Medical Science Report Advancements In Medicine

Heart-Kidney Transplants at U.C. San Francisco Renew Hope for Many

Most people suffering from long-standing heart failure are also likely to be plagued by reduced kidney function — the two problems tend to coexist, a result of the heart’s inability to sufficiently pump an adequate amount of blood throughout the body.

In addition to the terrible suffering that someone with these grave conditions must endure, options for treatment also are limited, as very few medical centers will pursue the pro-active approach of combination heart-kidney transplants. However, this trend has finally started to change because of the stance the University of California, San Francisco Medical Center (UCSF) has taken toward patient assessment and treatment.

“UCSF has a proud and pro-active tradition of using the latest technology and immunosuppression to optimize the outcome of transplant recipients,” says Dr. Flavio Vincenti, an internationally regarded nephrologist in practice at UCSF. As Vincenti infers, the Medical Center has built a unique environment where physicians and researchers flow together to meld theory with its practical application, many times giving the sick a second chance at life.

UCSF, with some of the most highly-ranked cardiologists, heart surgeons and renal specialists in the country, has further set itself apart from like institutions because of its aggressive approach in treating patients who present with failing hearts and impaired kidneys: Instead of immediately opting for standard medical management (dialysis, cardiac-implant devices, various orally administered drugs) until death, UCSF doctors often will first look toward dual transplantation of heart and kidneys in an attempt to restore a more complete quality of life to the compromised individual.

According to statistics, 19.8% of UCSF’s patient population is comprised of multi-organ transplants (these numbers include liver-kidney, heart-lung, heart-kidney, kidney-pancreas), compared to 2% nationally and only 1.4% at other hospitals in the region. Contrary to the common perception that multiple organ patients don’t do well upon transplant (because their bodies are in too fragile a state), UCSF physicians have showed that these procedures can indeed be successful.

“Previously, transplant teams believed that patients with single-organ dysfunction were the best candidates for transplantation, since only one organ needed to be replaced, while the other vital organs functioned normally,” says Dr. Kiran Khush, former Assistant Professor of Medicine in the UCSF Division of Cardiology whose paper analyzing the cost-effectiveness of combined heart-kidney procedures was presented at the International Society for Heart and Lung Transplantation in Madrid in April 2006.[1] “However, the reality is that the functions of multiple organs are closely inter-related, so that when one organ fails, another organ is often affected. The initial fear was that multi-organ transplantation would have more complications, more incidences of rejection, and worse survival. But multiple-case-series to date have actually shown the opposite: patients with multi-organ transplants do not have reduced survival compared to single organ transplant, the rate of complications is not significantly increased; in fact, they often have less rejection.”

The Link Between Heart Disease and Renal Failure

Typically, a person who has had long-standing heart disease also suffers from compromised kidneys – the long history of low blood flow because of heart damage over time greatly reduces the kidneys’ capacity to process and expel toxins/wastes, impairing the circulatory system’s ability to cleanse itself. These circumstances are often further exacerbated by hypertension and diabetes (and also by some of the oral medications used to treat the deteriorating heart).

Finally, when a person in the throes of such illness undergoes heart transplantation, they are given a series of medications called immunosuppressants meant to help the body to accept the new organ (basically, the body’s natural tendency is to reject or expel any foreign matter through immune system reaction. To over-ride this, drugs must be administered to suppress the immune system and allow it to tolerate the new heart). Yet, because these drugs are so powerful, they are also extremely hard on the renal system, often critically weakening the kidneys.

“The body’s normal defense mechanisms lead to rejection of foreign grafts,” says Dr. Vincenti. “Thus, immunosuppressive drugs suppress the immune system and lead to a state of  ‘accommodation.’ However, studies are [presently] being performed [now] at UCSF with the ultimate goal of inducing tolerance of foreign grafts without the need of long- term use of potentially toxic medications.”

Simultaneous Treatment of Heart and Kidneys Vital

However, clinicians and surgeons are quick to agree that performing a heart transplant on a patient in renal failure creates a disastrous prognosis – in order to give a patient in this situation a fair chance at survival each of the diseased organs should be replaced at the same time (with the organs from a single donor used to avoid compatibility and cross-matching issues).

