs, and they should tell their
"close contacts" about the possibility such germs could be
passed on, the guidelines say.
- Close contacts could include sexual partners, health care
workers and breast-fed children, Chapman said. "We're not
talking about people who sit on the school bus with you or work in
your office," she said.
- At this point, the concern over public peril is theoretical -- a
pile of what-ifs, a mound of maybes. It reminds Chapman of how NASA
quarantined the astronauts from the first three moon-landing
missions in case they brought back weird germs.
- "What we are saying is there' s some level of risk,"
she said. The task now, she said, is to figure out how big it is and
what to do about it.
- Here's why Chapman and others say there's reason to worry:
- --Animals do have germs that can infect people and then spread
person-to-person. The AIDS virus apparently came from monkeys long
ago, for example, and the flu virus that killed more than 20 million
people worldwide in 1918-19 emerged from pigs.
- --Dangerous germs can hide in healthy-looking animals.
Hantavirus doesn't bother mice, but when it spreads to people, it
- --People getting animal organs would be on drugs to suppress
their immune systems, which could make it easier for an animal virus
to gain a foothold.
- --Genes from an animal virus could mingle with those of a human
virus in an organ recipient, creating a hybrid virus with
- --Keeping animals isolated from infection ]nay not be enough.
Some viruses scientists are concerned about aren't caught, they're
- They're just part of being a pig, for example. That's because
eons ago, these viruses infected the ancestors of modem pigs and
planted their DNA in sperm and egg cells. As a result, the virus
genes mingled with the pig genes and are now passed on through the
generations. It was just this kind of inherited virus that popped up
in the pig cell study reported in March.
- So far, however, the limited experience with xenotransplants is
- Dr. Alan Dimick, who's put pigskin on severe bums since 1970,
says there' s no evidence treatment has infected anybody with pig
germs. But Dimick, director of the bum center at the University of
Alabama at Birmingham, notes that pigskin stays on for only a day or
two. An implanted organ might pose more of a risk, he said.
- Dr. James M. Schumacher, a Sarasota, Fla., neurosurgeon who has
put fetal pig tissue into the brains of a dozen people with
Parkinson's or Huntington' s disease over the past two years, also
reports no sign of infection.
- "We are extremely overzealous about studying these effects
and looking for viruses in the long and short run, and we haven't to
date found any problem," he said.
- While scientists ponder the risk of xenotransplantation,
thousands of people die each year because they can't get a human
- "It's a difficult issue," said virus expert Jonathan
Allan of the Southwest Foundation for Biomedical Research in San
Antonio, who calls the infection risk from pigs very small but worth
- "Here are people dying," Allan said. "You want to
do everything possible to prevent that sort of suffering. But you
certainly don't want to foster new infectious disease that would
make even greater suffering in the population."
Boy Survives Lung Transplant
- LOS ANGELES lAP 6/19/97) -- A 10-year-old boy suffering from
cystic fibrosis survived lung transplant surgery Thursday when a
doctor swapped his diseased lungs for healthy lung parts from a
relative and a family friend.
- Jordy Carper, of Hedgesville, W.Va.. was listed in serious
condition after the four-hour surgery at Childrens Hospital Los
- "He has aspirations of taking a big breath. He has
aspirations of running to his grandmother's house. He even has
aspirations of running to California," said Melissa Carper, the
- Jordy's family had been told he had a year to live without the
operation, which replaced the boy's diseased lungs with healthy lung
- One lobe came from family friend Vicky Koher and the other from
Jordy's second cousin. Debbie Shoenadel, 45, of La Vale, Md.
- Schoenadel's husband died last year of lung cancer while waiting
for a transplant. She said she wanted to help Jordy avoid a similar
- While 75 percent of those who undergo the rare surgery survive
the first year, infection and organ rejection reduce the survival
rate by 5 percent each succeeding year, said Monica Horn. hospital
- Jordy was expected to remain in the intensive care unit for up
to three weeks and could go home in about a month. A machine was
helping him breathe. The donors were expected to be hospitalized for
- Cystic fibrosis is an inherited disease that attacks the lungs,
producing a thick mucus that can cause infection and lead to death
by suffocation. It is America's most prevalent fatal inherited
disease, with 30,000 people now afflicted.
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