A team of Johns Hopkins researchers reporting their
early experiences with "domino" kidney donation suggest
that wider use of this strategy could effectively double
the benefit of the organs from these nondirected altruistic
living donors.
In a paper published in the August issue of the
British journal Lancet, the researchers, led by
Robert A. Montgomery, chief of transplantation at the
School of Medicine, show that by serving the needs of
multiple recipients, such domino transplants can maximize
the benefits of the donors' altruistic acts.
Under the terms of the domino-paired donation program,
a kidney transplant patient who has a willing but
incompatible living organ donor is matched with an
altruistic compatible donor. The incompatible kidney from
the recipient's intended donor is then domino-matched with
the next compatible patient on the United Network of Organ
Sharing waiting list. This strategy can be further used to
enable a triple transplant by adding an additional
incompatible donor-recipient pair to the chain.
However, Montgomery says that because there is
currently no national system of this kind in place,
altruistic donor kidneys often end up on an Internet
donation site or at individual transplant centers and so
are subject to variable ethical criteria. For example, in
some cases the kidney goes to the patient deemed to have
the best chance for long-term survival; in others, the
organ is given to the patient in greatest need, or to the
candidate at the top of the UNOS waiting list, regardless
of outcome or need.
"With domino-paired donation, all three of these
ethical tenets are satisfied," Montgomery said.
Specifically, the likelihood of a good outcome is increased
by spreading the risk of recipient graft loss across more
people. The neediest patients are served, since in many
cases patients with incompatible donors suffer
disproportionately long waiting times. Those on the UNOS
waiting list also benefit, by receiving the last kidney in
the chain.
To date, Johns Hopkins surgeons have performed two
triple and one double domino-paired kidney transplant
initiated by three altruistic donors who were able to
provide eight recipients with compatible kidneys. If
conventional allocation strategies had been used,
Montgomery said, only three of these recipients would have
benefited from these altruistic donations.
UNOS reports that since the first altruistic donor
came forward in 1998, 302 altruistic kidney transplants
have been performed in the United States. Using a computer
simulation program, Montgomery and his team calculated that
583 transplants could have been achieved if the
domino-donation model had been in place.
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