The decision to proceed with simultaneous replacement of both the heart and kidney necessitates that the transplant team assess both the origin and degree of the kidney failure and then attempt to make a determination on whether restoration of heart function alone will be sufficient to reverse the underlying kidney disease. This is of critical importance for the physician, because if the patient receives a new heart and doesn’t recover kidney function, the opportunity for dual treatment is likely lost: it simply becomes too perilous to replace the heart and kidneys at different times because of the increased potential for organ rejection (with the patient already having descended into a deeper state of weakness due to further loss of renal function).

“In a patient with heart and kidney failure, transplantation of the heart alone would still leave the patient with severe kidney disease,” says Dr. Khush. “This is detrimental in many ways, most notably in that it would affect the ability to treat the patient with appropriate doses of immunosuppressive medicines and would negatively impact the patient’s quality of life, since dialysis patients spend 10 hours per week hooked up to a machine. Also, it would render them more susceptible to infection through dialysis catheters, and immunosuppression from renal failure.”

Dr. Vincenti concurs: “It is clear that patients who are in renal failure and are in need of heart transplant have better survival and better quality of life [if they receive dual transplant].”

A Controversy Unfolds

Still, UCSF’s distinction in offering this life-saving chance at multi-organ transplant has not come without a certain amount of controversy.

The list for patients waiting for donor kidneys is long, and some have been suffering through dialysis for years in hopes of a fresh start. However, the standard protocol is suspended when a patient on the heart transplant list is also in need of a kidney and such patients are given priority — leap-frogging the kidney-only patients and jumping to the head of the line. Thus, patients with chronic renal failure who do not receive a transplant must remain on dialysis until transplantation or death.

“Patients can survive on dialysis for decades,” Dr. Vincenti points out, “but their quality of life and productivity are impaired significantly. And their survival is inferior to patients who undergo transplantation.”

These circumstances raise immediate ethical considerations as individuals on opposite sides of the spectrum debate the topic. Does the fact that heart transplant patients also get first crack at a new kidney create an inequitable distribution of resources, and is it unfair to kidney-only transplant candidates who, in some cases, have been waiting years for surgery?

Dr. Teresa De Marco, Director of the UCSF Heart Failure Program and Medical Director of its Heart Transplantation Program and considered one of the finest physicians in the United States, does not waver on her commitment to (and role in) this process; as a clinical cardiologist, she believes that she must take the best road available to prolong her patients’ lives: “To me the question comes down to doing the best I can for my patients,” De Marco says with a mix of empathy and deep conviction. “These are flesh and blood people and not just ‘cases’ or names on a piece of paper. As a patient advocate, my primary responsibility is to save lives and improve the quality of life for my patients. It is my moral impetus and my absolute duty to do the best I can for them.”

A sentiment Dr. Vincenti echoes with resolute certainty: “The kidney follows the heart. As physicians we have to do the utmost for each patient.”

Is There An Answer?

Obviously, the dilemma UCSF is faced with here – how to best serve the greatest number of patients while offering true long-term quality of life – is a harshly difficult one. The doctors and administrators at these institutions are confronted with the unique task of trying to marry social policy with doctrines of medical management of the sick so that the best decisions can be made for the best number of patients.

But how can medical professionals do this without some people suffering as a result of  the choice that is made? Since no one has the definitive answer yet, patients at UCSF are presently evaluated case-by-case, with the best course of treatment pursued on an  individual basis.

“A physician, ultimately, is an advocate for the patient,” says Dr. John Roberts, Chief of  Liver, Kidney and Pancreas Transplant Services at  UCSF. “And in that role there can be a conflict with social utility concepts [on how to best utilize available donor organs] because of the individualized decisions we have to make – making immediate judgments as to whether a patient might enjoy a favorable outcome that justifies the use of two organs. Basically, it comes down to trying to create a balance between utility of organs and social justice — maximizing the opportunity for survival in those with medical and biological disadvantages who are able to receive transplant.”

Obviously, these physicians face myriad challenges: trying to best use available donor organs while striving for ‘social justice’ – tear through the arguments and it becomes about giving as many sick people as possible a real chance at survival and a normal life.

“In the end, it’s truly a philosophical issue,” notes Dr. Roberts. “The level of aggressiveness [related to a doctor deciding to implant two organs in one patient] is going to be philosophic, and I don’t think there’s one standardized answer to the question.”

Notwithstanding the ongoing debate, it’s hard to argue against the success that UCSF has had in this arena: Out of the twelve heart-kidney transplants that have been performed at the University since 1991, eleven have survived — a striking 92%  rate of success.

“What the statistics say,” remarks De Marco, “is not to give up. Pursue a referral to a center that might look at doing multi-organ transplant. And get an evaluation.”

