Interviewed by: Kritika Soin
Dr. Humar is a physician and Senior Scientist and Director of the Toronto General Hospital Research Institute. Over the years, he has made major contributions in the area of translational research involving viral transfections in patients who have received organ transplants. Furthermore, he plays an important role in the Canadian Society of Transplantation (CST), the American Society of Transplantation (AST) and The Transplantation Society (TTS). Furthermore, he is involved in several initiatives including strategic program development, fundraising, and organ donation advocacy.
What inspired you to get involved in the field of organ transplantation?
Dr. Humar: When I was doing my training, I had some exposure to organ transplantation and I realized that I wanted to do something that was on the cutting-edge of medicine, groundbreaking, and open to all sorts of discovery in science. Also, I wanted to do something that would change lives. When someone gets an organ transplant, their life transforms.
How has your experience been in the industry?
Dr. Humar: I finished my training about 20 years ago and it has been remarkable. The advances that have been made, even in the last 10 years, have been pretty amazing. Transplants have become a real lifesaving treatment. The majority of the patients do really well and can lead close to normal lives after their transplant.
In your Global News interview in 2015, you stated that there is a tremendous need for organs and tissues as many patients die while on the waiting list for an organ transplant. Do you think there is a way to overcome the demand for organs, such that there is a better ratio of organ availability to demand?
Dr. Humar: Right now, there is a huge discrepancy between the number of people who will benefit from a transplant and the number of people who actually get a transplant. This is because there are not enough donor organs. There are two main sources of donor organs: living donations and deceased donations. Living donations are usually made by friends and family where they typically donate a kidney or a liver. The main source of organ donations are deceased donations. Canada’s deceased donation rates are better than they were before, but they are still not nearly as good as some of the best-performing jurisdictions. This includes places such as the United States and Spain. Canada has improved. Ontario has improved a lot over the last decade but there is still more room for improvement. Despite that, even if the organ donation rate is improved, there will still be a shortage of donor organs because there are so many people who will benefit from it. Some of the other ways that we have been working on in our centre include looking at how to repair damaged organs. A lot of the time when we get organs from deceased donors, the organs are not usable because they are damaged, as the person has died. Whatever caused them to die often causes damage to the organ, so the organs are actually not usable.
So does that mean that not all organs will be viable?
Dr. Humar: No, many times they are. For lungs, 70% of the time they are not usable. For liver, 50% of the time they are not usable.
Is this because they were not retrieved in time?
Dr. Humar: It is more common that whatever process that caused [the donor’s] death resulted in an injury to the organ. We have been looking at ways to repair organs outside the body, which is called ex-vivo organ repair. This is where the organ is treated outside the body; it is hooked up to nutrition and oxygen and we try to assess its function. We try to repair the organs so that we can use organs that we were not able to use in the past. That is one way to increase the pool of available organs. Another way is to promote more people to register to be donors. There are a lot of times where there is a potential deceased donor and the family does not give consent. If we have awareness and cultural change, with respect to organ donation, that would help. A third way is to increase living donation rates. A lot of people do not understand what living donation is, so they do not know that they can donate a piece of their liver. They can donate up to two thirds and it would grow back to its normal size. They also do not know that they can donate one of their kidneys. There are a lot of patients with either kidney or liver disease and do not know how to ask other people; they do not want to ask their family or friends to donate.
Would there be repercussions for the living donor upon donating?
Dr. Humar: Not typically. The living donor has to undergo surgery and there are always risks associated with surgery. But we always put the safety of the donor as the number one thing. We have been very successful with both the living donor kidney and the living donor liver. Patients do well in the long run, though they have to get over the surgery first.
Would you say that the process for receiving an organ and getting permission to use it for a transplant surgery is long?
Dr. Humar: This depends on the type of donor. For a deceased donation, the process is not lengthy because usually there is not much time. The transplant team is not involved in the consent process. The consent is done by the organ procurement organization, which is the Trillium Gift of Life Network in Ontario. Once the family agrees to consent, we send a team to procure the organ. We go either by plane or by car. There are teams of people that go out to retrieve the organ for the surgeons. For living donors, we have more time. We go through a careful process of working up the donor. We ensure that the surgery is safe to do. It often takes months and therefore is a much slower process.
In general, what do you think are some barrier that living donors may encounter?
