Skyrocketing drug overdose deaths are adding to the supply of transplantable organs. Contrary to the beliefs of many—and their designation as “high risk” donors–these are often high quality organs from youthful people. Even organs carrying disease that never would have been acceptable before are now able to be used if recipients accept them.
- Dr. Michael Porayko, Chief of Hepatology and Prof. of Medicine, Vanderbilt University Medical Center
- Dr. David Klassen, Chief Medical Officer, United Network for Organ Sharing
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16-45 High Risk Organ Donors
Reed Pence: America has an opioid addiction crisis and it’s no wonder. Opioid drugs are extremely easy to get hooked on. Even among people who take opioid pain medications exactly as directed, about five percent will become addicted within a year. According to the centers for disease control and prevention, about two million Americans abuse or are dependent on opioid painkillers. Heroin users nearly doubled between 2005 and 2012. And some of those addicts unfortunately don’t survive.
Porayko: The death rates from drug overdoses have nearly doubled since 2003 with over 47,000 deaths in 2014 alone in the U.S.
Pence: That’s Dr. Michael Porayko, chief of hepatology and professor of medicine at the Vanderbilt University Medical Center. Many patients he deals with eventually need a liver transplant. Nationwide, nearly two dozen people on transplant waiting lists die every day for lack of an organ. For them, the tragedy of drug overdose deaths has provided a lifeline. Dr. David Klassen is chief medical officer for UNOS, the United Network for Organ Sharing.
Klassen: The number of donors that die related to overdoses has increased fairly substantially, particularly in the last two years. It’s projected to be about 11 percent of all donors this year, which is quite high. It’s been gradually increasing for a number of years, but really it’s been most noticeable in the last two years. It’s an increase that we weren’t really expecting and it has had a significant impact on the total number of donors for transplantation.
Pence: The proportion of organ donors who’ve died of drug overdoses has quintupled since 2003… And in some areas of the country such as New England, today they make up nearly a quarter of all organ donors. But some potential recipients are wary of accepting an organ from a junkie. And Porayko says some doctors are hesitant to transplant them.
Porayko: There may be some stigma associated with a donation from these individuals, which many would argue is probably inappropriately placed on these people, because when you look at statistics, we categorize these individuals as increased risk, and what we mean by increased risk is that there is some concern about whether the organ will do well in the recipient or that we may be transmitting another disease, such as hepatitis B, hepatitis C and/ or HIV. But in reality with our newer techniques of checking for organ viability and suitability and looking for these types of infections, we’re very good at ruling those things out.
Klassen: The issue for people dying of overdoses for donors is the potential for disease transmission and that’s what we worry about because they are at somewhat of an increased risk of potentially transmitting diseases such as HIV or hepatitis. Although the donors are screened extremely carefully for that, and in fact, the rates of those transmissions are exceedingly low. So although they might be considered high risk, the real risk is actually quite low. There actually has not been a transmission of HIV through organ transplantation since the 1980s.
Pence: But even if surgeons aren’t transplanting a disease into a recipient, aren’t the organs of drug abusers likely to be worn beyond their years by lots of hard living? Klassen says surprisingly, no.
Klassen: I think a lot of people make the assumption that somebody dying of an overdose really is not an acceptable organ donor, and that really is absolutely not the case. The people that actually are dying of overdoses in many ways are very very good donors in that they are relatively young, which affects the quality of donated organs, and they often don’t have a lot of associated medical illnesses such as diabetes or heart disease, things like that, because of their relative youth. So it does make a difference. We have ways of assessing the quality of donated organs, particularly for kidneys. It turns out that patients or donors that die from overdoses actually the quality of their kidneys are better than the general population of donors.
Porayko: We are, of course, very careful about accepting organs. We want to make sure that we are getting good quality organs for people even in a desperate situation. We don’t want to add to the problems that a sick individual has. Somebody’s got illness they are desperate for sure to survive, but we want to make sure we’re getting good quality organs so that they can survive and thrive and do well. So we have categories of individuals where we classify them as low risk or increased risk, and we have to talk to families about donor organs from where we perceive there’s increased risk to make sure that it’s acceptable to them.
Pence: Asking if a recipient wants an organ is a departure from usual procedure. Under normal circumstances with a low-risk donor, doctors accept organs that are a good fit without consulting the recipient. The assumption is they’ll take it. But Klassen says for high-risk organs, the procedure is different starting at the very beginning.
