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For other articles and previous issues click here. June 20, 2005 Kidney Swaps —
New Hope for Those Waiting for a Kidney Transplant Ideally, a patient with a diseased kidney will have a relative who will step forward to donate. Statistical studies have shown that people who donate one of their two kidneys can still live a long and healthy life. The problems arise when the patient does not have a relative willing to give up a kidney or the potential donor’s blood type is not compatible. (Even if it is, there may be other problems.) Typically, the patient is placed on a waiting list. Often, the kidney will come from a cadaver, which runs a greater risk of failure than one from a living person. “With the increasing kidney shortage over the past decade, people are waiting and waiting, many dying waiting for an organ,” says Shamkant Mulgaonkar, MD, chief of the Renal Transplant Centers of the Saint Barnabas Health Care System in Livingston, N.J. “So there’s an obvious need to increase the number of living donations.” Over the past two to three years, a new procedure has evolved to try to improve the situation. Two patients, each needing a kidney and each having a family member or friend willing to donate but the kidney is incompatible, will make what is called a “kidney swap” from one family to the other—if there is a match and compatibility issues are resolved. This is still a pioneering effort, but a number of physicians around the country have been successful with the endeavor. Saint Barnabas, the largest healthcare system in New Jersey, is in the process of implementing what it calls the Living Donation Kidney Exchange Program. A consortium of five transplant centers in the state will administer the program. Two of the transplant centers are part of the Saint Barnabas Health Care System. “Currently, we do over 120 living transplants a year and could do 30 to 40 more if we had the match-ups,” Mulgaonkar says. He adds that improved procedures that allow donors to be in and out within one day have increased the number of general donors. “But four out of five or more can be incompatible with what you need, so all you can do is say thank you, but go home,” he says. The idea of joining different centers in a separate nonprofit organization is to increase the number of donors in a way that can maximize the number of transplants. “We feel this is the best way to deal with the many donors who have come forward to donate a kidney to someone they love but whom we have not been able to utilize,” Mulgaonkar says. “We are using a special software for this and are entering all of the patients and potential donors,” he continues. “This reconciles a number of different factors to make sure there is compatibility. You can’t just do it by writing names and a few details on a blackboard. We hope this will be a model for a national registry, which will greatly increase the number of successful transplants.” Meanwhile, Mulgaonkar says, each program will evolve a little differently. In New Jersey, when the match has been made, both parties are notified and proceed to their respective centers. The operations have to be nearly simultaneous. Because the centers are close to each other, the organ can be taken from the donor in one hospital and delivered quickly to the patient in another hospital. “This may not work in another state where donor and recipient may be several hundred miles apart,” says Mulgaonkar. “Each program will have to come up with its own strategy.” The two parties should remain anonymous, at least before the exchange, Mulgaonkar says. “You have to be realistic. Suppose someone promises to donate for his brother and he knows that exchange has been completed. You don’t want to be in the situation in which he can say, ‘Well, my brother got his kidney. Bye guys.’ The parties should be anonymous to each other and both procedures take place at the same time,” he says. There are other reasons for anonymity, according to Mulgaonkar. Racial prejudice can interfere with an exchange. Some people may be driven to offer money and gifts to make it happen. Following the procedure, it still may not be a good idea to have the participants get in touch. “One side may want to form an emotional relationship which the other may not want, so fending off calls and invitations can be irritating,” Mulgaonkar says. “Also, what happens if the exchange works in one pair, but not the other? There may be a lot of anger and frustration. All of these things need to be spelled out before the exchange so all sides know all of the factors and all of the risks.” In searching for matches, approximately 40 to 50 variables go into the computer, including age. Interestingly enough, matches are not limited to a specific age range, which runs the gamut from 18 to 65. “We won’t accept a kidney that is not healthy,” Mulgaonkar says. “So age is one factor among many. We take all of the variables into consideration and give the kidney a rating. To the possible recipient, we then lay out all of the variables so everything is spelled out ahead of time. It sounds simple, but it’s not. It’s like matchmaking. It’s an extraordinarily difficult procedure.” One physician who has successfully performed one of these exchanges and is in a position to address the difficulties is Lucile Wrenshall, MD, an associate professor at the University of Nebraska Medical Center in Omaha. Wrenshall removed the donor kidney and her husband, Brian Stevens, MD, implanted it in the recipient. “These exchanges don’t work out as much as