This issue of Pediatrie Annals addresses organ transplantation in pediatrie patients. Our guest editor, Herbert T. Abelson, MD, professor and chairman of the Department of Pediatrics at the University of Washington, has focused on kidney, bone marrow, and liver transplantation. The authors of the articles on these subjects tell us about the indications for transplantation procedures, the methods used to affect them, the difficulties encountered in achieving success, and the outcomes we can expect for our patients who are subjected to them.
Kidney transplantation in children began in the early 1960s1 and was followed by bone marrow transplantation later in that decade. It wasn't until the early 1980s when the then new immunosuppressive drug cyclosporine became available to complement corticosteroids that liver, heart, lung, pancreas, and small intestine transplantations became possible. The use of cyclosporine and newer immunosuppressive drugs and techniques to suppress T-lymphocyte activity have further improved the outlook for successful transplants, with survival rates of 50%, 75%, and 95% for as long as 10 years or more. Unfortunately, although survival will mean relatively normal functioning, it will abo be difficult, stressful, and costly for patients and parents.
Why should primary care practitioners be well informed about the intricacies of organ transplantation? The reason is that the list of diseases leading to early death if organ transplantation is not used is long and growing, and, while the incidence of each of these diseases is very low in any given practice, each and every practitioner will encounter at least one patient every few years who should be considered a candidate for organ transplantation. Success in organ transplantation depends on early referral of patients; too often, patients arrive at transplantation centers well beyond the point when optimum results can be expected or when transplantation can be implemented at all. Primary care practitioners need to think in these terms and be familiar with the indications for referral. They also need to know what their patients and their families will experience in the transplantation process so that medical and psychological support can be provided to them before and afterwards. Finally, because many patients who need an organ transplant never receive one for lack of a suitable donot, primary care practitioners should advocate organ procurement and assist in identifying potential donors and in implementing rapid organ harvests.
The number of organ transplants performed worldwide has grown rapidly in recent years. Transplants are being performed in medical centers in every region of the United States within reasonable distance of every patient in need. The United Network for Organ Sharing (UNOS)* reports that during 1990, these centers performed 692 kidney transplants, 548 liver transplants, 219 heart transplants, 7 heart-lung transplants, 6 lung transplants, and 8 pancreas transplants on persons under 20 years of age. Of these, 573 (39%) were performed on children under 6 years of age; children in this age group received the majority of pediatric-age liver transplants (333) and heart transplants (125). The UNOS has no data on small intestinal transplantation, a procedure still in its experimental phase in humans,2 or on bone marrow transplantation. However, the International Bone Marrow Transplantation Registry* reports that approximately 900 allogeneic bone marrow transplants were performed in the United States on persons under 20 years of age during 1990.
Some have asked the following questions regarding organ transplantation:
* Should we invest $40 000 to $150 000 per transplantation procedure when many other more common and equally life-threatening diseases are left untreated because of insufficient funds?
* Should we invest diminishing medical center resources in these costly procedures when space, equipment, supplies, and personnel for other critical patient care needs are left wanting?
* Should we subject patients and their families to the physical, emotional, and economic stresses associated with organ transplantation, which replaces one set of suffering circumstances for another and that may prolong life for only a short period of time?
* Should we involve our students in the provision of care for transplant patients when only a very small number of them will be required to provide such tertiary care during their medical careers?
The answer to each of these questions is "YES" because:
* We already spend these amounts of money on the treatment of other potentially fatal diseases of infants and children in our neonatal and pediatrie intensive care units and on patients who suffer from those diseases for which organ transplantation is recommended.
* We as physicians should not now or ever place ourselves in the position of allocating resources or determining who should and who should not receive the full scope of care available when there is a reasonable prospect of preventing death and offering some hope for survival with some quality in the life that is left.
* We are not capable of knowing what our patients and their families are willing to suffer or sacrifice in order to prolong life, even if that prolonged life does not meet our own definition of an adequate or a good one.
* We have been able over the years to improve dramatically the outcome of the diseases for which organ transplantation is used and of many other related fatal and nontatal diseases through the knowledge gained in organ transplantation.
* Finally, our students, regardless of their career choices, should be exposed to the full spectrum of pediatrie diseases so they can become informed about the caring and curing process for as many of those diseases as possible, even though they may be only peripherally involved with those patients.
1. Statzl TE, Marchioro TL, Porter KA, Paris TD, Carey TA. The role of organ transplantation in pediatrics. Pediatr Clin North Am. 1966;13:381-422.
2. Broyer M, Otte JB, Goulet O. Organ transplantation in children, intensive Core Medicine. 1989;15:876-T79.