Footnotes 

[1] Dr. Kiran Khush’s treatise was presented in April 2006 at the annual meeting of the International Society for Heart and Lung Transplantation in Madrid; it was co-authored by the following individuals: Dr. Teresa De Marco (Director of the UCSF Heart Failure Program and Medical Director of its Heart Transplantation Program); Dr.Vivek Bhalla (nephrologist); Dr. Dana McGlothlin (transplant cardiologist); Celia Rifkin (transplant coordinator and clinical nurse); Dr. Flavio Vincenti (nephrologist); and Dr. Charles Hoopes (cardiac surgeon). 

2008 Update

In January 2008, the Scientific Registry of Transplant Recipients (SRTR) announced that the one-year survival rates for patients receiving heart, liver and lung transplants at UCSF Medical Center exceed national averages at statistically significant levels.

According to the SRTR report, the one-year survival rate for the UCSF Heart Transplant Program was 100 percent, compared to an expected survival rate of 87 percent. In addition, the UCSF Liver Transplant Program produced a one-year survival rate of 92 percent, compared to an expected 88 percent survival rate (while the Lung Transplant Program generated a one-year survival rate of 90 percent as compared to an expected 80 percent survival rate).

UCSF physicians continue to undertake the most complex transplant surgeries (including multiple organ procedures), and the center is the only hospital among U.S. News & World Report’s top18-ranked facilities to exceed the national averages for expected survival rates in these highly specialized programs.

by John Aiello

Update published April 10, 2008

Statistical Probabilities/Related Facts

• According to data presented by University of California San Francisco physicians at the International Society for Heart and Lung Transplantation conference in Madrid in 2006, dual-organ transplantation offers patients in the throes of end-stage heart and kidney failure a cost-effective alternative to treatments which focus only on palliation of symptoms. For example, costs for a patient who is not a candidate for transplantation but who undergoes implantation of a left ventricular pumping-assist device ranges from $197,957 to $210,187, with hospital stays for these patients averaging between 29 and 37 days. Comparatively, individuals who undergo combined heart-kidney transplants end up staying in the hospital an average of 2.5 weeks. Thus, costs are reduced by 40-45%, as heart-kidney transplant patients tend to have fewer complications, requiring less critical-care measures. In addition to placing a reduced financial burden on our health care system, dual-organ transplantation has been shown to offer patients markedly better odds at long-term survival and an increased overall quality of life, as those who undergo heart-kidney transplantation enjoy a 73% survival rate after five years.

• The overall 3 year graft survival of kidney-only transplant recipients at UCSF is 88%. This ranks above the national average of 83%.

• The one year survival rate for a heart-transplant only recipient is 90%. At five years, survival rate is 70%; and at 10 years, it’s 50%.

• In the San Francisco Bay Area, between 60 and 80 heart transplants are done annually amongst 3 programs, including Stanford University, UCSF and California Pacific Medical Center.

• The University of California, San Francisco is ranked as the seventh best medical school in the country according to the July 2007 US News and World Report Survey.

• UCSF launched its Heart Transplant Program in 1989 and expects to perform its 500th procedure in the near future. The program focuses on pulmonary hypertension and right ventricular failure, combined heart-kidney transplant, transplant for Chagas disease, transplant for congenital heart disease, transplant for HIV, and research on the genomics of heart failure and allograft loss (rejection of donor organ).

• Since its inception in 1988, the UCSF Liver Transplant Program has performed more than 2,100 liver transplants for adults and children.  The program has been designated as a Center of Excellence by the U.S. Department of Health and Human Services and it performs more liver transplants than any other hospital in Northern California.

• The UCSF Lung Transplant Program has performed more than 250 transplants since the program began in 1991 and it continues to maintain its place as a specialized center for treating cystic fibrosis and pulmonary hypertension.

Some Other Facts About Transplantation

• In terms of heart transplantation, the primary criterion is that the donor heart has to fit the patient’s chest cavity; so, along with blood-type match, the donor and patient must basically be the same body size.

• For kidney transplantation, donors are tested for exact blood-type match; the transplant team also tries to match donor and recipient in terms of body size (as is done for heart transplantation procedures). In addition, kidney donors are tissue-typed against recipients. Such tissue typing requires that the surface of donor cells be tested for the existence of HLA Antigens  – substances that stimulate the recipient’s natural immune system response and spark the production of antibodies. Should this occur, these antibodies will recognize the new organ as a “foreign” or enemy property and immediately attack it. However, by matching HLA Antigens between donor and recipient, such rejection becomes much less likely, further reducing the need for powerful immuno-suppressant drugs that can tax the body.

