How a City Hospital Won Transplant Title

Many doctors declined to perform a kidney transplant on the 82-year-old man who contacted Dr. Sandip Kapur two years ago.
Dr. Kapur, a surgeon at NewYork-Presbyterian Hospital, agreed to operate on the man, whom he described as mentally sharp and otherwise physically healthy. Today, the patient is "living a great life," Dr. Kapur said.

Operations such as these have helped NewYork-Presbyterian become the largest transplant center nationwide. In 2006, surgeons there performed 800 transplants, including 562 at the main hospital and another 238 at a center for kidney disease that is affiliated with the hospital, the Rogosin Institute. Nationwide, UCLA Medical Center was the second busiest, with 697 surgeries. In New York, the next largest program was Mount Sinai Medical Center, with 373 surgeries.

In part, NewYork-Presbyterian's patient volume reflects the hospital's size, but transplant surgeons there also described a philosophy that includes the use of "expanded" criteria for transplantation, which ultimately means doctors there will operate on patients whom other doctors may reject as risky. In July, for example, doctors at NewYork-Presbyterian successfully transplanted five organs — a liver, small bowel, pancreas, colon, and stomach — into an 8-month-old baby boy born with congenital abnormalities.

By definition, "expanded" criteria refers to the data points surgeons consider when finding an appropriate organ for transplantation. Expanded donors may be older, and they may include those with prior hepatitis B or C infections, a history of hypertension or diabetes, or unusual anatomy. The term does not include patients who are medically unsuitable for surgery, such as those with active infections or cancer.

The approach, which has gained in popularity over the past five years, comes in part from a nationwide organ shortage. As of August 31, there were 97,125 individuals registered on a national waiting list for organ transplantation that is maintained by the United Network for Organ Sharing. In New York, there were 8,566 transplant candidates on the list, including 1,618 with a projected waiting time of five years or longer.

A new procedure three decades ago, transplantation has become one of the most highly regulated areas of medicine with a waiting list that is determined by a complex algorithm. A patient's place on the list is determined by such factors as blood and tissue type, medical urgency, time on the waiting list, and the transplant center's criteria for accepting organ offers.

While doctors at NewYork-Presbyterian said their emphasis on extended criteria comes from a drive to treat the sickest patients and make research advances, it is clear the missive is also a personal one for the hospital's president and CEO, Dr. Herbert Pardes, whose son has received three liver transplants.

"It's both a personal, medical, scientific, and business priority for the hospital," the chief of transplantation at NewYork-Presbyterian/Columbia University Medical Center, Dr. Jean Emond, said.

In recent years, NewYork-Presbyterian doctors have also worked to reduce immunosuppressive therapy for transplant patients, and they have developed a noninvasive test to predict organ rejection.

According to the Scientific Registry of Transplant Recipients, NewYork-Presbyterian showed statistically higher survival rates for kidney and lung transplant patients as of July 2007.

However, it is sometimes a precarious line to walk. Drawing on the example of treating an older patient, the chief of nephrology and transplantation at NewYork-Presbyterian's Weill Cornell Medical Center, Dr. Manikkam Suthanthiran, said: "These are the challenges when you're taking a scarce resource."

"You'd say, there are young people, why don't you put the kidney in them? This is where the challenge of utility versus social justice comes in," he said.

There are those who feel that using expanded criteria increases the chances of complications.

The director of transplantation at NYU Medical Center, Dr. Lewis Teperman, said using expanded criteria is a medically accepted practice. "The question is, how expanded are you willing to go? In certain individuals, these are going to work fine," he said. "On the other hand, if you put a 70-year-old liver into someone who had Hepatitis C, it would come back quicker in the older organ in the new recipient."

At Mount Sinai, the chief of the hospital's Transplantation Institute, Dr. Jonathan Bromberg, said expanded criteria donors are "not optimal."

"Their initial function is not as great as a standard criteria donor," he said. However, he painted a bleak picture of what a patient might otherwise face during an extended waiting period for a better organ. Sometimes, Dr. Bromberg said, "I'd like to get them a kidney, any kidney."

NewYork-Presbyterian doctors expressed a similar sentiment, saying the waiting list for organs has grown so large in recent years that the mortality rate is sometimes greater than the risk associated with receiving an organ that is less than perfect. Nationally, about 6,000 people a year die while waiting for transplants.

"We try to focus on the relative risk," the medical director of NewYork-Presbyterian/Columbia University Medical Center's Division for Liver Disease and Transplantation, Dr. Robert Brown, said.

"There's a big difference between perfect, acceptable, and unacceptable. And for any given individual, it's about a risk benefit decision," he said. Transplanting a 70-year-old liver into a 70-year-old recipient may be acceptable, although that same liver would not be acceptable for a reasonably stable baby, he said. "If the baby is critically ill in the ICU, that 70-year-old liver is starting to look a little bit better," he said.

In the New York metropolitan area, the number of organ donors increased by 47% between 2003 and 2006, according to the New York Organ Donor Network. However, those numbers are still too low to meet the demand, the group's president and CEO, Elaine Berg, said. "The limiting factor is organ donors," she said. In 2005, 319 individuals donated organs, up from 217 in 2003, she said.

But only about 1.5% to 2% of deaths are viable donors, she said. In New York, middle-age stroke patients are the most frequent donors.

"If there's a young person who dies, those people are generally healthier. They die healthier than older people, they are better organ donors," Ms. Berg said. However, she added, "Doctors like those at Columbia and NewYork-Presbyterian have really, really pushed the envelope because the need is becoming so great, and you can't wait for that young donor."

Some have proposed financial incentives to promote organ donations. "A regulated system that creates incentives for donors, whatever those incentives may be, would save lives, reduce the shortages that promote the black market, and level the playing field," the associate director of the American Council on Science and Health, Jeff Stier, wrote in the New York Post last month.

Ms. Berg rejected that proposal: "I think there are things we can try as a society before we turn the human body into a commodity."

Dr. Kapur said difficult cases don't necessarily translate into poor outcomes. In the case of the 82-year-old patient, he said: "Someone who is 70 or 75 doesn't need 15 years. They need maybe five or six years of quality life off dialysis, preventing some of their secondary conditions from progressing. That's an ideal situation to match extended donor organs."