We asked some of the top transplantation experts in British Columbia what the most significant advances in transplantation science and research have been over the last ten years. Here’s what they told us.
Steroids and cyclosporine made the modern era of transplantation possible, but both drugs have many side effects. Steroids cause osteoporosis, cataracts and elevates blood lipids level. It also interferes with normal growth and development of pediatric transplant recipients. Cyclosporine (and other related drugs collectively called CNI’s) result in cardiovascular disease and kidney disease. Steroid-free and CNI-free immunosuppressive protocols have now been developed that make use of new classes of drugs (rituximab, alemtuzumab, and eculizumab) that prevent immune cell activation using different mechanisms.
The past decade has seen development of devices that allow us to improve the condition of organs from deceased donors. Lungs that are not initially suitable for use can be repaired in an “Ex Vivo” (outside of the body) incubator prior to transplantation. Similar repair incubators now exist for hearts and liver. For people waiting for heart transplants, left ventricular assist devices (VADs) have become very small and non-intrusive. Inserting VADs into people waiting for heart transplants vastly improves their health while waiting, and in some cases allows their own heart to recovery sufficiently that a transplant is not needed.
Surgeons can now remove kidneys and liver segments from living donors with minimally invasive surgery. This laparoscopic technique tremendously reduces the recovery period after surgery and has increased the number of living donations.
A paired kidney exchange occurs when a living kidney donor is incompatible with the recipient, and instead exchanges kidneys with another donor/recipient pair. The paired donation transplant enables two incompatible recipients to receive healthy, more compatible kidneys from living donors. Canada has one of the largest and most effective national programs in the world.
We now have excellent anti-viral drugs for hepatitis C (HCV) and HIV recipients undergoing transplantation. In fact, treatment of HCV patients with current anti-HCV drug could reduce viral load sufficiently to prevent liver damage and the need for transplantation. Management of infections (including cytomegalovirus and BK polyoma virus) in other recipients have also improved so these serious infections are no longer life threatening.
The old methods of tissue matching (also called HLA typing) have been replaced by high resolution molecular typing that allows precise matching of donor and recipients. These technologies also allow early detection of rejection through monitoring levels of anti-donor HLA antibodies.
Matching donor/recipient blood type remains one of the first considerations in transplantation. However, for those donor/recipient pairs for which no other option is viable, methods now exist to remove the offending anti-blood group antibodies from the recipient. This enables living donor transplants that were previously impossible.