• For patients in end stage liver disease, transplantation is often the only hope for survival (an example of a disease that attacks the liver is Hepatitis C, which can lead to cancer and cirrhosis). Although body size does not matter for a liver transplant, blood-type matching is critical, and patient and donor must have the same blood type. Interestingly, since the liver can regenerate itself, it is possible for a donor to donate only part of their liver for this procedure: over time and through cell regeneration, the organ will naturally grow to normal size.

Tales of Success: Two UCSF Transplant Patients Talk About Their Lives

I.

Wayne Teramoto, 47, of Madera, California, was a healthy and active bus mechanic for the City of Fresno for nearly two decades when he fell ill with what he thought was the flu. Teramoto, who also grew up in the San Joaquin Valley, had no idea that his ‘cold’ was really a severe form of cardiac disease called Ventricular Dyplasia, a congenital condition that enlarged Teramoto’s heart and caused such horrible arrhythmias they nearly killed him. Now recovering from dual-transplant of both his heart and kidneys, Teramoto speaks with deep conviction and gratitude – for both the doctors at UCSF who saved his life and for the donor family who offered the resources with which that operation was performed.

Tell me a little bit about how you came to require a heart-kidney transplant.

I got sick roughly 12 years ago, in 1993 – I was around 35 years old. At that time, I played racquetball a lot. One time when I was playing I fell down and hurt my knee. I injured the cartilage, quit exercising, and gained a lot of weight. And then just after that, I caught a bad cold. I was off work for a week and thought I had really caught a bad flu. When I finally went to the Emergency Room I gave those folks [the ER personnel] quite a shock. When they examined me my blood pressure was so low it wouldn’t register on their electronic machine. The doctors said I was in Ventricular Tachycardia [a potentially lethal rapid heart rhythm which may cause the heart to become unable to pump adequate blood through the body] and they hit me with a paddle [defibrillator paddle] to shock my heart back to its normal rhythm. That was the beginning of my heart problems. Prior to that time I was a fairly healthy guy — until my knee gave out.

What were you going through prior to the operation?

For the first 7 or 8 years, I slowly went down hill. I was on a lot of medication and an automatic internal cardiac defibrillator [an electronic device which detects abnormal heart rhythms and delivers a shock to stop such life-threatening arrhythmias] had been implanted. But over-all  I was pretty stable and continued to work at my job until 1999. But in November of 2001, I got worse. In the span of  6 weeks, I had 38 different episodes of tachycardia. Several times my heart rate got around 170 – and it all really wore me down. From that point I got progressively sicker. The doctors increased the amount of medicine I was taking, which made feel even more tired. All I could do was stay home and try and care for myself. At the same time, my kidneys also started to fail [because of the impaired heart function]. Even though my blood was becoming toxic from the loss of  kidney function, the majority of what I was feeling [in terms of symptoms] was because of my heart. The doctors told me I was only a month away from needing dialysis when I received the transplants. Being able to receive the kidney transplant with my new heart saved me from a lot of extra suffering.

How did you feel when the doctor told you needed organ transplant?

I was kind of stunned. I didn’t think I was that sick. I guess I was in a whole lot of denial. But at the end I was so sick I had no chance. Like, if I had to go grocery shopping, it would take the whole day. That’s how tired I would get. I would get so tired and short of breath that I had to stop and rest constantly. A thing like buying some groceries became an all-day effort.

How did you get to UCSF?

Well, like I said, I was in denial for a long while. In 1994, my cardiac doctor in Fresno told me to sign up for the transplant list because my heart was so enlarged. But I didn’t think it was necessary, because I felt I was still functional. But in 2001, after I had those severe attacks, I knew I was getting sicker. So I signed up for the transplant list and my insurance company referred me to the UCSF Medical Center. I began testing in late 2002 and the transplants were done in December of last year [2004].

How has your life changed in the wake of the transplants?

Other than not being able to go into large crowds, I am pretty much back to where I was over ten years ago. The doctors don’t want me to go into crowds because they don’t want me exposed to too many germs [because of the immunosupressant drugs being used to allow Teramoto to tolerate the new organs]. Looking back on the transplant, nothing was all that painful except for the IVs — those hurt somewhat. Now, as far as my medical care,  I see Dr. De Marco once a month for a full check-up. And I have my blood tested weekly to monitor my kidneys.

