 Today, Dr. Fetsen, Savi Fetsen, a friend, colleague, and neighbor, is going to present a paper not on the original title that we had listed is Multi-Organ Transplantation Ethical, but rather on the title Ethical Considerations in Simultaneous Multi-Organ Transplantation. I do think we'll get close to the original question also. Savi and I have been talking about this topic for a while, but today's paper is very much Savi's work. Savi, as you know, is the Associate Director of the Adult Heart Transplant Program and is the Director of the Pediatric Heart Transplant Program, is an expert in the management and care for patients with severe heart failure, has been much involved in the LVAD program, and Savi and I go back quite a ways. Savi's father followed me by one year in the Chief Residency here, and I don't know if you were born quite yet. It was very close, but so we've known each other for a long time, and it's a pleasure to welcome Savi to the seminar and to look forward to the seminar. Thank you. It's a pleasure to be here. Wednesdays are always a good day because it's filled with all the ethics conferences, and this year, of course, is certainly... So, yes, this year has been a great year in conference. I was saying how much I like Wednesdays, and it's actually... I'm glad that I came after both Laini and Dekko, although they're hard speakers to follow, just because of I think some of the questions I hope to raise. What I'm going to present today are more ideas that I think I want to use to spark conversations. So the presentation hopefully will be a little bit shorter to allow some more time for discussion, because this is simultaneous multi-organ transplant. It's talked about a lot, is questioned a lot, but is actually not very common. So to get started, I just... My son likes airplanes. Okay, so I have no relevant disclosures other than that I am a multi-organ transplant cardiologist. So the SMOT, as I am going to call it, the simultaneous multi-organ transplant. Just to let you know what I will not be talking about today when I refer to simultaneous multi-organ transplant. I'm not talking about retransplantation. I think that poses a different set of ethical questions. I'm not going to be talking about sequential transplants, which involve different donors, and I'm also not going to be talking about either on block renal or double lung transplantation. I'm going to consider those as being one organ transplant at the same time. So that's what I'm not going to talk about. I also want, for the sake of this discussion today, to have everyone realize that we work in a system that is full of inequities, and they are just a given with the system with which we work, and they are inherent at equities. There is geographical inequities, depending on what region of the country you live in. There is not equity within a region because of our insurance. If you are uninsured or insured, that is good. If you are underinsured, that is no good for transplantation. Referring practices have both sex and racial biases. So that is an inequity that is intrinsic in all of medical care, but certainly in transplantation. There is misinformation about the success of transplant. This cover from Life Magazine is from 1973 about the tragic record of heart transplantation when most of the first transplant recipients died, and this is still a misconception, and certainly thoracic transplantation, a large part of the community, that it just doesn't work. There are inequities in the listing criteria, and I think the last two weeks we've certainly talked about some of that, and I want to allude to some of that as we talk about people listed for multiple organs, and lastly, there is the inequity with who is able to receive a transplant. You could be an undocumented citizen and donate you cannot receive in this country because of many reasons that have to do with our health care system. So this is our givens, and this is the system which we are working. So when we talk about simultaneous multi-organ transplantation, there are many aspects that we could talk about from an ethical standpoint. I want to really focus on two. In part just because they were focused on the last two weeks, so I think it is in good continuity to the last two weeks, but I want to talk about the equity of allocation or justice, depending on which word you prefer to use, and the utility or efficiency of the receipt of that organ. So I'm going to focus primarily on those two. To answer the fundamental question, is it just to use three organs for one person rather than to use one organ each for three people? That is the big question that often comes up with the discussion of simultaneous multi-organ transplant. Is it better to save one, so to speak, or to save three? And in order to think of that, you have to think about what is the need for the organ, what is the acute need for the organ, the present need, what is the urgency, how great is that need for the organ, and what is the lifetime use or need for that organ. And then also are all organs equal? There are life-saving organs, there are life-prolonging organs, and what I refer to as lifestyle organs. So depending on which organ you add, is it a life-saving or a lifestyle life-preserving organ? Because I think these play in these need to be considered when you're talking about allocation and need for the organs. So this is UNO's data, and it goes from 1980 in the top to 2012 on the bottom. In green is the total number of transplants done in red, that little teeny sliver you could probably barely see at the back is the percentage which are simultaneous multi-organ transplants. I should probably say to begin with simultaneous multi-organ transplants are from deceased donors. So I'm just going to be talking about the allocation of deceased donor organs. But you could see starting back, the database just goes back to 1988, there were 38 simultaneous multi-organ's done at that point in last year, 567, out of a total of 25,000 transplants roughly. So a very small number of simultaneous multi-organ transplants. Looking at those centers over the last 24 years that have done over 100 simultaneous multi-organ's of all varieties. So you put a thoracic organ with an abdominal, you put two abdominal organs, you put three abdominal organs. These are any type of configuration of organ transplants. There are 24 centers that have done greater than 100 simultaneous multi-organ transplants over the last 24 years. The majority of these about 58% are going to be liver kidney. They're actually broken down in such way using the UNO's database that they actually don't differentiate KP's and they don't kidney pancreas and they don't differentiate heart lungs because the numbers are so small. So those are going to be excluded from these pictures. We are sitting here at number 13. Lucky or unlucky, however you want to look at it, but we're number 13 in this group. These are just baseline. So 58% liver kidney for those of you can't see, liver intestines 10%, liver pancreas intestines are 16%, heart kidney 8%. These are all simultaneous multi-organ transplants over the last 24 years in the US out of UNO's database. That is us and this is our breakdown of what we have done here and we have done certainly the majority are going to be liver kidney. We have done a fair number of heart kidneys and liver hearts and we probably have, we have the second greatest number next to Cedar Sinai in California actually of the liver hearts. We're very aggressive in that population. Now looking at 2000, this is again regional and national data looking at simultaneous multi-organ transplants from 2011. This is again UNO's database and it represented only 2.6% of deceased donor allocation. So again a very, very small number, but you could