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The newspaper of The Johns Hopkins University April 14, 2008 | Vol. 37 No. 30
Surgeons Perform Historic 'Six-Way Domino' Kidney Transplant

By Eric Vohr
Johns Hopkins Medicine

Surgical teams at Johns Hopkins have performed what is believed to be the first six-way donor kidney swap among 12 individuals. The 10-hour surgeries on April 5 used six operating rooms and occupied nine surgical teams at The Johns Hopkins Hospital.

All donors and recipients are doing well and recovering at the hospital.

The surgeries were set into motion when five transplant candidates visited Johns Hopkins for evaluation, each with a willing donor whose blood or tissue types were incompatible. Using a Johns Hopkins-developed living donor matching system, the transplant team introduced into the mix a so- called altruistic donor — one who volunteers a kidney to no particular recipient — and were able to arrange a six-way swap. This allowed all five original candidates to receive compatible kidneys from someone they had never met, while the remaining kidney went to the next patient on the United Network for Organ Sharing's recipient list.

The Johns Hopkins transplant team pioneered the exchange of kidneys among incompatible donor-recipient pairs — a procedure called kidney paired donation. Johns Hopkins performed the first KPD triple transplant in 2003, the first triple domino transplant in 2005 and the first five-way domino transplant in 2006. In a paper published in August 2007 in the British journal Lancet, Robert Montgomery, chief of the Transplant Division at JHH, and a team of Johns Hopkins researchers 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.

Without a universal system of this kind in place, Montgomery says, 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 UNOS 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."

In the recent procedure, the six donor surgeries began simultaneously. The kidneys remained in the operating rooms, which were then sterilized and readied for the intended recipients.

The donors will be monitored for the remainder of their lives to make sure their remaining kidney continues to function properly. The recipients will be evaluated weekly for the first six weeks, then monthly, with the frequency of hospital visits slowly tapering off. The average expected life of a live donor kidney is 18 to 20 years.

Nearly 100 medical professionals were required to make 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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