Carlos Esquivel, MD, PhD: More Equitable Ways for Organ Transplantation

Carlos Esquivel, MD, PhD
Credit: Stanford University

There remains a major need for not only more organs suitable for transplantation, but better practices that allow more equitable decisions regarding organ transplants.

There remains many barriers in the US, including the fact that livers are only given to 1 recipient, rather than split into 2 separate units.

In an interview with HCPLive, Carlos O. Esquivel, MD, Pediatric Transplant Surgeon and division chief of transplant at Stanford Medicine Children's Health, explained why there needs to be changes in decisions on organ transplants in the US and how tools like artificial intelligence (AI) could help in the future.

HCPLive: How important is the Donate Life Month campaign every April?

Esquivel: It is very important. Having a month like this for organ donation is an effort to enhance awareness about the great need we have for donors to save patients to save adults, children, mothers, fathers, kids.

There are so many patients within the United States waiting for organs. More than 100,000 patients in the US are waiting for organ transplants, and also the mortality on the waitlist is significant. So this month is really important.

HCPLive: During the pandemic there was an increase in alcohol use in the general population. Are you concerned we are going to have an increase in the number of patients who need liver transplants?

Esquivel: This is a very interesting question and is not an easy question to answer. Certainly, alcohol is one of the indications for liver transplantation. But obesity is also has reached epidemic proportions in the United States and also in other countries. Because of the pandemic and maybe because of the discussion, we have had more donors than any time in the past.

And some of these deaths were due to the use of opioids to overdoses. And so, certainly there are more patients on the waiting list, but there is also more donors. However, it's not enough. We still have, as I said, many patients who died on the waiting list.

HCPLive: What are some of the challenges and barriers for pediatric patients who need organ transplantations and how has it changed over the years?

Esquivel: So we continue to struggle, and pediatric transplants accounts for less than 5% of all the transplants done in the United States. And so they formulas that have been created for a fair allocation of organs have been with adults in mind, just because of the sheer number.

So there are not that many pediatric donors. But if we get a pediatric donor, and the priority is to give these organs to pediatric patients.

So I looked at the mortality on the waitlist for pediatric patients here in the United States over the last 25 years and about 7500 children died on the waitlist.

So which averages roughly around 300 per year. And it's kind of plateaued. So I think that we have to change the organ allocation system. For instance, in Europe, every liver is splitable.

When I say splitable, it is because you can split the liver into two transplantable units. So one part will go to an adult patient, and the other part will go into a pediatric patient.

But we don't have this system in the United States. And so what happens is that a liver will go to the sickest patient. And sometimes the team feels that a split in the liver will put this recipient at risk, and therefore, the kid doesn't get a portion of the liver that could save his or her life.

The thing is that when there are not enough organs to go around, it's really difficult to have a fair system because some patients are going to fall through the cracks.

The other thing around this issue is that, for instance, if we do a kidney transplant in a 65 year old person and we get 25 years out of that kidney, that person can live up to 80 years, which is a full life.

But if we give that kidney to a three year old, and we can only get 25 years, that kid when it's 28 is going to need another kidney transplant.

And so I think if you're giving the organs to the sickest patients, sometimes we put the kids at a disadvantage, because sometimes the kidney they are going to get are not the best kidneys. It would be nice if you could just match. Maybe in the future with AI, we can have a better match of these organs with the recipients.

HCPLive: How is new technology changing things in terms of matching organs to patients?

Esquivel: AI has the potential to do that. I think we're just in the beginning, I think we have to change their entire paradigm, I think we need to make a push to have more living donors.

That has been a problem as well because in the US not until recently, if a person was going to donate, they had to take time off from work. They would lose income and the recovery would be rough also without any income. All these things have to change.

For living donors, there should be some sort of subsidy, so that they can go through the process, help a patient or a loved one, but also not to take a financial hit.

HCPLive: If you could change one thing in how organs are disseminated, what would it be?

Esquivel: I think it will vary from organ to organ. For livers, I would say it's every single liver should be considered to be split into two functional units. Technically, that's not that complicated to do and is being done in many other places.

And I think it will have a positive impact for kids on the waiting list.

The second thing would be the living donors.

And one thing that is a little bit is a controversial is whether the living donors should get paid a stipend. That has some ethical implications.

Artificial intelligence, maybe eventually we will have algorithms for a better match between donors and recipients.

And then the final thing is that we can do organ transplants without immunosuppression, without the risk of rejection, then these kids can keep these organs as long as they live.