see just on this slide, I tried to color code to match so you could easily see which region matches with which. We're sitting here in region, in the blue line in region number seven. Our region's pretty good as is number five and number two, but if you're in region number six, you're not really going to be listed or get a successful simultaneous multi-organ transplant. Again, these are an inequities of our system. If you live in this part of the world, you've got to travel a long way to get a transplant. How do we compare with our European colleagues? Now I only have data here from the Euro transplant which is Central Europe, so that's going to be Germany, Austria, Hungary, Croatia, those Central European countries and then the Scandia transplant. I unfortunately could not easily get some of the Spanish data which would be interesting given how aggressive they are in their organ procurement that their data are not transparent and they're all in Spanish and my ability to read Spanish is non-existent, so it was very difficult for me to find this. But based on at least Euro transplant and Scandia transplant, these are from 2012 for Scandia 2011 for Euro transplant, they actually do proportionally greater number of simultaneous multi-organs than we do. And the breakdown that you could see about here, this is a KP, so certainly in this big line here in the Euro transplant is Germany. So they do a lot of kidney pancreas for those of you who can't see, they do, they actually include the heart loan here, which the UNOS doesn't include, they do a fair number of liver kidneys and then heart kidneys. The big two lines here are Austria and Germany are the two big transplant centers in Central Europe where Croatia is coming up there. Looking at the Scandia transplant, they do a significantly fewer number of transplants, certainly the population is less, but they still do 3.2% of their total number of deceased donor, and I've just put deceased donor numbers here, are simultaneous organs. So they do proportionally more than Europe, in Europe than we do here. So again, still a very small fraction of the number of allocated donors. So going toward two questions, is a just or is it fair to take one person to give them three, or should we take three people and give them each one? So this really, I think ties nicely with what Dr. Thistlefoy talked about last week and then Laini the week before about the idea that if someone needs an organ, they should have the same chance as another person who needs an organ. There should be equity in the potential to be allocated in organ. Equal opportunity for scarce resource. So this should be independent of how many organs you need. If you need an organ, you are the same as someone else who needs an organ. If you are, if you need two organs, you should still be the same as someone who needs one organ, because you still have the need for an organ. Again, this is going to tie into how great is that need for the organ? Is it a life-saving versus life-preserving or lifestyle organ? The way allocation works in this, in this system, I think is important to at least reflect upon. Allocation scales are certainly different for each organ and each allocation system has a different intent behind it, so to speak. So for example, the meld is to try and reduce mortality while waiting on the transplant list. The long allocation system, which I know we're going to hear about next week, when Dr. Rusa comes back to talk about a perhaps a new proposal, the long allocation system is designed to improve the recipient's survival. So for one organ, we're trying to improve survival on the list. For the other one, we're trying to improve survival after the transplant. So these are two very different goals of our allocation system of organs. For the heart, it's in theory to reduce mortality on the waiting list. I put in theory because with VADS, now we have a different way to keep people alive while waiting and that in itself is a no, a whole another, I think, ethical quandary that we're going to have to address. But just to keep in mind that our allocation system is not the same and the intent behind each organ is not the same. There are certainly morphologic and biologic constraints for whether or not people are acceptable for a given donor and the intent behind all of these is of course to reduce the waste. We know there's a donor shortage, we want to have whatever organs are out there to be used equitably and efficiently. So what is the UNOS policy on simultaneous multi-organ transplants? What I've highlighted here is the fact that within region patients who are simultaneously listed for multiple organs are in fact given a priority. So the Highlight Report says the second required organ shall be allocated to the multiple organ candidate from the same donor if you're located within region. So if your number gets pulled for whatever organ you need, the second one will get allocated to you within reason. The policy goes on to say however if you are outside, if the organ is coming from outside the local organ distribution of the OPO, voluntary sharing is suggested to give you the second organ. So basically we're asking for altruistic donation from one OPO to another OPO of the second organ. So within region you get priority for both out of region we're asking for altruistic donor from one institution to another institution. With them the the policy being that you should then pay back that organ. So if I get a kidney from New England for example to go along with my liver or my heart then my next kidney that comes up should go back to New England. We know what altruistic donation is and how successful that can be with among individuals let alone among institutions. So just keep that in mind. Now when we talk about recipients I just when we think about recipients how do we choose a recipient because I think how we choose a recipient again depends on the organ and depends along all the not only medical considerations but should everyone be a transplant candidate? How old is too old for a solitary transplant? How old is too old for a simultaneous multi-organ transplant? Cancer whether or not you choose to transplant someone with a non melanoma to a skin cancer depends on what organ you have. It's a moving target. Other options I think need to be considered end-stage management which essentially in some ways comes down to lifestyle mechanical circulatory support for heart transplantation. When is this a good option or a better option? I don't think we have achieved equipoise with mechanical circulatory support and transplants but at one point is it a reasonable good option? At what point is continued hemodialysis a reasonable option as opposed to a kidney transplantation? Because there may be some situations which it is actually reasonable. It is a lifestyle choice because life prolongation for a 70 year old may not be that great with the transplant versus dialysis. Recipient selection is also important beyond the medical situation. So psychosocial considerations are valued very differently depending on the organ that a patient is being evaluated for and in the US thoracic centers use a much more stringent criteria based on psychosocial factors than do abdominal organs. So 5.6% of patients evaluated these are old data they haven't really been updated much better in the last 20 years but 5.6% of candidates were excluded for psychosocial reasons for thoracic organs for being recipients compared with 2.8 and 3.6 in renal programs. We're certainly better and more stringent about this than we are than they are in Europe and I think that actually has to do with national health care because insurance is part of the exclusion on a psychosocial level for transplantation and in a nationalized health care system you