you might think,” Wrenshall cautions. She explains the issue is not so much finding an identical blood type, but rather a compatible one. “A to B is ideal, for B is fairly uncommon,” she says. “O can be donated to anyone, but A can’t donate to O.” Yet just because blood types are compatible in theory doesn’t mean they will be in actuality, Wrenshall continues. Many other factors also come into play. For instance, the recipient may have built up an antibiotic resistance to the donor type. This could be true of a woman on dialysis or who has otherwise had blood transfusions or been pregnant. Also, white cell antibiotics can build up on the kidney tissue itself. If there has not been a pregnancy or transfusion, this is not likely to become an issue. The antibiotic factor is more difficult to overcome if it exists on the organ tissue than if it is in the blood. On the other hand, Wrenshall says, work is being done through new procedures and treatments to minimize the recipient’s antibiotic resistance. “The more different blood types are made to be compatible, the more obviated will be the need to swap,” she says. “In my opinion, as pretreatments improve, and B can better receive A and the other way around, this option will become the more common one. For you have to have a pretty big program to do very many swaps. You’re talking about groups of centers. And there are the other issues with swaps as well. I believe it might be better to do other things, such as perfect pretreatments to minimize antibiotic rejection.” Whatever the statistics might be for the swap vs. other methods, the successful recipients of the swap consider it to be 100% effective. Marvel Edwards underwent a successful swap conducted by the husband-and-wife transplant team of Stevens and Wrenshall. “In 1986, I had received a liver transplant,” Edwards recalls. “Because of the medication and other factors, my kidneys were weakened. I have four kids and they were tested to see if they could donate. None were compatible with me, but my youngest daughter had a rare blood type. It matched a young man in another family who had waited a long time and was very ill. I had actually been on the list about six months when I heard about the program. It took about a year from when we first started talking about it to the actual transplant. It turned out to be as good for him as it was for me.” Although the exchange was supposed to be anonymous, both families had been told to come back to the hospital at the same time. “I had a clue,” Edwards says. “My husband and I introduced ourselves. The man’s son was in the waiting area. My daughter was donating to him, and his father was donating to me.” The two families also met after the operations, again by accident. When asked how that meeting went, Edwards replies, “It was wonderful. The gentleman hugged me and I hugged him back. My husband noticed the young man was wearing a Green Bay Packers jacket and said, ‘Our daughter is a Denver Broncos fan, so if you wake up one morning cheering for the Broncos, you’ll know the reason why.’” — Thomas G. Dolan is a medical/business writer based in the Pacific Northwest.
UNOS is involved with transplants involving the six solid organs: heart, lungs, pancreas, liver, intestines, and kidneys. It is not involved with tissues such as the cornea or heart valves. Currently, there are more than 88,000 people waiting for an organ transplant. Of these, approximately 62,000 are waiting for a kidney. The first paired exchange took place in 2001. So far, 56 people have received kidneys through the exchanges. John Hopkins Medical School has been a leader in this area, having performed 21 swaps. “Last November, our board of directors endorsed the concept of the establishment and administration of a national live paired kidney donation program,” Paschke says, “with the understanding that the details of the program will be developed over time.” In other words, Paschke says, because the endeavor is relatively new, the concept rather than the development has been approved at this time. On the other hand, Paschke says, “there’s not a lot of controversy about paired exchanges. They help the people who receive them and take them off the waiting list.” Robert A. Montgomery, MD, DPhil, one of the pioneers of these exchanges, copublished a paper in the April 20 issue of The Journal of the American Medical Association titled “Kidney Paired Donation and Optimizing the Use of Live Donor Organs.” Referring to kidney paired donations as KPD, Montgomery and the other authors write, in part, “kidney paired donation is no longer just a concept. The ethical and legal concerns that once dominated the discussion of KPD have given way to administrative and logistical challenges inherent in organizing complex cooperative programs between transplant centers. “Local, state, and regional programs are being introduced around the United States. Despite this, only a relatively small number of patients have benefited from KPD to date. It is critical to the success and public perception of KPD that careful consideration be given to what impact a local/regional vs. traditional scheme will have on the ability to make transplants available to the greatest number of patients both equitably and cost-efficiently. “Determining optimal allocation priorities and algorithms is absolutely crucial to the smart proliferation of KPD in the United States and the prevention of a haphazard system that diminishes the impact of this promising approach to the organ shortage.” — TGD |
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