Have you met the donor family?

I have not, but I would like to meet them and express my thanks. You know, it’s hard to imagine what these families are thinking when somebody they love is sick and dying. But I can’t help feeling such gratitude. My life was hanging in the balance and they saved me.

And what would you say to someone in the throes of a similar ordeal?

The doctors and nurses at UCSF have been through this stuff many times and they know just what to expect; they know just what’s going on. As a patient, you can’t be afraid to ask them questions. These doctors really care about how you’re doing and there should be no fear going into the operation — because the end result out-weighs the fear. Just to be alive and live a normal life again, that far out-weighs the fear….

Interview conducted May, 2005 by John Aiello

II. 

We also posed these same questions to Ken Pence, a former Air Force pilot and school psychologist from Merced County (roughly 60 miles north of Fresno, in the center of California) who also underwent heart-kidney transplant earlier this year. Pence, now 72 years old, became sick over a quarter century ago with dilated cardiomyopathy – a condition where the heart muscle loses its ability to pump with adequate force, slowly starving the body for sufficient amounts of oxygen-rich blood.  After managing his illness for 25 years via an array of oral medications and the implantation of an internal cardiac defibrillator (an electronic device which detects abnormal heart rhythms and delivers a shock to stop such life-threatening arrhythmias), Pence was forced to proceed with a cardiac-kidney transplant: In essence, the heart he was born with had grown too tired to properly function.

Tell me a little bit about how you came to require a heart-kidney transplant. 

I was diagnosed with Cardiomyopathy in 1980. I was working at my job as a school psychologist in Merced County when I started experiencing flu-like symptoms. I just felt weak all over. They sent me to the hospital for an examination and the cardiac catheterization test [a diagnostic procedure where a flexible catheter filled with x-ray contrast material is injected into the heart through a vein or artery in order to measure blood supply] showed that my heart wasn’t functioning very well. The doctors put on several different medications, and I did pretty well over-all until the transplant [done in February 2005].

What were you going through prior to the operation?

Well, in the beginning [in 1980 following diagnosis], I felt pretty good. I was able to keep working [Pence retired in 2003] and functioned fairly normally. I wasn’t really a universal case, as most people with the symptoms I had usually ‘drop’ pretty quick. I actually had a lot of good years that most people don’t have. But during the last five years [2000 through 2005] the disease progressed quickly and I got worse in a hurry. At first I attributed these changes to old age, to nature. But then it actually got to the point where I couldn’t walk as far as I used to and I wanted to sit all the time. I just didn’t want to stand up. I had no stamina. All the ‘poop’ had gone out of me. At the end [before transplants] I couldn’t even walk from one end of our pasture to the other without losing all the strength in my legs. In the end, my kidneys also started to go downhill too [a likely result of Pence’s long-standing heart condition and the impaired blood flow to his renal system].

How did you feel when the doctor told you needed organ transplant?

I was elated – but also very much afraid. It’s a scary thing thinking about an operation of this magnitude and thinking about having something like a stranger’s heart and kidneys put into your body. After the tests were run and it was determined I was eligible for transplant, I was placed on the list to wait on a match [organ match]. I was actually only on the list for 2 weeks when the nurse called and told me to report to the University for the procedure. It was amazing how fast it all happened. It happened so fast I didn’t even have time to worry or brood about it.

How did you get to UCSF?

Well I persisted and kept asking my doctor in Merced to refer me to UCSF. I wanted an expert opinion on my condition. They were good in Merced — but they didn’t have everything I needed. And I didn’t want to leave any stone unturned. I eventually was able to see Dr. Kanu Chatterjee [a world-renowned clinical cardiologist at UCSF and a leading expert on many forms of heart disease, including cardiomyopathy], and he was extraordinary. He actually spent an hour talking to me about my problem and ways to approach treatment. He modified some of my medications and, eventually, recommended that I have a cardiac defibrillator implanted to help keep my heart beat stable and even. 

How has your life changed in the wake of the transplants?

You know, John, before the operation I had pretty much given up. I couldn’t do anything. But now [roughly 4 months following the multi-organ surgery] I can do the things I used to do. I can weed-eat and mow my lawn with a riding mower. I am active and I can do many of the things I used to do. I never thought it was possible to go backwards [to a time when he felt good]– but I’ve done just that. And it’s been fantastic to have this chance.

Have you met the donor family? 