don't have to at least cover this. But I think that when you're talking about simultaneous multi-organ transplantation someone might be considered a transplant candidate for let's say a kidney but might not meet the transplant criteria at the same institution for a thoracic organ because of some of these other issues. So the allocation practice for multi-organ transplantation in the US this simultaneous multi-organ recipient is given preference for the single organ candidate with the highest urgency as long as that other person does not exceed them on the list. An organ can be allocated to the small recipient and can pull the other organs the secondary organs with it. So the advantages are a harder or liver recipient can listed for a simultaneous kidney transplant can for example be listed be waiting for 30 days and receive a kidney worse someone just listed for a solitary renal transplant in this state may wait for five years for a catavaric donor that is certainly that is an advantage to the simultaneous multi-organ transplant absolutely and more importantly a simultaneous recipient might only be a candidate for a simultaneous organ and not for a solitary organ there are many institutions that would not consider cardiac transplantation and someone with a creatinine clearance of 40 but would consider a multi-organ transplant with a someone with a creatinine clearance of 40 so a heart kidney as opposed to a solitary heart the fact that we can offer simultaneous organ transplant might make someone a candidate where otherwise they would not be so there are certainly some advantages now there are disadvantages for being listed for a multi-organ transplant it's hard to find multiple organs in the same donor depending on how the donor died whether or not there's any trauma to either the abdominal or thoracic organs size constraints quality organs multiple procurement teams fighting for vascular access or vascular conduits it can be challenging to find the same and it limits you to within region because you're again counting on the altruistic donation of the second organ out of region so there are both advantages and disadvantages to being listed for a simultaneous multi-organ transplant based on the allocation system in the U.S. just a point of clarification if there might be some confusion so the regulation is within the OPO sorry and OPOs are then grouped into regions so it's really limits within OPO sorry everyone heard that in the back it limits within OPO rather than within regions okay so that's sort of justice and allocation and equity to being a potential candidate how about how we use the graphs the efficiency utility of the graft so there are a couple of things to consider there's the medical utility to the recipient right which is both patient survival and graft survival they are both important because if the graft fails then you might need re-transplantation so depending on what that graft is which organ it is you might need re-transplantation or not so the survival of course is changing over time and unfortunately a lot of the data that are out there regarding simultaneous multi-organ transplant are broad database analyses that cover a huge span of time at which there were different immunosuppressants so survival survival has improved over time for all of these but the survival graphs for multi-organs is a little bit confounded because the numbers are so small and they're looking at 20-year cohorts as opposed to 10- or 5-year cohorts with more modern day immunosuppressive techniques there's also the idea of social utility now social utility is generally not considered in allocation practices and yes with the exception of pediatrics so most people have said that we are not going to use social utility as far as you know how worthy is this person to receive one or two or three organs so with the exception of pediatric transplants this is not part of utility so it's really the medical utility to the recipient so is there an increased utility by using simultaneous multi-organ and this is actually data that Piotra was actually part of when he was at his previous institution published in 2008 about this was a UNOS database analysis looking at graph survival from donors from the same donor and what we have here just it's hard to read but these are heart transplant, rejection free liver transplant and kidney transplant looking at different combinations of heart alone which is the lowest line versus heart liver heart kidney you have liver alone which is here liver kidney is does better than liver alone and then you have simultaneous kidney heart you have kidney alone which is the middle and then kidney after liver which is the sequential transplant I was talking about but certainly this these data suggests that simultaneous transplantation confers improved survival in patients as long as the graph comes from the same donor so simultaneous not a sequential multi-organ transplant again these are published in 2006 looking at this is simultaneous liver kidney transplantation versus kidney after liver transplantation and what I've highlighted in the red dots or the red squares is the combined liver kidney or the simultaneous liver kidney with their terminology and again this is again looking at 1996 to 2003 so it's again a very broad period of time certainly early on you might have a little bit these are patient survival a little bit of early operative mortality but as you extend out you have patient survival improved with simultaneous transplant again this is graph survival long-term you have improved survival and then this is depth sensor graph survival so if you take out the early operative mortality you have improved outcomes as far as graph survival and rejection free graph survival if you have a simultaneous multi-organ transplant from the same donor now these are outcomes after the institution of melt which of course changed some of the liver donation allocation processes this was published in 2008 and these are simultaneous liver kidney versus just liver transplant on patients who have been on dialysis this is looking at people renal dysfunctions so these are patients who have been on dialysis less than three months and three months comes up as an interesting period of time because you're worried about the people who either have chronic kidney disease or those who have hepatic renal syndrome and trying to differentiate between whether or not you should give a kidney to someone who has hepatic renal where you anticipate that renal recovery will happen versus those who are truly intrinsic renal disease and you anticipate the chronic sequela of calcineurin inhibitors and renal dysfunction so in this one it's the colors are hard to show but the liver transplant alone does better in people who are on dialysis for less than three months these are people looking at people who are on dialysis longer than three months and in this case the liver transplant does worse so in people who are on renal replacement therapy for greater than three months if you take that to mean chronic renal disease not a hepatorenal syndrome they do better with simultaneous allocation of a kidney and liver from the same donor and then this again looks at overall survival you have a kidney transplant alone up here you have solitary or simultaneous liver kidney with a meld of less than or equal to 23 and then those with a meld greater than 23 looking at the the survival curves so certainly data to suggest that in the modern era simultaneous liver kidney transplantation with people with intrinsic renal disease is protective for the patients or beneficial use and is efficacious for the patients the question of course is whether or not hepatorenal syndrome what that does and whether or not we should look at the hepatorenal