Surgical teams at Johns Hopkins have successfully
completed the first five-way donor kidney swap among 10
individuals. The marathon 10-hour surgeries on Nov. 14
occupied six operating rooms staffed by 12 surgeons, 11
anesthesiologists and 18 nurses at The Johns Hopkins
Hospital.
Four transplant candidates had come to Johns Hopkins
separately for evaluation, each with a willing donor whose
blood and tissue types were incompatible with the intended
recipient and who therefore could not donate to their loved
one. Using a previously developed living donor matching
system, the transplant team included a so-called altruistic
donor in the mix and were able to arrange a five-way swap,
in which all four original candidates received compatible
kidneys from someone they had never met, and the remaining
kidney went to a patient who was next on the United Network
for Organ Sharing recipient list. An altruistic donor is a
person who, for personal reasons, has a generous desire to
donate a kidney to no particular recipient.
The Johns Hopkins transplant team is a pioneer in the
exchange of kidneys between incompatible donor-recipient
pairs, a procedure called kidney paired donation, or KPD.
Johns Hopkins surgeons performed the first nondomino KPD
transplant in the United States in 2001, the first
nondomino KPD triple transplant in 2003 and the first
triple domino transplant in 2005. To date, they have
transplanted 41 patients in KPD operations. In the Nov. 14
surgeries, teams took kidneys from five unrelated female
donors and transplanted them into the five unrelated
recipients, three men and two women, whose ages range from
40 to 77 years. Donors and recipients hail from California,
West Virginia, Florida, Maine, Maryland and Ontario,
Canada.
The one altruistic donor, Honore Rothstein, is a
healthy 48-year-old computer programmer who says she was
motivated to donate a kidney after losing her husband to
illness and her daughter in an accident.
"It has been a privilege to help Ms. Rothstein fully
realize her altruism by placing her into a domino
transplant where her gift has made five transplants
possible that would not have occurred," said Robert
Montgomery, director of the Incompatible Kidney Transplant
Program, chief of the Division of Transplantation and
director of the
Comprehensive Transplant Center at Hopkins.
In a paper published in August in the British journal
Lancet, Montgomery, also an associate professor of
surgery in the School of Medicine, laid out the blueprint
for a wider system of pairing altruistic donors and
incompatible recipient pairs to greatly increase the number
of available organs and better serve the interests of both
transplant donors and recipients.
Montgomery said that without a universal system of
this kind in place, altruistic donors often end up on an
Internet donation site or are subject to inconsistent
allocation systems in which only a single patient benefits.
For example, in some cases, the kidney goes to a patient
deemed to have the best chance for long-term survival,
while in others, the organ is given to a patient in
greatest need or to someone at the top of the United
Network for Organ Sharing waiting list regardless of
predicted outcome or need.
"With domino paired donation, all three of these
ethical tenets are satisfied," Montgomery said. "The
likelihood of a good outcome is increased by spreading the
risk of recipient graft loss across more people. The
neediest are served, since in many cases incompatible
donor-recipient pools have a high proportion of patients
who are hard to match. And fairness is served because the
last paired donor's kidney in the chain is allocated to the
next compatible patient on the deceased donor waiting
list."
The donor surgeries began simultaneously at 7:15 a.m.
on Nov. 14 and were finished at 11 a.m. Four donor kidneys
remained in the operating rooms, which were cleaned and
readied for the intended recipients; one was taken to
another room. The recipients' procedures began at 1 p.m.
and were finished at 5:15 p.m. All the donors were released
from the hospital by Nov. 17 and the recipients by Nov.
20.
All the donors will be monitored for the remainder of
their lives to make sure their remaining kidney continues
to function properly. The recipients have been placed on
medications that will help ensure that they won't reject
the kidney. They will be evaluated weekly for the first six
weeks, then monthly, with the frequency of hospital visits
slowly tapering off over time. The average expected life of
a live donor kidney is 18 to 20 years. The recipients had
lost the use of their kidneys for a variety of reasons,
including blood clots, end-stage renal disease and a motor
vehicle accident.
Nearly 100 medical professionals were instrumental in
making this complex series of transplants possible,
including immunogeneticists, anesthesiologists, operating
room nurses, nephrologists, transfusion medicine
physicians, critical care doctors, nurse coordinators,
technicians, social workers, psychologists, pharmacists,
financial coordinators and administrative support
people.
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