Hepatitis C. The opioid epidemic. Two devastating health crises that have affected the whole country and, unfortunately, my family as well.
The national numbers are staggering. Over 70,000 deaths by overdose in 2017 alone, mostly due to abuse of heroin laced with synthetic opioids like fentanyl. The vast majority in young people who are otherwise healthy and, in a ghoulish twist of fate, ideal organ donors. The traditional hesitancy to take donors of this sort has been overcome, largely though the insights provided by several studies that demonstrate outcomes at least as good as that seen with traditional donors. And these good outcomes make sense, especially to those of us who have seen reasonably healthy people stop breathing after getting carefully titrated doses of fentanyl and be brought back to life with fairly simple interventions in most cases.
No big deal if done in the operating room, bronchoscopy suite, or intensive care unit. Another matter altogether if done in one’s living room.
This is an issue of healthy people taking a drug that hangs around their system long enough to kill them but not long enough to cause end-organ failure that would prevent successful organ donation. I suppose the only silver lining to an otherwise dark cloud that has become a national tragedy and has devastated so many families and communities.
The hepatitis C story is the same, but different, perhaps a bit more hopeful. As has been widely published in the transplant literature, and our readers are no doubt aware, donors with hepatitis C, both viremic and non-viremic, are now being accepted and used for waiting patients who are not infected with hepatitis C. This practice is a departure from the more traditional strategy of mating hepatitis C recipients with hepatitis C donors, a group that in the last several years has comprised 5-8% of the donor pool nationally and even as high as 15% in certain urban areas like San Francisco and New York. This is different, a departure from the norm, a bucking of conventional wisdom.
The transplant community can use these organs comfortably because of the advances in hepatitis C therapy, making us all more confident that we aren’t giving hepatitis C negative recipients a fatal disease by transferring the virus to them through infected organs, all in an effort to save them from their primary life threatening disease that got them on the transplant list in the first place. This is a positive development, resulting from the massive devotion of resources and effort by the public and private sectors towards a disease that was clearly heading out of control.
What does this all mean for the transplant community? A few things. First, these two national health crises have provided the transplant community an opportunity to expand the donor pool Our efforts at exploring new ways to utilize the existing donor pool are important initiatives, and traditionally have resulted in two things: saving more lives while being able to embrace some risk. The transplant community has always been a bold group and one that is at its best when leaning forward. We should remember that. Let’s continually look for the next opportunity to utilize more of our donor organs. Second, it’s okay to say, especially with regard to using organs from opioid overdose victims, that we have found a way to honor the person that died, the person who succumbed to a horrifying societal heath calamity, whose family met unbearable tragedy. We in the transplant community have found a way to save people’s lives while at the same time understanding the suffering going on across our country. We can do both at the same time. By having a family chose organ donation, helping us save other people’s lives, we may be providing these families the only comfort they are likely to get any time soon. Let’s remember that. Third, the donor parameters that we consider “contraindications” today may very well not be tomorrow. We should challenge the conventional wisdom wherever possible, in all aspects of what we do, because most of us know: when it comes to transplantation, much of what we do is derived from “data-free zones” and we therefore are left to rely on our good judgement or, more importantly, ability to challenge established guidelines and ask the most important question, “What if…?”