syndrome and those people with acute renal failure differently this was published just at the end of last year looking again and this this is one study that actually suggests a different outcome and there were many actually Dr. Advocase wrote an editorial about this article that came out questioning their data because their data are very different from all the other subsequent data and did not exclude the people who had a patorenal syndrome because this is sort of a wash as opposed to whether or not it's beneficial or not so certainly more data are needed because of this question about how we actually look at people who are in need of a kidney versus just a liver alone and how do we use it so these are this is a survey done of those centers that did oh that that perform simultaneous multi organ transplants looking at specifically the heart kidney I'm sorry liver kidney which again is 58% of those multi organs in this country sorry about the the way it projects and it's regional these are what people use to allocate a kidney or not or to see and you could see here you have a 24 hour urine these are always sometimes rarely never so there are some centers that always use a 24 hour urine for a cranting clearance and there are some centers that never use a 24 hour measured cranting clearance for the allocation of a kidney in the setting of liver dysfunction there are some people who use whether or not you have renal replacement therapy whether or not they automatically put in on patients who are waiting for a kidney or whether or not they do a kidney biopsy there's some places who 2% never does and 4% sorry 2% always do 4% never and sort of sometimes are rarely so clearly there's no uniform standard practice in the U.S. among centers to say does this patient need a kidney in addition to their liver so the current guidelines for simultaneous liver are those people requiring dialysis so chronic kidney disease requiring dialysis those who have GFR less than 30 mils per minute by MDRD or a protein area of greater than 3 grams in a 24 hour period sustained acute kidney injury requiring human dialysis for six weeks sustained acute kidney injury with GFR less than 25 mils per minute for six weeks not requiring human dialysis sustained chronic kidney injury or metabolic disease however there was a summit at the end of last year which specifically looked at this which looked at whether or not we should adjust our criteria for simultaneous liver kidney and their recommendations they should use a stage 3 kidney disease creating greater than 4 or an acute increase or the need for renal replacement therapy or an estimated GFR typically MDRD of less than 35 they actually have included kidney biopsy so kidney biopsy with greater than 30% glomerulus sclerosis or fibrosis as a marker for the need for chronic kidney disease or the anticipation of truly kidney disease as opposed to a bad renal or 2 grams so slightly lesser amount of protein and making it into sort of a nice schematic of how one might take this to look at it they modified this from paper that actually came out in 2011 it really depends on the amount of dialysis so this is a acute renal failure in liver disease depending on whether or not you are on dialysis for less than six weeks you go straight to a liver transplant if you're on it for greater than 12 weeks then you go to simultaneous liver kidney if it's been in that intermediate period you have some type of operative assessment which might include a renal biopsy and depending on the result of the renal biopsy you'd either give them a kidney or you'd go straight to solitary liver this is chronic kidney disease again they would say if you have a cranting clearance of less than 30 you go to simultaneous if it's greater than 60 liver if it's that intermediate period you do a biopsy again so more concrete data to say yes these kidneys are not the hepatorenal they probably do need simultaneous multi organ replacement and this is looking at chronic kidney disease with cirrhosis so these are liver this is heart and this they need you to get a portal wedge pressure so if you have portal hypertension you get simultaneous liver kidney so you get a simultaneous liver with your kidney if you don't then you have to measure the hepatic wedge and if your hepatic wedge is high you get a simultaneous liver with your kidney if not you just get a kidney transplant so this is what has been proposed I haven't seen this been having been acted upon and this was actually published before this the summit that was at the end of last year so this is sort of data on how affective simultaneous liver kidney for example are on the use of the graft in patient survival now how about for hearts so we should I'm a cardiologist I think the heart's an important organ I think it's a a life sustaining organ as opposed to a lifestyle organ at this point I wonder that what are the benefits for doing simultaneous hearts with thoracic as heart with abdominal organs and one of the the big benefits for I think cardiac transplant recipients is to prevent graft vasculopathy which is one of the most common causes of graft loss after certainly one and certainly three years of transplantation and these are just pictures of what graft vasculopathy can look like and so if you do a heart plus one so a heart plus a liver or a heart plus a kidney for the most part again I'm not talking about heart lungs because the data are so few but a heart plus one transplantation this again was looking at a very broad period of time so 1992 to 2009 again old immunosuppressive strategies as well as modern ones looking at consecutive heart transplants and then simultaneous heart kidney transplants this was published just a few years ago and while you certainly what this shows is you have essentially equity in survival so certainly this was in the face of such suggestions that there was an increased mortality and decreased survival if you did simultaneous heart with abdominal or heart with kidney transplantation and in this group of patients you did have 13 of the transplants so 13 of the patients who just got hearts were on dialysis which is interesting they just got hearts but they were on dialysis and 18 of the 30 who got simultaneous multi organ transplants were on dialysis however 12 were not 12 who just had stage for renal disease and their survival is essentially this is patient survival and this is survival from any rejection with a trend towards perhaps the kidney being protected from a rejection standpoint however is it protective against coronary graft esculopathy which was at CAVS and this is looking at total again old period 1995 to 2003 so 22 solitary hearts and then 13 simultaneous heart kidney so again small numbers but what you have here in the blue line is patient survival the numbers are so small so you don't actually have statistical significance but certainly survival is here you have freedom from acute cellular rejection in the heart transplant this is heart kidney so heart kidney certainly does better again not quite significant but better from acute cellular rejection and then we think of graft esculopathy as sort of a marker for antibody mediated rejection and there is a significant protective effect of getting a kidney for the development of graft esculopathy in these patients so if you look at the people who developed there was 32 percent of the heart alone transplant patients who received who developed graft esculopathy four of them ultimately required retransplantation because of their graft esculopathy so kidneys were protective in these patients for the development of graft esculopathy this is again data saying that it actually caused less rejection in both graphs so not only did you have less acute cellular rejection of the heart you