Introduction - Professor Richard Kirk 2023

Professor Richard Kirk
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Multi organ transplants may be indicated when, in addition to the primary organ, another organ is failing. This is a common scenario in end stage cardiac failure when there is severe renal impairment and also in late Fontan failure when liver failure may occur. Multi organ transplants, particularly when they are combined (simultaneous), rather than sequential, generally lead to better short and long term outcomes than the primary transplant alone.

There is constant dilemma as to whether a significant functional improvement of the second failing organ will occur if the primary organ is successfully transplanted. If it is likely that the second organ will improve after the primary transplant due to better hemodynamics, then avoiding a combined transplant reduces the complexity of the procedure and releases the organ for another recipient.

Multi organ transplants however raise the ethical principles of medical need, utility (optimal use of organs), justice (equitable access to organs) and how to balance these competing principles. These ethical principles are particularly important in defining the organ allocation policies.

Multi organ transplants increase the level of complexity of transplantation requiring:

  • Professional collaboration and decision making from different teams
  • Expert assessment of the severity and permanence of damage to the secondary organ
  • Consideration of simultaneous or sequential (delayed) transplantation of the secondary organ
  • Excellent organisation at the time of transplantation and surgical coordination during organ implant
  • Balancing potentially competing organ requirements in the acute management in the ICU.
  • Agreement of protocols to manage the long term follow-up - especially immunosuppression

Finally it must be recognised that the scientific data underpinning current practice is weak - often single center retrospective outcomes on small numbers of patients. Even registry data (with all it's deficiencies) is also hampered by heterogeneous populations, age differences and small numbers. As an example the ISHLT registry which focused on multi-organ transplants in 2018, registered pediatric combined primary transplants with only 32 kidneys and 12 livers between the years 1990 and 2016. In 2016 they represented just 0.4% of transplants. The number of pediatric (and adult) heart-lung transplants is also very low - only 4 in 2016.
Last Updated: June 2023
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