Dr. Humar: Awareness is one of them and it can be overcome through education. There are financial barriers too. For example, if you need to get a part of your liver removed, because it is a big operation you are in the hospital for five to six days. Then it takes several weeks to recover. That means you must take all that time off of work. If you live in a different city, then you must move and live close-by and there are costs to that. Then there are people who just do not have family members that are a match. They have to be a match, both a blood group match and for kidney especially, an immunological match.
Is public healthcare involved with financing this?
Dr. Humar: The healthcare is all free. Surgery, medication, and the stay are all covered. But it is the other stuff, such as taking time off from work, [that matters]. Not all employers cover expenses during this time. However, there are some programs in place that help to cover donor expenses. But, I think that they need to be fleshed out a little bit.
The transplant program at the Toronto General Hospital is the largest and deemed as the most comprehensive program in Canada. There are world-class experts involved in this program. As a chair of this program, how is this program currently spearheading scientific development?
Dr. Humar: We have combined the clinical part of what we do with the research part. We have those two arms working really closely together. We have a really large research footprint. For example, we have an animal O.R. [operating room] where we do animal models of transplantation. This way we can research new therapies and technologies. Because the research department is so closely linked with the clinical department, we are able to translate any research finding into clinical trials or clinical practice. This allows us to do research and make sure that it makes a difference in the clinical situation. We also invest a lot in research. All our physicians and surgeons also do research. Being a clinician, we know what the needs are for the patients and so we know what the right research questions are. I think clinicians who do research in science are a powerful combination. We supply a lot of funding to our researchers as well, either through grant support from government agencies, or through fundraising. Almost all fundraising dollars are used to support research for transplant programs.
It is known that you have made major contributions in the area of translational research involving viral infections in transplant recipients. Can you give me an insight into your research and how some things that you discovered can help reduce organ rejection?
Dr. Humar: My area of research has been in viral infection in transplantation. All the patients get immunosuppression or anti-rejection medication so that they do not reject the organs that has been transplanted. One of the main problems with that is that it knocks down the immune system. This is why they get all the unusual infections because they have an impaired immune system. My own research has been on this virus called CMV. It is a herpes virus related to the chickenpox virus. CMV virus is a common virus after transplantation. In our lab we developed tools to predict CMV and completed clinical trials to determine the best way to prevent and treat CMV. If you can prevent complications, it is easier to manage the anti-rejection pills and keep the organ functioning.
Are there certain lifestyle changes that must be made once a patient has received an organ transplant? Are there any restrictions/limitations that they may encounter as a result?
Dr. Humar: After the transplant, patients do need to be careful because their immune system is suppressed. They are at risk for getting an infection. The whole purpose of doing a transplant is to try to let them lead as normal of a life as possible. We encourage them to do as much as they can, but they have to take certain precautions. If they are travelling, they must make sure to get all their vaccines and take whatever antibiotics they need to take. Certainly, during the first six months to a year post-transplant they need to be extra cautious about being in large crowds. But overall, in comparison to the life these patients were leading before the transplant, their lives are much better. For example, patients who had failing kidneys were on dialysis and therefore made visits to the hospital 3 to 4 times a week. It is even worse for liver and heart patients who were bedridden. After the transplant they are able to go back to work and do all sorts of things that a ‘normal’ person can. In the first couple of months they must make frequent visits [to the doctor], once every week or two weeks. But eventually when they are better, they may only have to make visits once every year.
Do you think that our healthcare system is adequate for supporting families who need a transplant, in terms of treatment, post-transplant and financial support?
Dr. Humar: It is pretty good, I’d say. For example, all in-hospital care is covered by the health system. The medication is also generally covered through various drug plans. The anti-rejection medicines are also covered. But there is an issue for all the patients who have to relocate here. It is quite costly. If somebody comes from New Brunswick and needs a lung transplant, they have to physically live here for at least three months. This is because they do not do lung transplants in Atlantic Canada. The financial hardship of renting a place to stay is a huge problem. But it’s either that or the patient dies. There are assistance programs to help patients with that. They are not great, but are okay.
Is there a prevalence of mental health illness among post-op patients?
Dr. Humar: Yes, there are a lot. In our program we have two teams that deal with that. We have a social work team and a psychiatry team. They see all patients that have mental health issues after receiving their transplants. It is a huge issue. We must remember that oftentimes these patients have had chronic disease for many years. It is not an easy thing to go through.
Do you think there is something that we, the upcoming generation can do to help this crisis?
Dr. Humar: I think that the best thing you can try to do is to educate the public and create awareness and culture change around organ donation and transplantation. This can help dispel some of the myths that are out there. This is really an amazing thing. It is an amazing gift that donors give.