had less cellular rejection of the kidney so if you did a simultaneous transplant of a heart kidney you had better outcomes in both graphs so this is the time to cardiac rejection and time to renal rejection in again small numbers and a very broad time period I keep bringing it up because the data are so few because we're doing hundreds of these as opposed to thousands every year this is the only slide I'm going to show you about pediatric data this was just again UNOS database looking at pediatric thoracic use of multi organs either heart plus another or lungs plus another and these are heart only so if you had a heart lung liver a heart kidney or a heart liver they did better than the heart alone in the pediatric population these are the lung only which is matched by the heart lung but if you put a lung with an abdominal organ they had better survival in the pediatric population as well now Mark Russo who is again coming to Todd next week when he was at Columbia worked with some people looking at the UNOS database looking at whether or not we could predict risk for getting a simultaneous heart kidney transplant and survival risk and what they included I'll read it out just because people in the back may not see this but what they included in their risk model was peripheral vascular disease recipient age over 65 non-aschemic etiology a bridge to transplant with an assist device and dialysis dependence at the time of transplant these are each given a weight what they excluded was diabetes previous transplant african-american race or ethnicity donor age greater than 40 and morbid obesity BMI greater than 35 and they divided it into low, moderate and high risk four four to six and seven just to give you an idea peripheral vascular disease gives you a four so if you have peripheral vascular disease that immediately puts you in moderate risk according to their risk model being an older recipient gives you a score of three and a half so if you're over 65 with vascular disease you're automatically in a high risk category just to give you an idea and I looked at only 274 patients for the ENOS registry for 10 years who received simultaneous heart kidney so again very, very small numbers and what they found was that depending in the people who had a creatinine clearance less than 33 the patient's survival stratified out by this risk model so that if you had a high risk your patient's survival at one year was only 61 percent we would expect national averages now to be anywhere between 88 and 92 percent so certainly that would fix with the low risk what's 93 percent moderate risk again this is a historic periods you have to take that into account is 74 percent but certainly this was significant depending on your risk model what was interesting was that in those patients who had a creatinine clearance greater than 33 so you'd assume these are people who had chronic kidney disease were not on dialysis it didn't the risk stratification didn't work as far as numbers now there were only 60 patients so there may not have been a statistical significance just because the numbers were so small but certainly this is the only study that's really out there that might suggest how we might choose to allocate or choose to list someone for simultaneous organs with a risk model now we this is data that we presented now nine years ago it's hard to believe at the AST looking at some of our the first sort of cohort of our simultaneous heart with other organs here and this is really this was 16 simultaneous heart kidneys three heart liver kidneys three heart KPs and 10 heart kidneys so these are our data and we had a mean follow-up at that point of 51 months six of these patients were on dialysis at the time of transplant and patient survival here is in the blue was for simultaneous certainly was better than those who had solitary kidney I mean solitary heart so adding an additional organ at the time of transplantation in our institution here conferred a patient survival benefit two patients did lose their renal graft so two patients ultimately ended up on dialysis after their sequential or those simultaneous transplant so to go back to the question should we give two or three organs to one person instead of to two or three equities as Dick pointed out last week is is legally mandated so the the ability to be listed for an organ or the the access to an organ is is mandated so we have to have equal access to an organ so the question is if I have if I need two when you need one do I have as much right to be listed as you do yes I have as much right to be listed as you do it is a very small proportion of deceased donor allocation of this country less than three percent of deceased donors this is the the population we're talking about so I think on that respect I think we we it is appropriate to list people for simultaneous multi-organ optimal use we want to have the resources used to the greatest benefit possible so both patient and graph survival are certainly at least as good if not better if you do a simultaneous multi-organ transplantation whether or not it's patient survival graph survival freedom from complications if you do a simultaneous transplant you have better outcomes so the efficiency is certainly there so if we want to do it in efficiency model as opposed to an equity model even in that respect I think it's more efficient however age does appear to be a risk so I would say that age has risk for poorer outcomes in many centers including ours have lower age criteria for simultaneous multi-organs than they do for listing for solitary organs and I think that is also an ethically justifiable position to take based on outcomes and based on the fact that often the second organs are lifestyle organs as opposed to life life sustaining organs so I hope this is this is will spark some conversation and some debates and perhaps some distention I'm sort of I was torn about how I felt about this I mean I practice it but I I still am conflicted in myself depending on what side of the bed I wake up on about how I feel about this so hopefully this will spark some debates and I certainly want to acknowledge I had to put everyone here and I was started typing at all the names and there were just too many so just all of the transplant attendings the surgeons the procurement coordinators the VAD coordinators I mean everyone on this list certainly who helps take care of these patients multi-organ transplantation is a huge production the stuff that goes behind scenes and the people involved so everyone has been involved here we have a very successful program because everyone on the slide who I have not named because there are too many work together so thank you I'll start off the questioning I think there's a couple of additional issues that we need to get out one is I think you've made a compelling argument for ethically justifying the multi-organ transplant for a particular patient the side that you didn't really address of course is the policy issue and that is is that every time let's just limit it to let's say heart liver every time you do that heart liver right there's presumably some liver patient who doesn't get the organ who may at least at some level of frequency die and that's where the real issue is so we can I'll say that one and then the other issue is the pre-transplant mortality of that particular patient who is listed for a heart plus right and versus if they were just listed for a heart let's let's for this one let's go with heart kidney okay so you've got a patient who is listed for a heart kidney but in reality could just get a heart and because of donor issues that donor pool is smaller and the pre-transplant mortality for that particular patient to address those issues okay so the first I'm going to deal with