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Interviews with Thoracic Surgeons, Lung Transplant

Talking about Transplant with Dr. R. Duane Davis

(Part of a series on the lung transplant program at Duke University in Durham, North Carolina)

Dr. R. Duane Davis is the Chief of the Lung Transplant Program at Duke, which is the second largest lung transplant program in the United States (after Cleveland Clinic which performed 154 transplants last year to Duke’s 117*).  During my visit, surgeons performed their 70 & 71st transplant this year, and will probably complete around 140 transplants before the year’s end.  Much of Duke’s success at becoming a high volume transplant center lays at the feet of Dr. Davis, who took over the program in 1994, after training with the famed Dr. Joel Cooper.  However, he credits many of his achievements to his training with several pulmonologists.  In fact, he reports that it was his collaborative efforts with pulmonologists that led to his initial observations regarding the frequency of gastric reflux among transplant patients.  (Later this was translated into the seminal work on the relationship between reflux / aspiration and graft failure**.) He cites this as one of the more important recent discoveries in the field of lung transplantation.

He estimates that during his career (thus far) he has performed around 750 – 800 lung transplants, making him one of the world’s more prolific lung transplant surgeons.

Dr. Davis is also responsible for several decisions that have distinguished Duke among transplant programs.

One of these decisions was the elimination of upper age restrictions for recipients.  Unlike many facilities, Duke does not limit eligibility for transplantation solely based on age. (Many facilities limit transplantation to patients in their mid-sixties or below.)  As part of this, he also rejects much of the ageism that is often implicit in transplant.  “If we have two patients, otherwise equally matched but one is 18-years-old and the other is 53, then everyone always wants to give the transplant to the 18-year-old,” he explains.  “It’s ageism to do that, particularly when research shows that the 18-year-old may not do as well [due to risk of noncompliance with anti-rejection meds. etc] so we need to carefully consider all of the factors before deciding,” he continues.  “It makes us all feel good to give it to the 18-year-old, but that’s not always the right decision.”

One of the other decisions is something we talked about in a previous post – the use of organs that other facilities have turned down, sight unseen.  He credits this decision with the short waiting periods for Duke patients compared with other patients nationwide.

Dr. Davis explains this policy along with other efforts to expand the donor pool.  “There will always be a larger demand than the supply, but by expanding our eligibility criteria we increase our likelihood of finding an organ for our patients.  As Dr. Davis explains, using traditional criteria, only about 10,000 donors are available every year, and in this donor pool, only about 17% of donations are lungs.  He believes this number should be at least 40%, and that many useful organs that could have been transplanted are discarded.  This is why Duke often sends their procuring surgeon on site to examine the lungs personally before deciding to reject organs for transplantation, if the lungs are otherwise a good match; (by size, blood type, etc.).  In an attempt to meet demand and extend the lives of patients that might not otherwise receive transplants due to the shortage of donors, Duke surgeons recently implemented a program to accept donors from cardiac death patients (where the heart has stopped beating.)  In traditional donor criteria, the patient’s heart is still beating at the time of organ retrieval.  However, this criteria severely restricts the amount of donors available.  As part of his efforts towards these ends, he reminds people of the value that organ donation has to help others, and encourages people to become organ donors.

During the interview, he also talks about breakthroughs in transplantation, such as the double transplantation of Laura Margaret, a 16-year-old with an immune deficiency disorder (bubble boy disease) who received a double lung transplant, followed by a bone marrow transplant from the same donor.  In particular, he sees this particular case as a gateway to future discoveries in preventing graft (organ) rejection.

Like most Lung transplant surgeons, transplantation is only part of what Dr. Davis does, he is also an accomplished cardiothoracic surgeon, and performs cardiac surgery (such as bypass surgery/ valve replacement and surgery for atrial fibrillation) routinely.  He states that he doesn’t have a favorite procedure, but he does have a favorite scenario.  “I love the Christmas transplant,” he explains, when a patient receives a transplant on or around the holidays, and I get to come out to the family after the operation, and tell them Merry Christmas.”  It really is a wonderful gift for the patient, he finishes.

** Surprisingly, even very large centers such as John Hopkins (24 last year), Massachusetts General (16) and Mayo Clinic (16) perform less lung transplants that we might expect.  Even UCLA only performed 50 lung transplants in 2010. (Information from Organ Procurement and Transplant Network).  Like many thoracic procedures, (as mentioned during discussions on esophagectomy and other lung surgeries) better surgical outcomes are linked to high-volume centers.  Whether this is a result of ‘practice makes perfect’ or is due to the fact that high volume centers like Cleveland Clinic and Duke are usually large academic centers with a wealth of resources is not entirely clear.  However, I would advise patients to use caution before seeking organ transplant at a center that does only a few transplants per year (less than 20- 30.) A recent study by Weiss et. al (2009) at John Hopkins places this number at 20, which as Dr. Mathew Hartwig noted during a recent lecture, is coincidentally,the three-year average [number of lung transplants] at that center.

* Future article planned for this topic.

More about Laura Margaret:

Double lung transplant saves teen’s life

Pioneer transplant surgery

Laura Margaret story

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About K Eckland

World of Thoracic Surgery is a blog about the work, research, and practices of thoracic surgeons around the world. It includes case studies, [sometimes] dry research, interviews with thoracic surgeons along with patient perspectives, and feedback.

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