Oriented to Thoracic Transplant Recipients -- July 1997

The UPBEAT! Archive

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, Illinois

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 TRANSPLANTATION


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 of cardiomyopathy;
but unfortunately, cardiomyopathy is often diagnosed after heart failure has become chronic, and myocarditis can no longer be implicated.

Heart transplantation has also been performed, although not commonly, in patients with active inflammatory processes causing cardiomyopathy.

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 CHF.

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
Absolute
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
Relative
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
Cachexia

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 screening test)
Rapid plasma reagin (RPR) test (syphilis screening)
Hepatitis B surface antibody and antigen and Hepatitis C antibody
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 >50 years)
Sigmoidoscopy (if >50 years and has not had test in last 3 to 5 years
*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 borderline candidates.

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 nondiabetic patients.

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 transplantation.

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 retardation.

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 transplantation.

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 transplant hurdles

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 heart transplants.

"Money didn't buy him a heart in America," the associate said.

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 people."

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 organs.

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 ?



PVCS

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 their lives.


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 Their Wonderdrug:

l0) Offers men real insight into PMS.
9) Enables you to say twice as much in half the time.
8) Makes cyclosporine seem easy.
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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 of cheesecake.
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.

DM


ANIMAL TRANSPLANTS

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 people?

"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 thought.

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 xenotransplantation issues.

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 can kill.

--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 unpredictable behavior.

--Keeping animals isolated from infection ]nay not be enough. Some viruses scientists are concerned about aren't caught, they're inherited.

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 encouraging.

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 organ.

"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 worrying about.

"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 Angeles.

"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 boy's mother.

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 lobes.

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 fate.

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 transplant coordinator.

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 a week.

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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