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Organs: Supply and demand

As you read this, more than 80,000 Americans are waiting for transplants - with no guarantee that organs will become available in time to save them. If today is typical, 16 will die by midnight.

The waiting list - 2 1/2 times larger than it was just a decade ago - isn't all bad news. It stems in part from the growing success of transplant surgery and, with that, the increasing tendency of doctors to recommend patients for transplant surgery.

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But experts worry that disease trends, along with an aging population, will only widen the gap between the supply and demand for organs - leaving thousands more desperate for help that might never arrive.

"Epidemics of morbid obesity, hypertension and diabetes hold the potential to drive the need to higher levels," said Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations. Last week, the group announced a nationwide campaign to boost donations.

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In 1993, doctors performed 17,600 transplants, and the year ended with 31,000 people waiting. Last year, the number of transplants exceeded 25,000 while waiting lists swelled to more than 80,000, according to the Richmond, Va.-based United Network for Organ Sharing.

The problem is particularly acute for African-Americans, who suffer disproportionately from high blood pressure and diabetes, diseases that trigger kidney failure.

"Our kidney waiting list in Maryland has more African-Americans on the list than any other group," said Charlie Alexander, interim director of the state's Transplant Resource Center. "The minority is the majority."

The Joint Commission's call to action wasn't without precedent, coming nine months after the U.S. Department of Health and Human Services launched a similar effort.

The groups are urging public education to topple myths about organ transplants, including the belief that doctors won't try as hard to save patients who have signed donor cards.

Dr. Clive O. Callender, chief of surgery at Howard University in Washington, said the myths are not unique to any group but run particularly deep among African-Americans, some of whom distrust hospitals because of past discrimination.

Transplant groups also hope to boost donations by focusing recruitment on hospitals that treat the most accident and stroke victims.

Those patients are more likely than others to meet criteria for organ donation, which require brain death along with mechanically sustainable breathing and circulation.

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Five hospitals in Baltimore are considered high-potential facilities. Each has worked to meet the federal goal of "converting" at least 75 percent of potential donors into actual ones.

Many have met the goal or are well on their way: In the first six months of this year, Sinai's rate was 56 percent, while the University of Maryland Medical Center reached 67 percent; Johns Hopkins Hospital, 78 percent; and Johns Hopkins Bayview, 80 percent.

Leading all was the Maryland Shock Trauma Center, 100 percent.

Though brain-dead patients can be sustained on machines indefinitely, there is a narrow window before cells start breaking down and organs become useless. Once a patient is declared brain-dead, transplant groups have as little as a day to gain a family's permission, conduct lab tests, find a match and arrange for surgery.

"We're really running against the clock," said Kimmith Jones, a Sinai nurse who is part of a team trying to boost organ donations at the hospital.

Under federal law, families cannot override the wishes of patients who have signed donor cards. But transplant authorities generally don't push the issue if the family opposes and the patient cannot speak for himself.

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Even so, approaching families requires a delicate combination of sensitivity and persuasiveness.

Patricia Tellmann, an official with the Maryland Transplant Resource Center, said representatives first try to help families through their grief, often to the point of advising them how to find a funeral home or register the death with Social Security.

Only when the family seems emotionally ready does the representative broach the subject of organ donation. If the patient is a registered organ donor, the liaison might inform the family of this and ask for help preparing a medical and social history - rather than asking first for permission.

"It's very infrequent that a family says no," Tellmann said.

Gloria Marrow, board chairman of the Transplant Resource Center and a history professor at Morgan State University, said the group reaches out to all communities - but particularly African-Americans.

"We find they don't donate as quickly because of historical reasons and some religious reasons," said Marrow, whose husband, James J. Marrow, lived five years after receiving a heart transplant in 1988.

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Gloria Marrow said she has worked with African-American churches and service organizations to raise support and dispel myths. The efforts, which have also included radio and television ads, seem to be paying off.

"Since our recent efforts, over half of the African-American families we've spoken to consented to donation and helped save the lives of fellow community members," said Alexander, explaining that the rate was about 40 percent not long ago.

Black patients on waiting lists continue to face steeper odds than Caucasians. In the case of kidney transplants, preference goes to patients who share all six "surface antigens" with a particular donor. These are proteins on the surface of cells that play a role in whether a recipient accepts or rejects an organ.

Dr. Clarence Foster, a transplant surgeon at the University of Maryland Medical Center, said it is less likely that an African-American patient will be a perfect match for a given organ. As a result, an organ donated by a Baltimore donor could go to a perfect match in Michigan rather than a patient who lives down the street but scores only a "5."

African-Americans have also suffered historically poorer survival rates after transplantation - largely caused by higher antibody levels that predispose them to rejecting a new organ.

But, said Foster, doctors get excellent results with black patients by giving them slightly higher doses of immune-suppressing drugs.

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"Ninety-nine percent of the acute rejection episodes are treatable," said Foster, himself an African-American. "There is no reason not to transplant [to] an African-American."


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