No; I don’t know anything about them except that the donor was a nineteen year old man from San Diego. I haven’t tried to meet the family. But I would if  I could. And I would tell them how sorry I am for their loss. And I would tell them that the fact that this young man elected to donate his organs is a real gift of life and shows what a quality person he was.

And what would you say to someone in the throes of a similar ordeal? 

Well, in the course of going through all this, I kept asking Dr. Hoopes and Dr. De Marco how this [the operation] could happen so fast. And Dr. Hoopes said the reason things happened as they did was because of a combination of my persistence and attitude coming together with the right circumstances [being able to find an organ match]. Dr. Hoopes said I explored all possibilities, and that’s just what I would tell someone else to do – do everything you can to get treatment. I had originally thought that because of my diabetes and because of my age [over 70] that I would have been disqualified for a transplant – but that wasn’t the case at all. What these doctors were able to do for me was just phenomenal. I can’t say enough about Dr. Hoopes and Dr. De Marco – they were there day and night. They are truly dedicated to the practice of medicine and their positive attitude helped me through this. It may sound funny to you – but it ended up being a great experience to be treated by these people at UCSF.

Interview conducted May, 2005 by John Aiello

References

• Interview with Teresa De Marco, M.D., F.A.C.C., Professor of Clinical Medicine, Director Heart Failure and Pulmonary Hypertension Programs, University of California, San Francisco Medical Center.

• Interview with John Roberts, M.D., Chief of  Liver, Kidney and Pancreas Transplant Services at  the University of California, San Francisco Medical Center.

• Interview with Flavio Vincenti, M.D., a nephrologist and specialist in diseases of the kidney and pancreas in practice at the University of California, San Francisco Medical Center.

• Interview with Charles Hoopes, M.D., Director of Heart and Lung Transplants at the University of California, San Francisco Medical Center.

• Interview with Kiran Khush, M.D., former Assistant Professor of Medicine in the University of California, San Francisco Division of Cardiology now working at Stanford University. Khush is the first author of a report that explores important changes in medical perspective as related to treating patients who present with both heart and renal failure (refer to footnote [1]).

• Interview with Wayne Teramoto, heart-kidney transplant recipient from Madera, California.

• Combined Heart-Kidney Transplantation Reduces Costs and Improves Survival Compared to LVAD Destination Therapy for Patients with Concomitant Heart and Kidney Failure. An abstract presented by Dr. Kiran Khush at the International Society for Heart and Lung Transplantation conference in Madrid, Spain, April 2006. By Kiran Khush, MD; Vivek Bhalla, MD; Celia Rifkin, RN; Karen Rago, RN; Dana McGlothlin, MD; Flavio Vincenti, MD; Donald Hill, MD; Charles Hoopes, MD; Teresa De Marco, MD. From the divisions of Cardiology, Nephrology, and Cardiothoracic Surgery, and Medical Center Administration, University of California, San Francisco.

• Combined Heart and Kidney Transplantation in Patients with End-Stage Heart and Kidney Failure. An abstract presented by Dr. Kiran Khush at the International Society for Heart and Lung Transplantation conference in Madrid, Spain, April 2006. By Kiran Khush, MD; Vivek Bhalla, MD; Celia Rifkin, RN; Dana McGlothlin, MD; Flavio Vincenti, MD; Charles Hoopes, MD; Teresa De Marco, MD. From the Divisions of Cardiology, Nephrology, and Cardiothoracic Surgery, University of California, San Francisco.

• Interview with Ken Pence, heart-kidney transplant recipient from Merced, California.

• University of California, San Francisco Medical Center web site (news service overview).

• The United Network for Organ Sharing website (www.unos.org).

Chronic Kidney Disease, Dialysis and Transplantation (Companion to Brenner and Rector’s The Kidney). Second Edition. Brian J.G. Pereira, MD; Mohamed H. Sayegh, MD; Peter Blake, MD. Elsevier/Saunders Publishers. This text, recently revised in its second edition, provides the latest data on diseases of the kidney, and includes in depth analysis on renal failure (with discussion on both the different factors that cause kidney failure and the treatment options available to the patient). Written from an advanced scientific perspective for the practicing clinician/surgeon, and is thus not appropriate for the consumer/patient.

Hurst’s The Heart. 11th Edition. Valentin Fuster, Editor (with others). McGraw-Hill Science. This text outlines the primary diseases of the heart and also discusses treatment options in full and comprehensive terms. Also written from an advanced scientific perspective for the practicing clinician/surgeon, and thus not appropriate for the consumer/patient.