our heart kidney first so certainly getting a simultaneous heart kidney increases your weight time absolutely when we have a patient who's been on house waiting now I think for six weeks as a 1a for our heart kidney and it limits them to to the to the region it limits them because of cross match that being said depending on how sick they are again it's an individual choice depending on how sick they are we might choose to say fine we're just going to give you a heart and you end up on dialysis and we try and either do a sequential transplant later or dialysis is a lifestyle or a living donor living donor but it's dialysis is like you know kidney transplants are like prolonging but I don't think their life sustaining so it's it's one of those I consider that to be in my category of lifestyle organs so you try and if someone were acutely sick you would say fine let's do the life saving organ bag the lifestyle which is how we do it we plan to do to organs we go down to the OR we they get the life saving one if they can't get the second one because of instability we stop so yes I think it has to be evaluated once they're listed and often yes you know we list people and depending on their creatinine clearance that week we don't give them the kidney which is not to to transplant the kidney I think it's tough on an individual basis but that's what medicine is you'll have someone listed and the day an organ becomes available they may not be suitable or not I mean that happens with single organ listing so I think it does that's one of the disadvantages of being listed and that you haven't taken to into your account in regards to your survival correct so you've got presumably an increased pre-transplant mortality for those patients and the numbers are just too small to figure out but that I mean so the waiting time is absolutely greater right absolutely greater and so in the theory the pre-transplant mortality is also greater right but then the post but then you would hope that the post transplant benefit would counter it which is what you're which is what you're right so we gotta I mean it would be nice and we of course we cannot have the data but it would be nice to say okay from the time of listing versus you know right of single versus multi and it's and we're trying to look at at least some of our numbers here it's just it's hard and it's hard to get that information from you know so now the question with the liver is tough because you have places where people are getting transplanted with a melda 14 and should we be transplanting people with a melda 14 or should we use that liver for someone who is in a different region who needs it so I think when you're I mean you're tealing when you're talking about the liver and a hard liver you're talking about two life sustaining organs and I understand it's it's difficult and it's always difficult when it's your patient who is either the one who's getting the organs or your patients the one who's not getting the organ to try and figure out what's the best thing to do as an individual doctor our patient in front of us is the one we have to care for so again it's whatever organ is highest within a region that would drive so if I have someone who's a 1a but has a melda of 12 and you have a liver patient who has a melda of 40 we're in the same region the liver's going to get allocated to you so my patient may miss out and that's that's sort of what our allocation with all of its inequities is stuck with right and we you know as you and I know but perhaps the whole audience says we've always gone to the side of taking care of our patient and doing both the transplants I'm going to follow a little on Mike's question there it seems to me that in some ways what you were calling utility is really efficiency for the individual and saying yet it's more efficient for that individual in terms of their best interests to get the simultaneous organs but it doesn't you know address the question of social utility and I know you you can finesse you know who's at you know one end of the spectrum versus another but just back of the envelope calculations even if you discount the one kidney that's going to somebody who's on dialysis by 50% and say that that's you know a lifestyle versus life saving intervention and you can even argue about that because it'll probably extend their life to get a transplant versus dialysis and the person you know lives for 10 years or you know from all of these things when you're looking at something like 20 utiles you know versus eight utiles just sort of on a back of the envelope calculation so it's really hard from a social perspective to sort of say you know saving these three live versus the other doesn't you know from a utilitarian point of view but if you look count so wait so that's that's just the sort of you know sort of back of the envelope broad the solution right is whether you're looking at equity of access to individual organs versus equity of access to life saving organ transplantation right and everything is based on the number of organs and what we could do with them and if you do that then it seems to me that utility is so clear in terms of giving them to three different people that you can't make the argument that way but then you'd have to make an argument that it's something like this person who is in front of me needs access equivalent access to life saving organ transplantation and that's the way in which I'd build a justice argument for this so the the bring up your point and I agree that if you look at you know it would be nice to have two people survive as longer longer but if you look at actually the function of the graft a kidney graft is better with a simultaneous other organ so if you're looking at the use of that graft that graft is going to do better if it's transplanted with another person than a not so I mean if you could sensitivity analysis and you know you could do that but but then these big different but the but the data point out that if you're looking at the efficiency of a graft use I mean if you want to talk about the efficiency of graft use then you'd never transplanted a teenager as that was brought up beforehand right because they're just not going to take care of their organs and we aren't we aren't prepared to do that in this country just sort of say if you're a teenager sorry you've got five years sorry just you're the black hole and we're just not going to take care of you but it's it's we have never I don't think this country is prepared to look at social utility in that respect certainly in transplantation I don't think we're prepared to look at it in any of our health care I don't think we're prepared to look at social utility when people come in and they choose to take their cocaine instead of their clopidogrel because they both begin with C I don't think we are prepared to make statements in our country about that until we get to a point where we are prepared to actually make people be accountable for their health care to that degree it's going to be difficult to have any idea of social utility and then you you end up with a whole idea of you are born into a certain situation if you are born into a certain situation you how how do you ever overcome that if you if your social worth is deemed by what how many how many millions of dollars you're going to make how many companies you're going to direct how many kids you grow up with a nice good secure home I mean what what is social utility one of the biggest you know the two biggest I guess multi-organ transplants that have got received pressures that was the the boy who got twelve in all he got four three times sequentially because they they failed or the governor I guess of Pennsylvania who got a heart liver you know it's like the decades