Results Lead Hospital To Expand Multiple-Organ Transplant Program

Lloyd E. Ratner, MD, FACS


Yoshifumi Naka, MD, PhD


Donna Mancini, MD

Researchers at NewYork-Presbyterian Hospital/Columbia University Medical Center are studying methods for imroving outcomes in multiple-organ transplant procedures, including heart–kidney and liver–kidney transplantations.

"Because we have such a large heart and liver program and our kidney program is substantial, we probably have more experience than anywhere in the country in doing these combined transplants, and we have ample opportunity for research," said Lloyd Ratner, MD, who collaborates with Yoshifumi Naka, Surgical Director of the Heart Transplant program, and Donna Mancini, MD, Medical Director of the Heart Transplant program.

Dr. Ratner and his colleagues are comparing the outcomes achieved when heart or liver transplantation is simultaneously combined with kidney transplantation with the outcomes obtained when kidney transplantation is performed after heart or liver transplantation. Thus far, the outcomes appear to be better with simultaneous procedures.

"We aren't sure why, however," he said. Dr. Ratner and his team believe that a 2-organ transplant may decrease the risk for rejection. Another theory is that a patient who is followed by 2 teams of transplant surgeons simultaneously may have better access to care than a patient who is followed by 1 team at a time, as is the case for patients undergoing subsequent transplants, according to Dr. Ratner. This type of research, especially that involving liver–kidney transplantation, is important because the policy for liver allocation, according to the United Network for Organ Sharing (UNOS) Model for End-Stage Liver Disease (MELD), implemented in 2002, ensures that patients with relatively poor kidney function receive a liver first.

"The expectation is that the need for simultaneous liver–kidney transplantation will increase," said Dr. Ratner.

Overall, among the most important new developments applicable to all types of organ transplant procedures is the ability to detect the rejection of donor organs via a blood test of molecular gene expression rather than a muscle biopsy. About 7 years ago, this technique was evaluated in patients undergoing heart transplantation, and the diagnostic blood test is now commercially available. About 4 years ago, NewYork-Presbyterian/Columbia researchers started investigating the use of this diagnostic technique in lung transplantation, and the liver and kidney teams are now discussing it, too.

Jonathan M. Chen, MD

Other researchers at NewYork-Presbyterian/Columbia, led by Mark Russo, MD, have evaluated UNOS data for heart–kidney transplants. Dr. Russo's team has examined whether patients with marginal kidney function who received a combined heart–kidney transplant fared better than those who received a heart transplant and then were followed to see how their kidneys functioned after heart transplantation. Determining whether a patient's kidney problems are intrinsic or secondary to heart disease is difficult, according to Jonathan Chen, MD, a study investigator. Still, the researchers found that patients with chronic kidney disease had a survival advantage with a combined transplant. Heart transplant patients who must undergo hemodialysis or continuous venovenous hemofiltration require the placement of indwelling catheters, which can be a source of infection, leading to complications and death.

The research at NewYork-Presbyterian/Columbia also touches on the ethical issue of whether a patient should receive more than 1 organ while other patients remain on the UNOS waiting list for a single organ. Data to date indicate that because outcomes will be better in some recipients of multiple organs, the transplantation of multiple organs makes both medical and fiscal sense.

In addition to heart–kidney and liver–kidney procedures, physicians at NewYork-Presbyterian/Columbia have performed 4 heart–liver transplants—2 simultaneous procedures with organs from the same donor and 2 sequential procedures. These transplants comprise fewer than 1% of surgeries in the entire heart transplant group at the Hospital, which is the largest in the country.

"Heart–liver transplants are very specialized surgeries that can only be done in large centers such as ours," said Mario Deng, MD. Collaboration among specialties is key, he added. The procedures require the input of cardiologists, anesthesiologists, and hepatologists, in addition to the skills of the transplant team.

Dominique M. Jan, MD

Liver–small bowel transplants are also quite specialized, particularly in children, according to Dominique Jan, MD. One of the keys to a successful procedure is to coordinate pre-transplant management. The results of intestinal transplantation are generally better if the recipient's overall health is good, he explained. Another consideration in pediatric patients is that space may be limited. Because the pediatric transplant recipient is receiving organs that are healthier and bigger than the native organs, more room is needed for them than may be available.

"With placement of these donor organs, you sometimes can't close the abdominal wall," noted Dr. Jan. When the plastic and reconstructive surgery team performs an abdominal wall transplant, using muscle and skin to enlarge the abdominal wall, space is obtained for the new organs and results may be improved.

Another important development at NewYork-Presbyterian/Columbia is the rejuvenation of the heart–lung transplantation program, said Dr. Chen. Combined heart–lung transplantation was enthusiastically received in the early 1990s, he explained. However, patients given this combination of organs did very poorly, he said, mostly because of lung complications. "There was almost a moratorium on them," he said. "NewYork-Presbyterian Hospital performed their last heart–lung transplant in 1998."

Since that time, thoracic surgeon Josh Sonett, MD, and pulmonologist Selim Arcasoy, MD, have helped to greatly improve the outcomes of lung transplantation at the Hospital, reducing associated morbidity and making heart–lung transplantation an option, according to Dr. Chen. Only 5 other centers in the United States offer this combined procedure.

"For kids in the New York area, this is really important because they used to get shipped out to Pittsburgh and St. Louis for surgery, and their families had to relocate," said Dr. Chen. "Now there's an option along the East Coast corridor."