Once David Mulligan, MD, chose to become a transplant surgeon, his field became his passion—both in and out of the operating room. Dr. Mulligan has made important contributions to transplant surgery. The field itself is a complicated puzzle with pieces that include finding ways to refine surgical techniques, personalizing immunotherapy, and, most of all, procuring transplantable organs.
There are more than 114,500 people in the United States on transplant waiting lists. A new person is added every 10 minutes, according to the United Network for Organ Sharing (UNOS), which updates the exact number daily. In 2018, there were more than 24,000 transplants, according to data updated in September. On average, 20 people die each day waiting for a transplant.
“Even the best health care in the world won’t help people who spend years waiting for an organ and who may get sicker and even die long before an organ becomes available to them,” says Dr. Mulligan, who is the chief of Yale Medicine Transplant Surgery & Immunology, and director of the Yale New Haven Transplantation Center, which is known for its work in liver and kidney transplantation.
Dr. Mulligan answered our questions about efforts to improve outcomes for people who need organs.
What are we doing to improve organ transplantation?
There are a lot of efforts. There always have been. Thirty years ago, when transplantation was first being established as a successful treatment, we focused on finding the right medications and immunosuppression agents (which keep the body from rejecting the transplanted organ). Since then we’ve minimized time spent in surgery and shortened hospital stays. We now have excellent long-term survival. For kidney transplants, the expected survival at one year is 98 percent, and we expect these patients to live 30 or 40 more years. For liver transplants, we expect similar results, certainly 10 years or more.
But there are still many people you can’t help.
Yes, and that’s because too many people wait for years to get an organ. In this part of the country, it’s an average of five years for a kidney—in other parts, it’s 10 years. One thing we’ve done is change how we prioritize organ allocations, to help the sicker patients earlier. But it’s a rough roller coaster for them. There are ups and downs: They get sick, things plateau for a while, and they can crash.
Has this changed your approach to organ transplantation?
Our Living Donor Program is the most important thing we’ve done in response to this issue. We pair living organ donors with recipients, which can be like a puzzle. For instance, a paired kidney exchange involves taking several donor-recipient pairs and trying to match the right donor with the right recipient, so their blood types and antibodies fit together. For liver transplants, you have to think about the size of the donor’s liver and the size of liver the recipient needs, and other factors. But this program allows people to get a transplant before they become so ill. The organs are healthier, so patients have a better outcome and live longer. And we provide long-term support for the donors—in fact, we are the first academic medical center in the country to provide community-based support and free lifelong medical monitoring for any health-related issues that arise for someone who is a living donor here at Yale. We’ve transplanted more than 1,132 living donor kidneys and 88 living donor livers at Yale.
In what other ways are you becoming creative?
We are transplanting more organs that we used to think we couldn’t use. When I was training to be a transplant surgeon in the mid-90s, the donors were typically young people in their 20s or 30s who had died from head injuries in automobile accidents or other traumas. They hadn’t had any other medical problems. But as the need grew, we started expanding the donor pool—with donors who were older, who were recovering from drug addiction, or who had died from heart attacks and strokes. The average donor now is in their late 50s.
And donors can be even older than that, correct?
For kidneys and livers, we routinely use organs from people who died in their 70s, sometimes even in their 80s. Not every transplant center will do this, and not every one of these organs is usable. This is where judgment comes into play. We also need good timing and teamwork to transplant the organ into the recipient quickly. When a kidney or liver from an older deceased donor is determined to be usable, we can expect a reasonably good outcome about 50 to 70 percent of the time. The organ may not function as long as it would if it came from a younger person, but it can allow us to take a patient off of dialysis sooner or avoid liver failure.
How is it possible to transplant these organs that you once considered unusable?
We’ve done and continue to do a lot of research in this area. When a prospective donor dies, one thing we do is take the organ out of the body and put it in a perfusion machine (which pumps solutions that help preserve the organ during transfer). We’re studying warm and cold perfusion, and the agents that need to be in there to optimize the function of the organ. With the liver, we’ve also learned that the older the donor, the more difficult it is for the organ to regenerate or recover once it’s taken from the donor’s body. We are looking at ways to speed up regeneration, then transplantation of that liver into the recipient, so that the organ will work more efficiently in the recipient.
Is it true that the opioid epidemic is resulting in more organ donations?
Yes. There are young people who inject a substance like heroin into their system—often for the first time—and overdo it, and they go into cardiac arrest and don’t always recover. (We also see people who have abused substances for a long time, but the more experience they have, the more they can regulate their habit so they don’t overdose.) But the early adopters still have healthy livers, and people need those organs. These young people are dying tragically, but we are turning these tragedies into legacies as much as we can. This has pushed us from 8,000 to almost 10,000 donors a year in the United States.
But there are still many people on the waiting list. How do you give them hope?
It’s tough. But we’re taking a more proactive approach. We’re changing our mindset to think more about building communities that emphasize living donation and finding the best ways to connect anyone who needs a transplant with a potential donor. Our Living Donor Program has been a pioneer in building a community of living donors who will support people considering this act of kindness, demystify the experience, and provide emotional support to those who are recovering from donating an organ.
Are there “outside the box” tools patients can use to help find a donor?
One big tool is social media. It’s not always something our patients are familiar with. Maybe they’ve done a little browsing on Facebook to keep up with the family, but they’re not actively using it or Twitter and Snapchat and Instagram—all of these platforms where people can make statements. They can say “I’ve developed a liver disease, and I need a transplant. If anyone is interested in being a donor, please call this number.” I would love to gather as many donor stories and experiences as I can and distribute them to help share the joy that these amazing individuals have given to others. It would be incredible for interested people to connect with engaged donors to ask questions or hear more about their experiences.
Are you doing research now that will make future organ transplantation easier?
Definitely. One thing we’re studying is how to generate a new liver from a person’s own cells. The ultimate goal is to replace the liver without ever having to go through this process of procuring an organ. We want to see if we can actually grow organs for people out of their own tissue regeneration in a matter of a few weeks. Then, we won’t even need immunosuppression. So, I think things are going to look a lot different.
So if someone wants to be an organ donor, what is the first step?
You can express your wish to become a donor when you receive or renew your driver’s license, or you can register online at Donate Life America. You can learn more about becoming a living kidney or liver donor by calling the Yale New Haven Transplantation Center at 203-785-2565. Call us at that number with any questions at all. We’ll be happy to talk about this.