happen right so do you take him as being he was social worth or do you take you know Mickey Mantle I mean there's what is what is social utility and to a kid who's going to lose their mother that's pretty useful or their father so I have a comment and a question the comment is you could look at it you could look at it as we're not ready to look at social utility or you could look at it as we've decided not to look at social utility and you know all men are created equal you know just regardless of their social utility you know people with more need get more Medicare dollars than people with less need according to their their need so I'm okay with not looking at social utility I think our culture or our society is okay with that maybe prefers that my question is it was I love the way you you called OPOs sharing organs kind of altruistic donation between OPOs except it's not really donation it's a loan because you're you get paid back you're supposed to get so why doesn't it happen more if you get paid back and it's not just a one-time donation I I I will I will defer to Mike on that so actually actually you know has tried to eliminate all the payback issues and I'm surprised still that in your laundry you can I mean right the kidney payback is is going away or gone three in the hole yeah that right the whole the whole Maryland thing right right and no no three and all but all the other all the other organ extra renal things the payback has pretty much been eliminated right right there is no payback for any other extra renal scenario so but but that's really not the the issue of why they don't do it it's it's not altruistic in the way that we like to think of it in terms of altruistic kidney donation right where you have a kidney and you altruistically want to give it to someone else when it's an OPO and transplant centers and they have an organ their responsibility is for their patient and for their transplant centers to utilize those organs and they always have a recipient and so it's it's would be very difficult there for them to justify let's say let's say it was a heart liver that that they were going to do right or that that we had a patient and the heart and Indiana they got they got the heart team got a call we've got a we've got a heart that your patient comes up for and our response is okay great we will take it and you know our patient needs a liver as well and so we're going to ask you to give us your liver and let's say that they do and then the Indianapolis Register or whatever the the newspaper is comes to find out that during the time period even if there was a payback a liver patient in Indiana died then they have a big problem because they gave away a liver to Chicago and one of their patients died that's why the initiation of the whole we're going to give you an organ and yeah we'll get one back really doesn't work very well the the kidney patients left over and there are great geographic disparities amongst recipients as well as OPOs there are this is a very small percentage overall but our region and our particular OPO has certain issues for instance in the last gift of hope report of the standard criteria donor kidneys there was only one standard criteria donor kidney available for a kidney recipient everything else was either donation after cardiac death or circulatory death or extended criteria donor kidney so one could argue that the kidney patients are now receiving kidneys that are less likely to function long term and have poorer patient and graft survival and it's difficult for me looking at my patient although I'm fully supportive of the multi organs because you know it's a great program that's not it but I do have concerns about the kidney patients that are left over that are arguably getting the worst quality kidneys because the best donors are the ones where we can do multiple organs and I wonder if you could comment on that yeah I mean that's yes I can but yeah no maybe afterwards now it's I mean that's really the challenge the challenge is whether or not we look at a patient in front of us who it depends on how you look at a kidney transplant I mean I tend to I'm sort of above the dive from I think I mean it's a lifestyle it is a lifestyle or it is a life prolonging organ but it is a lifestyle organ it is not a life saving organ no exactly but it's and a lot of people just get high on the list no they don't they actually get those where I already didn't know who they were oh no well I mean in our you petition the other centers to get them high on the list one person always goes down so you have to have so one person always goes down for those patients who block their dialysis exactly okay so with the exception those who are patients who lose complete dialysis it is a life so that's a part of my part of my sort of ambivalence about this is because I think for the most part when I'm talking about simultaneous organ I really mean sort of kidney in addition to a life life saving organ and in which case I think it is a lifestyle on both ends you could argue that you could have a heart transplant patient who goes to dialysis three times a week or someone who who goes to dialysis three times a week who is in need of a kidney transplant I mean so in either event someone's going to continue to go to dialysis the question is the person who gets the heart and gets the kidney is going to do better in the long term than if they didn't and that's really what for me I mean for me first of all they're I mean they're my patients so from a from a individual doctor patient I want my patient to do better but from a from a standpoint of policy they're still going to do better so it is a better use of the organ because the organ is going to do better I think that cutting down age requirements so that you you do not do multi-organ transplants and people who are older whatever that older is you know 60 65 I think is reasonable because I think that if you could give that good organ to a younger renal transplant patient solitary renal they're going to get better benefit out of it it's a risk benefit as and as vads get better the arguments between Savi and Yolanda might come closer together absolutely because essentially it's going to be the same issue of a lifestyle of having a pump I agree I absolutely agree versus going to dialysis three times a day it's going to be very very close I agree but adding to Dr. Becker's question you know we seem to get a lot of consults where let's say you have a patient because you're bringing up a heart kidney who is requiring dialysis versus a kidney who requires dialysis but what about the heart kidney whose GFR is 3035 not on dialysis we know they're going to get on dialysis no but I'm talking about at some point in the future they're going to be on dialysis because there's certainly people listed for kidneys who are not on dialysis right there are people who are listed for kidneys without being on dialysis so we know eventually we know this from I mean multiple all organs calcium and inhibitors eventually lead to progression of renal disease so they may not come out of the hospital dialysis they may be on dialysis a year later two years later absolutely I mean I agree with what you're saying in that sense but when you're calling it a life style organ so if you have a patient who's not on dialysis yet and needs a heart and you're wondering should we also give them the kidney knowing that they have CKD knowing that probably eventually they'll require it but then you have a patient who is listed for or is listed for a kidney it's already on dialysis and you know there's a mortality benefit to giving them a kidney it's really hard to justify double listing I don't think so because I think if you look at just the efficiency of the graft there it's going