Laura Lladó, surgeon: ‘The population should not have the perception that they are going to have a pig’s organ implanted’

On February 23, 1984, the first liver transplant was performed at Bellvitge Hospital in Barcelona, at a time when only four teams in the world carried out the surgery regularly. Nearly two decades later, in the same hospital, a young 35-year-old surgeon performed the first transplant of her career. She doesn’t recall the patient’s identity — only that he was thin — but she does vividly remember how she felt in that moment: overwhelmed with emotion and thinking of the most important people in her life, imagining their pride in seeing her in the operating room.

That surgeon was Laura Lladó, 54, a liver transplant specialist who today is the Head of Hepatobiliary Surgery and Liver Transplantation at this trailblazing Catalan hospital. Last year, she achieved another milestone, becoming the first woman in 40 years to be named president of the Catalan Transplant Society (SCT). She is also a member of the Scientific Committee of the Spanish Liver Transplant Society and serves on the editorial board of JAMA Surgery, the surgical journal of the American Medical Association.

Lladó can’t pinpoint exactly why she chose to focus on transplants, but after more than two decades in the field, she’s certain it was the right decision.

Q. This year, the first successful transplant with a genetically modified pig kidney was carried out. Are these the transplants of the future?

A. Ever since I’ve been in this field, I’ve always heard that the future of transplantation is xenotransplantation [organ transplantation from a non-genetically related organism that requires genetic modification], and I have the feeling that this future has yet to come. There are advances today that we couldn’t have imagined 20 years ago, and in the past five years, significant progress has been made in xenotransplantation, particularly in genetic manipulation. But it’s very complex.

Q. Why?

A. The development and ethical aspects of the process are far from straightforward. For now, there are other alternatives, and the safety and effectiveness of this procedure remain in question. Offering it to a patient who has another option, especially in a country like Spain, where the mortality rate for liver transplant waiting lists is below 5%, is not something I would consider. Xenotransplants are still in the developmental phase. We must continue working and advancing in this field, but I don’t believe it will become the definitive solution

Q. It could change citizens’ ideas about donating human organs.

A. The public should not have the perception that they will be given a pig’s organ. Xenotransplantation will be one more thing, which is always helpful, but it is very important that it adds to the solution and does not detract from it. Spain’s donor pool is its greatest treasure, thanks to investment and the presence of hospital coordinators who are trained to help families understand that every donor can save the lives of up to six [different] people. If we standardize this understanding through the media, schools, and institutes — helping people realize that when someone’s organ fails, another can be used to replace it, and that we all need to be donors — we would have far more donors than we would through xenotransplantation or any other alternative.

Q. Even so, Spain is a world leader in transplants, far ahead of neighboring countries such as France, Italy and Germany, and the European Union average. And donations continue to rise.

A. A fundamental change has been the increase in donations after circulatory death [donations that occur after the irreversible cessation of cardiopulmonary function]. More and more people understand that when a family member is in an irreversible situation, no additional measures will be taken to unnecessarily prolong life or keep them connected to a machine for 15 years. Families are more accustomed to saying, “This is as far as we go.” This has become a source of donations after circulatory death. There have been more advances in this area than in xenotransplantation.

Q. So the famous “Spanish model” still works.

A. For two fundamental reasons: investment and training. In a hospital, there should be people dedicated solely to educating families, not someone who does this in addition to their regular duties. There should also be coordinators focused on finding donors. These individuals must, in turn, be well compensated. The Spanish model began many years ago with the understanding that this is not an extra task. If an intensivist or neurologist, after a full day of work, is tasked with finding donors, it won’t work. However, if someone arrives at the hospital with the sole goal of locating and selecting donors, it will.

Q. But it’s not a perfect system.

A. Currently, in healthcare, everyone is overwhelmed with work. If we want improvements, we must continue investing in people, ensuring there are full teams dedicated to increasing the number of donors. We need to take care of the teams, from the surgeon to the nurse. In the Spanish Society of Liver Transplantation, we conducted a survey on burnout syndrome among transplant teams, and the results are concerning. There is a strong sense of exhaustion, of tremendous effort. Teams are finding it difficult to recruit people who want to dedicate themselves to this work, whereas in the past, it was almost like winning the lottery.

Q. And this isn’t the case anymore?

A. At first, transplantation was considered elite, the most innovative procedure. Now, it is a standard surgery, but it still requires a great deal of dedication and availability on call for many days. It’s very challenging to find a 35-year-old person willing to be on call for 15 days, ready to go to the hospital at any moment. To achieve this, these individuals must feel valued. In the survey, financial compensation wasn’t even the main issue; rather, it’s about achieving a stable, balanced life with proper work-life balance.

Q. What will be the next big advance in transplantation?

A. The ability to manipulate, such as altering the metabolism or fat content of organs, for example. This can be done with medications or in perfusion machines [the process of circulating a fluid through the circulatory or lymphatic system of an organ or tissue] to perform various manipulations that, for instance, reduce the fat in a graft. Essentially, manipulating the organs to ensure they function better.

Q. Are you referring to genetic modification?

A. Not just genetics. There can be genetic changes, but also metabolic ones. For example, a big problem in liver transplants is that, more in the United States, but also in Spain, with excess weight or obesity, the livers have a lot of fat. Fatty livers do not function well. There is a significant opportunity for improvement in reducing the fat content in these grafts, in these organs, so that they function better. Metabolically modifying them in machines with various substances is one way to recover organs and, also, to ensure their proper functioning.

Q. And also to reduce the risk of rejection?

A. Currently, the tools to prevent or treat rejection are very broad and highly effective. We’ve made significant improvements in reducing the risk of death, hemorrhage, and technical complications. Rejection is now much better controlled. This has led to changes in the profile of transplant patients and the types of complications. There are fewer technical complications, but the patient profile is now older, often with cardiovascular issues. The management of these patients has become multidisciplinary.

Q. And what are the complications posed by this new transplant profile?

A. The two most important causes of mortality risk in transplantation are the development of tumors and cardiovascular issues, both related to immunosuppression. To improve this, it is essential to manage immunosuppressive drugs effectively, as they prevent rejection but can sometimes influence [other processes].

Q. Manage in what sense?

A. Measuring the exact amount each patient needs to prevent rejection is challenging. A major area of research is learning how to administer the right dose to each individual — enough to prevent rejection but not cause complications. This is something that is not measurable at present. If we could achieve this, we would prevent many of the causes of death among transplant patients today. The focus should be on advancing the management of immunosuppression, not just the drugs themselves, but in determining the correct dosage for each person and assessing their immunological response.

Q. Could artificial intelligence play an important role in this process?

A. There will certainly be algorithms that, with data, will improve the selection of both the donor and the recipient. The donor selection process is based on a set of information that is limited for the human mind. AI will have its applicability [in this process]. For example, in what is called matching, determining which organ is best suited for each recipient. Or in determining what we call the rejection parameter. The prediction of rejection with artificial intelligence, using much more data, could help deduce the risk of rejection for a patient and allow for better adjustment of immunosuppression.

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