Reference Resources For Transplantation

BRENNER AND RECTOR’S THE KIDNEY – 9TH EDITION. In two volumes. Maarten W. Taal. Glenn M. Chertow. Philip A. Marsden. Karl Skorecki. Alan S. L. Yu. Barry M. Brenner. Saunders.

This is the proverbial bible of nephrology, stitching together the perspectives of the leading minds in the field. Brenner and Rector’s provides a detailed summary of all aspects of kidney disease, with this edition augmented by its cutting-edge insight into the topic of Pediatric Nephrology. In terms of heart-kidney transplantation, Brenner and Rector’s presents relevant discussion of cardiovascular-renal prediction in patients with chronic kidney disease – this vital ‘heart-kidney link’ outlined in depth and detail. In sum, Brenner and Rector’s is the best general renal-resource currently available today, appropriate for surgeons and clinicians alike.

by John Aiello

KIDNEY TRANSPLANTATION- 6TH EDITION. Peter Morris. Stuart J. Knechtle. Saunders.

Just as Brenner and Rector’s serves as the bible on general kidney discussion, Kidney Transplantation serves as the go-to reference surveying all aspects of kidney transplantation (including incisive discussion on the ethical considerations confronting the segment of the medical community focused on organ transplant procedures). In addition, the authors have taken great care to present data on immunological considerations and ways that physicians can handle these challenges to insure favorable patient outcomes. Other key focus-areas include passages on pediatric transplant and renal transplantation in developing countries. Noted for its ability to speak to the surgical and clinical teams with equal precision.

by John Aiello

TRANSPLANT – AN ISSUE OF CRITICAL CARE NURSING CLINICS. Darlene Lovasik. Saunders.

Lovasik (RN; MN; CCRN; CNRN) is an expert in the field of critical care nursing, and this reference serves as an indispensable resource for the after-care team. Simply, the surgery team is only as good as the nursing crew that supports it; in turn, successful outcomes often depend on the ability of a critical care nurse to spot problems before the patient is compromised. In Transplant, Lovasik discusses all the major areas that critical care nurses must master, including: basic immunology; pharmacology; liver, pancreas, and renal transplants; heart, lung, intestinal and multivisceral transplants; complications after surgery; patient education; and organ donor considerations. A well-written and insightful reference that paints a picture of those vital hours after surgery where patient battles are often lost or won.

by John Aiello

CARDIOLOGY -3RD EDITION. Michael H. Crawford. John P. DiMarco. Walter J. Paulus. Mosby.

This serves as a major reference offering expert dissection of the eight major clinical syndromes that comprise cardiovascular disease. Eight color-coded sections delineate each syndrome – these mini-textbooks meant to help clinicians keep pace with this ever-evolving sub-specialty. Crawford (University of California, San Francisco) and co-authors have done a laudable job in augmenting their text, with over 2,000 illustrations and graphs helping the reader transfer information from ‘classroom’ to ‘examination room.’ Impeccably written and referenced – the best general cardiology title available.

by John Aiello

INSTRUMENTATION FOR THE OPERATING ROOM – 8TH EDITION. Shirley M. Tighe. Mosby.

This reference includes over 1,000 photographs of surgical instruments, in addition to tips on how physicians and nurses can best approach use of these instruments in the operating-room setting. Instruments are organized by surgical specialty – beginning with the basics before progressing to advanced sets. Tighe’s writing is noteworthy for its clarity and ability to speak to both the student-reader and practicing clinician with equal lucidity. This 8^th edition includes instruction on preparation, sterilization and set-up, in addition to a review of common instruments now being used in the realm of robotic surgery.

by John Aiello

LIVING DONOR TRANSPLANTATION. Edited by Henkie P. Tan. Amadeo Marcos. Ron Shapiro. Informa Healthcare.