to do better so it depends on the individual for the individual yes but from the society's spend point no you really can't call it addition utilization of well we can't well depend so you can in this setting depending on insurance because your dialysis is covered your your immunosuppressives are covered for three years and then you can't get immunosuppressive so you could lose your graft and go back in dialysis I mean most of our patients are hypertensive and diabetic absolutely so you know as well as as well as I do that you know patients who are on dialysis who are diabetic have much higher mortality rate so calling you know kidney transplant or it's like prolonging it's like prolonging for those patients absolutely but calling it lifestyle I would transplant I'm not really I would say I would I would say like prolonging but I don't think it's life saving I don't think it's life saving the way a heart transplant is life saving it is like prolonging but it's not life saving so Savvy with your with your introduction of this term lifestyle okay it's clearly causing friction but I I meant to be controversial oh I'm okay I know I I think it's actually great but I I think for me you know what what is becoming evident in this series of of talks that we're having around transplantation is to me I'm wondering whether the ethical questions that that are rooted in your talk in your presentation today aren't just sort of the tip of the iceberg for broader questions about really social utility decisions that are being made at a policy and at a national level but are not being made you know in any kind of systematic way because one could start take the reasoning that you've presented and and the the counter arguments that are presented here and rationally go back down this line of argument that says are we spending too much on transplantation overall at the expense of other lifesaving endeavors right people are questioning your multi-organ transplants for the precise reason that their patients need those organs right and one could take a step back from that in a wider health care system perspective and say are we just spending too much on these very advanced very expensive very worthwhile techniques in one respect but what are we what are we short-shifting in other areas of the system I absolutely agree which is why I think for for patients in whom there are other management strategies for end-stage disease those should be given weight great consideration to I don't think VADs are at an equipoise with transplant necessarily but I think for some people a VAD is the appropriate thing to do and not to transplant them I absolutely think that we have to make decisions about how much money we're going to spend on these things whether or not it's transplant whether or not it's VAD absolutely I think we spend far too much money on this end of the spectrum and not nearly enough on prevention absolutely but prevention isn't sexy prevention doesn't get newspaper articles written about it unfortunately I mean again society demands certain things whether or not we need to concede to their demands is is different and I absolutely agree savvy I mean to get out of this lifestyle versus life saving by by keeping keeping two hearts and livers we're in agreement let life save it correct but but I do want to press you just a little bit on the social utility because you gave it a laudable defense of of individual utility and of the doctor's responsibility to advocate in a vigorous way for his or her own patient in order to benefit the patient and I think that's all correct but but from a social utility point of view if you took something as simple as qualities quality adjusted life years and I don't know if anybody has done the study and simply ask on these life saving I'm putting it in what it's right here 20 versus 8 yes it's back in the envelope it's the back of the envelope I'm sorry I'm sorry so take the envelope away from that just finish it yes but I mean something as simple as that and and showing yes indeed that for the individual patient a multi-organ transplant that the individual does better but if you divided those organs between two people you might I don't know what double or or triple the number of quality adjusted life years and in the system where shortage is the unfortunate given how do you reconcile those tensions I don't I don't think we have data I mean that's part of the problem the numbers are too few that I don't I don't think we could get those data to either support or counter the argument that the that the quality and survival rejection free survival of the graphs in one person or better than the failure of the graph and two I don't I think our numbers are too small and the data that we collect on a sort of on a national basis are just too sparse we could certainly I mean we could try we have a fair number of patients here we could look at and see but you know qualities are qualities are tough yeah I mean I I think that that that is the issue and I mean we could maybe work on a model to try to to demonstrate that I'm afraid even though I'm an extraordinarily strong advocate of multi-organ simultaneous transplants that it would not show the quality of life benefit that we would hope for except for the individual who actually got the three organs I think the other way of pulling back from the specific issue is to say that we spend spend too much on sick patients you know not just on expensive procedures but on sick patients they they soak up too much resources and there's an alternative to that and which is called quotas so it's it's not a data issue it's a political issue so I well you want to respond I mean you said called quotas quotas well I mean there's a quote in that we have a limited resource with transplant we make decisions all the time about allocate I mean whether or not someone is a transplant candidate or not I mean so within transplant we do that all the time now we ration our resources people hate the outward we do it in transplant all the time so so I mean I think that we you know this isn't a fine argument and fine discussion to have we know that every dollar we spend on a especially on a kidney transplant because that's the easiest one to justify and talk about we save over a period of time multiples of that versus their own dialysis so we can say that we spend too much money on transplant let's we can go down the kidney because we have that data but it saves the health care system a whole lot of money so it's it's kind of nearsighted to say we're going to decrease the amount of money we spend on transplant because we spend too much and not recognize that in fact that would increase the cost of health care overall if you did that in just as an exclusion now if you said we're going to decrease the amount of money we spend on transplant and we're going to have make sure that we have an effective preventative program then that would be fine but it has to work and you have to be awake reading the article in the newspaper about prevention see which one ever is there's only been one really good cost effective analysis of heart transplant that I know of that was done in the UK years ago when it was actually cost saving to do a heart transplant but that's in the situation where you could go back to work as opposed to risking losing your disability coverage which then gives enables you to get your immunosuppression which is why many of our patients are the functional class one cannot go back to work yeah and and in most there have been there have been studies so in all the organs that show that it is like it is cost saving but kidneys is the easiest one because we have the control of dialysis so I work we're a bit after our one o'clock hour and thank you very much and sadly thank you