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The newspaper of The Johns Hopkins University October 9, 2006 | Vol. 36 No. 6
'Domino' Transplant Makes the Best Use of Donated Kidneys

By Eric Vohr
Johns Hopkins Medicine

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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