This book constitutes the authoritative voice in the field of living donor transplantation. In today’s world, due to aggressive media attention, the public’s perception of transplantation procedures has been focused on cadaver donors (and on the harvesting of useable organs from people who have died). However, living donor transplantation remains just as important an area of focus for transplant teams, since the contributions that living donors are now making to the preservation of human life has increased dramatically (due to significant advances by scientific researchers). Here, the editors (who all practice at the esteemed Thomas E. Starzl Transplantation Institute at the University of Pittsburg) have created a reference that explores all the major components of living donor, solid organ and cellular transplantation presently in use. Specifically, the authors offer complete discussion of current trends in living donor transplantation, including pertinent review of kidney, liver, pancreas, lung, small bowel and islet transplantation (in addition to a sterling chapter on hematopopoietic stem cell transplantation – a procedure which is representative of far-reaching advancements that have taken place in the field during the last two decades). Yet, going further, the authors also carefully explore the psycho-social factors which impact living donor transplantation (including chapters on both the ethical considerations of organ transplantation and the financial ramifications of pursuing such radical medical treatment). The text is notable for its inclusion of data on the technical aspects of live-donor right hepatic lobectomy as well as in depth exploration of live-donor pancreas transplantation (two areas of burgeoning interest now fully explained for the benefit of researcher, surgeon and practicing clinician). In sum, Living Donor Transplantation is cutting-edge in both scope and presentation, and it will likely serve as the ‘source in the field’ for years to come.

by John Aiello

MEDICAL COMPLICATIONS OF KIDNEY TRANSPLANTATION. Claudio Ponticelli. Informa Healthcare.

This volume begins an enlightening journey into the aftermath of kidney transplantation surgery. Simply, the lesson Ponticelli (University of Milan) tries to impart here is that the ‘nuts-and-bolts’ of the surgery process is but half the battle for the patient in renal failure and in the midst of transplantation (as a host of other mine fields exist requiring the physician’s in depth attention). As is common knowledge among medical personnel, the implantation of a donated or “foreign” organ into the human body requires immunosuppressant therapy to prevent rejection. However, these drugs pose their own significant dangers to patient health. Accordingly, this text addresses current approaches to managing this issue (in addition to information on delayed graft function; acute rejection of organ; chronic allograft nephropathy; recurrent primary disease; concurrent cardiovascular considerations; skin complications; and pancreatic and hepatobiliary complications). Aside from Ponticelli’s mastery of the subject matter, this text separates itself from like titles in the field on the basis of its clarity, authoritative tone and precision in presenting the most up-to-date perspective on kidney transplant surgery and its aftermath. In sum, Ponticelli is a gifted science writer able to convey the fine-points of an ever-evolving area of surgical focus.

by John Aiello

HEART DISEASE AND THE SURGICAL PATIENT. Edited by Simon Howell. Chris Pepper. Donat R. Spahn. Informa Healthcare.

Any surgery is stressful to the body and its great labyrinth of systems. Specifically, the cardiovascular system is taxed dramatically during surgery, as the combination of anesthetic and invasive trauma alters the heart’s delicate balance (often resulting in myocardial infarction or injury). Here, the authors build a reference aimed at providing a roadmap for protecting the post-surgical patient against life-threatening cardiac events. Topics of coverage include the epidemiology of perioperative cardiac complications; pathophysiology of ischemic heart disease; management of ischemic heart disease; the mechanisms of perioperative myocardial injury; arrhythmias and the surgery-bound patient; heart failure and the surgical patient; diagnosis of perioperative ischemia and perioperative infarction; and adult congenital heart disease in the surgical patient. This reference is vital to the ever-evolving canon of scientific literature because it teaches both surgeons and clinicians how to properly assess cardiac risk in the surgical patient (while simultaneously providing pertinent direction on strategies to adequately manage high risk individuals who present with myriad complications). Notable for its in depth presentation and for the authors’ adroit writing style which coveys information in clear and economical terms (rendering this a resource that can be applied to the direct care of patients who find themselves at the threshold of the operating room).

by John Aiello

ADVANCED DRUG FORMULATION DESIGN TO OPTIMIZE THERAPEUTIC OUTCOMES. Edited by Robert O. Williams III. David R. Taft. Jason T. McConville. Informa Healthcare.

This volume includes chapters on both cardiovascular pharmacology and immunosuppressant drugs, the latter examining the affect suppression of the immune system by pharmacological means has on the transplantation patient (as well as on those with other auto-immune disorders). Since the question of how to stave off the body’s rejection of a donated organ is one of the greatest hurdles a transplant team faces (and because the shortage of viable organs has made “marginal donor” procedures much more common-place), there is now a clear and precise need for better formulation design in immunosuppressant drugs (in order to improve the patient’s chances to tolerate transplantation surgery and its aftermath). Readers will find this text comprehensive in scope – this authoritative voice offers penetrating evidence that affirms the fact that smartly designed drugs (together with a clinician’s ability to prescribe the right medicines at the right time) offers those in the throes of serious illness renewed hope for the future.

by John Aiello