Now, while other parents brag about their children’s new words, Cardoso boasts about simpler achievements. As she told Damien’s surgeon, Tomoaki Kato, M.D.: “He loves ponies, toys, his rocking horse,” and most exciting to her, “eating pizza.”
Damien Cardoso’s story is remarkable, but it’s no longer unique. Each year more than 500 people receive organ or cellular transplants at the University of Miami/Jackson Memorial Medical Center. In the last three decades, transplantation has evolved from a largely experimental surgery to a routine practice, with more than 19,000 people nationwide receiving new organs annually. Today the School of Medicine’s transplant program consistently ranks among the top three in the nation for volume and research. Patient survival is above the national average for almost every type of organ transplant. People come to University surgeons from throughout the world for kidney, pancreas, intestine, liver, heart, lung, and multi-organ transplants. Physicians and scientists at UM’s Diabetes Research Institute have pioneered much of the work on removing islet cells from the pancreas and transplanting them into patients with diabetes, and University faculty are breaking ground using bone marrow and stem cells to treat patients with cancer and diseases of the immune system.
The transplantation program’s success is due, in no small part, to the University’s commitment to recruiting top-notch transplant surgeons and supporting a research agenda aimed at improving surgical outcome. In 1994 the program reached a turning point with the arrival of Andreas Tzakis, M.D., a University of Pittsburgh transplant surgeon internationally recognized for successfully performing procedures few surgeons would attempt. The liver and gastrointestinal transplant division, which he directs, is now one of the leading liver transplant programs in the nation, doing about 180 such surgeries a year. Its physicians are among only a few in the world who do intestinal and multi-organ transplants, making headlines this year with the simultaneous transplant of eight organs in a six-month-old Italian baby.
eventeen years after his first liver transplant, David Yomtoob, 35, a computer specialist from Lowell, Michigan, came to the University of Miami for a retransplant. Years of scarring from a blocked bile duct had damaged his liver.
“We were told that David’s transplant would basically be a matter of carving out his old liver to put in a new one,” says Paricherhr Yomtoob, David’s mother. “We knew you needed extensive experience to do retrans-plantation and that Dr. Tzakis doesn’t give up when other surgeons might.”
Since arriving in Miami, Tzakis, now codirector of the Division of Transplantation, has developed a novel “piggyback” procedure that preserves the patient’s inferior vena cava (vein) and keeps the patient more stable during surgery. To remedy the severe abdominal wall damage found in many patients undergoing multi-organ transplant, he developed a technique for replacing the entire structure. Similarly, to deal with the difficulty of removing tumors from organs in the lower abdomen, he pioneered an “autotransplantation” method in which the organs are completely removed from the patient’s body, the tumors excised, and the healthy tissue reimplanted.
Still, Tzakis and his colleagues remain vexed by the problem of transplant rejection. “The last 15 years have been very important in organ transplantation because immediate postoperative morbidity and mortality have been reduced,” he says. “A lot of the problems we now face have to do with quality of life and long-term survival.”
Included among these are the problems associated with taking anti-rejection drugs throughout life—such complications as kidney failure, diabetes, nerve damage, and an increased risk of infection and cancer.
he major change we’ve seen in recent years has been in the use of new immunosuppressive agents that are stronger and more specific,” explains Joshua Miller, M.D., codirector of the transplantation division. “The bullet now is directed against just those cells that cause rejection, which is less disruptive to the entire immune system.”
“With Campath, we can achieve the same or better results than with other immunosuppressives while using half the dose,” Tzakis says of the drug that was long used to reduce kidney rejection immediately post-transplant and is now being studied for use in liver transplantation. “This means that patients experience half the side effects of conventional immunosuppression.”
Three years ago, Tzakis and colleagues successfully took 20 out of 100 liver transplant patients off of anti-rejection drugs. All had received liver transplants at least three years earlier and had experienced no signs of rejection in the year before being taken off the drugs.
In recent years, the kidney transplant team has been particularly interested in agents that reduce rejection in African-American and Hispanic patients, who face a higher risk of losing their transplant. Gaetano Ciancio, M.D., professor of surgery, and his colleagues recently published a study in which a combination of three relatively new drugs reduced kidney rejection in African-Americans from about 30 to 8 percent one year after receiving the organ.
One of the most promising approaches involves injecting patients with bone marrow cells from the same donor who provided the transplanted organ. This creates a state of chimerism in the patient’s body—in which the immune cells produced by the donor and the recipient coexist. In an ongoing study, Miller, Ciancio, kidney/pancreas specialist George W. Burke, M.D., and director of the Diabetes Research Institute Camillo Ricordi, M.D., have found that the more than 100 patients who have undergone this procedure since the mid-1990s are surviving long-term with fewer drugs than those who received only kidneys.
While immune tolerance will revolutionize the field of transplantation, other technical advances have already improved the lives of patients. Among these are less-invasive laparoscopic techniques for obtaining kidneys from donors and innovative methods developed at the School of Medicine for preserving lungs, one of the most difficult organs to maintain.
Another specialization earning the School of Medicine a reputation of excellence is the heart and lung transplant program. In 2000 Si Pham, M.D., a cardiopulmonary surgeon recruited in 1998 from the University of Pittsburgh, performed the first heart-lung transplant in South Florida. Pham, who directs the heart and lung transplant program, performs about eight lung transplants and almost 30 heart transplants a year. He credits the 90 percent survival rate—well above the national average—to improved techniques for matching organ donors with recipients. He also cites the specialized cardiopulmonary team assembled at the School of Medicine and the new devices that help patients survive longer while awaiting a donor heart.
Once a patient is deemed a candidate for transplant, it could be days, weeks, and sometimes months until a matching organ becomes available, with postoperative care extending that time even further. Since 2002 the Transplant House has been serving out-of-town patients and their families undergoing this process. Established by the Transplant Foundation, Inc., a nonprofit organization founded in 1987 by organ recipients to assist patients in need, the Transplant House is a temporary, affordable living space located on the seventh floor of Jackson Towers at UM/Jackson. Staffed round-the-clock, the facility includes 13 fully furnished rooms with space for up to three people in each.
The University also has implemented ways to expand outreach throughout Florida. Patients in Orlando can receive screening for transplantation at a University-operated satellite clinic, and UM surgeons travel weekly to Broward County to perform transplants at Broward General Hospital in Fort Lauderdale.
At the end of the day, there is no transplant program without an organization that procures donor organs. The University of Miami’s Life Alliance Organ Recovery Agency (LAORA) has, by necessity, become extremely proactive, educating physicians and families of potential donors and refining techniques for obtaining and preserving organs. Not surprisingly, LAORA pioneered the method for obtaining the donor abdominal wall used by the University’s liver/GI team and has developed new procedures for obtaining multiple organs from a single donor.
David Levi, M.D., associate professor of surgery and medical director of LAORA, proudly notes that the waiting time for organs tends to be less at the University than at other centers. “The community is supportive of transplantation as something that can be of tremendous benefit,” he says, noting that South Florida has a high volume of both potential donors and recipients. “They know that being an organ donor is a profound gift.”
|Joan Cochran is a freelance writer in Boca Raton, Florida. Photos by John Zillioux and Donna Victor.|