At the Department of Transplantation at the California Pacific Medical Center in San Francisco, we perform an average of 200 organ transplant procedures per year. Approximately 30 percent of those procedures are liver transplants, necessitated by the ravages of alcohol, autoimmune liver disease, metabolic disease and, most importantly, Hepatitis B and C. The proportion of patients undergoing liver transplant for hepatitis C has increase from 20% to greater than 50% of our patient load. Although our one year survival as published by UNOS stands at 97.6%, we are frustrated by the average wait for a donated liver organ in the San Francisco Bay Area which is now up to 17 months. Our expectation is that the numbers of Hepatitis C patients requiring a liver transplant will increase markedly over the next ten years.

Dr. Robert G. Gish, MD
Hepatology and Gastroenterology
Department of Transplantation
California Pacific Medical Center
San Francisco, California

Emergency Room Physician
I've worked as an emergency room physician in Northern California for eleven years, and I am sure that my experiences are similar to those of critical care doctors and emergency room doctors throughout the country. Trauma victims make up the majority of organ donors. They are people who one minute are healthy and the next minute have suffered a catastrophic injury. Family members are often in a state of shock after hearing the news and trying to comprehend an overwhelming situation. At some point in the discussions we then try transition to "and there's one more thing I would like to discuss with you." At that point, we ask if the person had ever discussed his wishes regarding organ donation. Usually, the answer is no. In rare instances, the reply is "yes, he definitely wanted to be a donor and wrote it in his will," or "yes he would not have wanted donation." It is not unusual to for the family to say no he never discussed it, and then the victims drivers license is produced with the organ donor designation, unbeknownst to the family. In the majority of cases where is was not both explicitly written and discussed with family members, families will choose not to donate. It is a huge decision for a family member to make in a time or crisis and grief. If you are serious about donating your organs if the situation arose, and also would like to spare your family
a "what would he have wanted" decision, it is crucial to lay down the appropriate groundwork ahead of time. State you wishes in your will or other signed document. Get the designation on your driver's license. Make your thoughts on the subject known to your family. And then, if you yourself have any second thoughts , try to imagine that you have been on a waiting list for a life sustaining transplant for two years, and suddenly got the gift of a lifetime, a call from the regional transplant center saying that it was your turn.

Dr. Howard Schwartz. MD
Chief, Emergency Department
Kaiser Vallejo Hospital
Vallejo, California

Clinical Researcher
Hepatitis C is the major indication for transplant in civilian and military health centers. The prevalence of HCV among military personnel is similar to reported rates in the USA general population, therefore we can expect greater need for medical care and liver transplantation in the future. The need for organ donation cannot be highlighted enough. It is imperative that we continue to encourage organ donation so that we are able to meet future challenges.

Colonel Maria Sjogren, MD
Chief, Department of Clinical Investigation
Walter Reed Army Medical Center

Veterans Administration Medical Center Gastroenterologist
It is the policy of the Veterans Health Administration to make liver transplantation available to all eligible veterans with complications of end-stage liver disease or acute liver failure.

Hepatitis C is the leading indication for liver transplantation in veterans, accounting for more than 50% of transplants performed. The outcomes of veterans following liver transplantation are comparable to those of non-veterans. Waiting times for organs at VA liver transplant centers are long, in part due to the referral of these patients from all over the country to 2-3 centers, but in greater part due to the critical national shortage of donors.

There have been two mechanisms for veterans to undergo liver transplantation 1) At one of three VA Medical Centers specializing in liver transplantation (Portland, Pittsburgh and Nashville) or 2) through sharing agreements between the VA and local University hospitals where liver transplantation is performed. Recently, liver transplants at the Pittsburgh VA have been halted, so that Portland and Nashville are the main programs. The patients are then brought to these medical centers for formal evaluation and if considered to be suitable candidates, are placed on the liver transplant waiting list.

Dr. Teresa L. Wright, MD
Chief, Department of Gastroenterology
San Francisco VA Medical Center
San Francisco, California

Heart Transplant Program Director Brooke Army Medical Center
As a heart transplant surgeon, I am able to witness the marvelous benefits of a "gift of life" offered by families in their time of deepest despair. I think it must serve as a small comfort that some good can be salvaged from a family's
greatest tragedy, the death of a loved one. I see the despair of the terminally ill heart patient waiting for an organ donor, yet knowing that that donation will only come at the time of someone else's great loss. Nonetheless I also have the marvelous experience of witnessing the transformation, literally overnight, of a chronically ill patient into a
heathy, happy individual with a future that they can share with family and friends. It is almost a miracle.

The military has one heart transplant program at Brooke Army Medical Center (BAMC) in San Antonio, Texas. We also have a liver and kidney transplant program at Walter Reed Army Medical Center (WRAMC) and Bone Marrow Transplant Programs at BAMC, WRAMC and Wilford Hall Air Force Medical Center. All of these programs have been very successful in providing their services to our military family. You may be surprised to learn that half of our heart transplant patients have been young active duty soldiers when they became ill. Cardiomyopathy, which is the leading cause of heart failure requiring transplantation, is a disease of young active people--many of whom develop it as a result of a viral infection. The rest of our patients are dependents of active duty soldiers and retirees.

We are proud, as military physicians, to be able to provide whatever medical care is necessary for our soldiers and their families. In this case, caring for that need requires the unselfish "gift of life" from families at the time of their most profound sadness. It is impossible to express our gratitude for such an act.

David J. Cohen, M.D.
Colonel, Medical Corps, US Army
Director, Heart Transplant Program
Brooke Army Medical Center
Parent, USMA Class of 2003