Klassen: When patients are listed on the computer matching system they do have to indicate whether they will accept what’s termed a public health service high-risk organ or not. If they say they they are not interested in that then the offer never comes their way. But if they do indicate that they might consider such an organ then the offer would go potentially to that recipient and then at the time the offer is made they would make a decision whether to accept it or not. They are not under any circumstances required to accept any particular organ. Recipients and transplant centers always have the option of declining any offer that’s made to them.
Pence: High-risk donors include a variety of people — more than just drug abusers.
Klassen: Patients who’ve recently been in prison, patients who have certain sexual histories and sexual contacts. There are a defined set of criteria that the CDC publishes. They are fairly extensive, but it really revolves around sort of social risks related to potentially virus transmission, particularly hepatitis and HIV.
Pence: For high-risk donors like that, doctors consult the potential recipient before accepting an organ. That’s required. But what the doctor says is up to them. Some are a little less specific about the risk than others.
Klassen: The content of that discussion isn’t defined except that is has to take place. So I think each conversation between a potential donor and the transplant program depends on their ability to asses what the patient needs to understand. I think in these cases where we’re talking about these PHS high-risk organs, I think the conversation gets generally fairly specific. And the transplant program almost always discloses exactly why a potential donor organ is labeled as a higher risk.
Pence: Klassen says most transplant centers are comfortable dealing with high-risk organs, because the risk really isn’t as high as the term makes it sound. But recipients can be another matter. Some recipients worry that a drug user may have contracted an infection within the last week or so, making it undetectable. But Klassen says that’s extremely rare.
Klassen: Testing is never 100 percent sensitive, but the testing these days through evolution in the technology really is very, very good. It’s possible to detect infections that have potentially developed within the last few days prior to death. So it really is quite excellent. These patients are considered high risk from a public health standpoint and they are classified as public health service high-risk donors and the recipients of those organs are required by UNOS policy to be notified of that, although again, the true risk is actually quite low.
Pence: But even the specter of a hepatitis or HIV infection is losing some power. Porayko says in the last few years, there’s been a major shift on the use of organs that test positive for an infection, and in the risk posed by a missed infection. What’s perceived as tolerable risk is changing.
Porayko: Even in those individuals where we may miss an infection we have the opportunity to treat the patient after transplantation. We are actually in the process of using organs in individuals. We just in our own program here — an individual who does not have hepatitis C received a heart from somebody who is positive for hepatitis C. We’re actually giving that individual hepatitis C and in the past we would have never done that. But our medications are so good now, our antiviral medications against hepatitis C are so good at eliminating the virus that we are now accepting an organ with an actual infection that we would have never accepted before, and we can almost be reassured that we will clear that virus and the patient will do well.
Pence: But will a recipient be convinced of that? Would they consider an organ that’s even riskier? Doctors today are considering organs you’d be surprised about. But Porayko says whether those are used depends on how desperate the recipient is.
Porayko: If you came to a recipient and said, “Well, this individual has HIV and we realize you’re desperate. We have medications that can control, but not cure HIV. We’d be willing to move forward as long as you are willing. I think that’s the situation where someone would be hesitant if they felt that they had a little bit more time to wait for a more optimal organ. I’ve seen this happen even with hepatitis B. Hepatitis B right now is a virus that we can suppress, but not cure and individuals will have to think about that in the setting of their underlying disease. So if they have more time to wait, they are not critically ill, I have seen individuals say, listen, I’m not going to take that organ because I think I have more time. I’m going to take a little bit more time to see if we can get something that’s not infected.
Pence: However, Porayko sees both doctors and patients becoming more comfortable talking about the use of organs that would have been rejected out of hand not long ago.
Porayko: We clearly need more organs. There are plenty of recipients sitting on lists nowadays waiting for organs and desperate for organs, and yet we’re letting a population of individuals who are donating go by. Now, I’m just seeing this in my colleagues who are doing renal transplantation and I gave the example of heart, they’re all of a sudden saying, jeez, we’ve got patients who have been waiting years for an organ, they are desperate and now you’re saying, oh, we can clear hepatitis C, well, huh, we’re going to start looking at those organs more seriously. So that’s just evolving right now. So I think in the future we’re going to see better utilization of these organs. There needs to be education to say, listen, this is okay. We can do this. We can utilize these organs successfully and not have to worry so much about infecting their patients.
Pence: When patients are desperate for survival and chronic diseases like hepatitis C and HIV are manageable, risky organs are much more worth taking a chance on. Even an infected organ is better than none at all.
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I’m Reed Pence.