Is there a growing crisis in organ transplantation?
Crisis is perhaps the wrong word. There is a permanent discrepancy between the numbers of patients we would like to transplant and the numbers of organs available for those patients.
How does this manifest itself?
In terms of renal transplantation, what we see is very large numbers of patients --thousands -- sitting on waiting lists and waiting in dialysis units. For heart and lung transplantation, where the numbers of transplants are much smaller, we see patients dying before they receive one. At the present time on our own waiting list, if you have cystic fibrosis there's a 40 per cent chance that you will not survive to get your transplant.
Why has this situation developed?
Transplantation has become very successful. We've developed a very successful treatment for increasing numbers of patients, but the numbers of organ donors is for very good reasons steadily decreasing. The numbers of patients who die abruptly and tragically of head injury or intercerebral bleed is mercifully going down.
Where do you find the organs that you need? Is the living donor concept something that should be encouraged?
To answer your first question, we could increase the number of transplants we do with organs from brain dead patients if we could persuade all of their relatives to consent to organ donation. At the moment something between 20 and 30 per cent of relatives, when faced with what is a very difficult question, refuse donation. And we could do a lot more transplants with those extra 30 per cent of organs.
How do you persuade that 30 per cent to take a different view?
I think we need to persuade the public as a whole that organ donation is a good thing. One way of looking at it is to regard the occurrence of severe brain injury -- of intercerebral haemorrhage resulting in brain stem death -- as something that's completely black, something that's completely negative, but organ donation is a means of producing a little light in that otherwise completely bleak picture.
Unless they agree to a donation, someone else will die as well . . .
Well that's one way of looking at it. It's a means of bringing a little bit of good out of a completely black position.
Can you talk about kidney transplants?
Certainly if we had more consent for organ donation in the conventional fashion that would result in more kidney transplants. As well as the medical advantages kidney transplants have huge financial advantages. Transplantation's cheaper than dialysis. An alternative route would be to encourage live donation in kidney transplantation. The UK lags behind other European countries, and particularly North America, in the amount of live donation that's carried out, and I think there is scope for more activity in that area.
How do we achieve it?
I think there is already quite a striking interest in the media of live donation being carried out. The idea will begin to spread within the renal failure population, both medical and amongst the patients. People will come forward, people will be positive to the suggestions and we will see more live donation and kidney transplantation.
If somebody wants to put themself on a register as a living kidney donor, how do they do that?
I think the area of the unrelated, unknown donor is very difficult. One can understand very easily a family member wanting to go through what's still a painful operation, a big operation and a period off work in order to save another family member. We can understand a spouse wanting to go through the same or perhaps a close friend wanting to wanting to do it. It's a little bit more difficult to extrapolate that to somebody who is entirely unknown to the recipient.
So if someone wants to help Sarah the medical profession will make it quite difficult if that person is unknown to her?
I think the medical profession knows what the donor will go through and I think we would question the motives of somebody who was entirely unknown to that potential recipient.
Can you talk about lung donors? What about the case of Ron Johnson?
The donation of a lung by somebody such as Ron Johnson in this country, would be very difficult. We have a robust mechanism to examine unrelated donors - the ULTRA committee. There are biological advantages to having a donor from a family member, which you would not have if you went outside the family for that donation.
Can you talk about a lung operation?
Yes, we perform lobectomies, removal of half of the lung, every day of the week in the treatment of lung cancer. I would typically quote to a patient a two or three percent chance of dying as a result of that operation if I was doing that operation for lung cancer. Admittedly those patients will almost inevitably have been smokers and they're often in their sixties and seventies, but nevertheless the removal of half of a lung is a major operation. It involves a large cut in the side of the chest, it involves a difficult anatomical dissection to both produce adequate structures for the surgeon to perform the transplant and to leave all of the structures such that the remaining lung will function then. We know that if you make measurements of lung function about six months later there will be a permanent 20 per cent loss of the measured function. If you measure kidney function after removal of a kidney you can't detect any difference.
So where do we stand on long term transplantation in this country and what are the numbers?
With regard to lung transplantation in this country, we've made a number of advances over the past few years. We've standardised the techniques, so that the operation is now very successful at least in the short and medium term. We are doing somewhere between 150 and 180 transplants per year and the number is slowly increasing. The lung is very easily damaged and only about 20 per cent of potential organ donors are able to give us usable lungs. So we are clearly not performing anything like as many transplants as we would like. There are still 200 patients a year being born with cystic fibrosis in this country and most of them will die of lung failure in early adulthood so our current transplant activity is not even keeping up with the cystic fibrosis population, never mind the patients with emphysema and all the other lung conditions we find in transplantation.
How successful is a lung transplantation?
For a straightforward patient at the moment we can quote an 80 per cent one-year survival, perhaps a 60 per cent five-year survival and maybe a 20 or 30 per cent 10-year survival. It's approaching the sort of success we were achieving with heart transplants perhaps 10 years ago and the success rate is improving every year.
So the operation will become more and more common assuming you can find a source of more donors?
Yes, there are very large numbers of potential recipients for lung transplantation.
Where do you permit living donors to offer lungs?
Another exciting area is the prospect of taking lungs from living donors in lung transplantation -- we've just begun to apply this. By no means all sorts of lung disease are suitable for living donors, by no means even all patients with cystic fibrosis -- who are the best group -- are going to be suitable. But it clearly has a way for a substantial minority of those patients.
Why did the Americans allow Ron Johnstone to have the operation?
I suspect you'd have to say the British medical community is more conservative.
What's your view on the idea of persuading governments to change the law so that instead of opting in as a donor you actually opt out as a non-donor?
I'm not in favour of a scheme that would involve opting out of organ donation. It's been tried in small countries but I feel, and many other people in the transplant community feel, that it has potential problems in the in the United Kingdom. The voluntary aspect of giving is very important in organ donation and I think I would feel very uncomfortable if we took away that voluntary aspect.
How do you think the public's awareness of this issue can be raised?
To change society's attitude we need repeatedly to show the benefits of transplantation. We need to show the patients lying in a bed, maybe on a ventilator on oxygen, and then transformed by two new lungs. We need to reach a situation where when this catastrophe appears out of the blue, this terrible tragedy of abrupt brain stem death, organ donation is the accepted thing to do. We need to persuade people that it is the right thing to do under those circumstances.
What is brain stem death?
Organ donation takes place under very special circumstances, where the brain stem has died either as a as a result of trauma or as a result of haemorrhage or as a result of starvation of oxygen. Under those circumstances we can keep the other organs functioning and in reasonably good condition with a breathing machine and appropriate drugs until they be they can be removed, but with brain stem death we know that there is no prospect of recovery. We need to persuade the public that when that occurs and it's it occurs out of the blue it's a terrible tragedy but, when it does occur the right thing to do is to consider organ donation.
How as a society do we raise the level of awareness?
We need to demonstrate to society the benefits of transplantation. We need to show them these patients lying in their bed on oxygen, perhaps on a ventilator, transformed by receiving two new lungs, living for many years afterwards, going back to work, raising families.
So it's a move towards a more civilised society?
That's a pleasing way of looking at it.