Johns Hopkins Gazette | March 16, 2009
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The newspaper of The Johns Hopkins University March 16, 2009 | Vol. 38 No. 26
'Daisy Chain' Transplants Possible From One Donor

10-way swaps of kidneys could theoretically give way to dozens or hundreds

By Eric Vohr
Johns Hopkins Medicine

A new variation in kidney paired donation — pioneered and developed at Johns Hopkins — could theoretically generate an endless number of transplants, researchers report.

The possibility of sparking "daisy chain" transplants, described in the March 12 issue of The New England Journal of Medicine, was prompted by reports of one round of 10 kidney transplants, all generated from a single kidney donated by an altruistic donor, said Robert Montgomery, transplant chief at the Johns Hopkins University School of Medicine and senior author of the study. An altruistic donor is someone willing to donate a kidney to any needy recipient.

What the authors dubbed as nonsimultaneous, extended, altruistic donor chain, or NEAD, begins with a kidney from an altruistic donor that is compatible and transplantable in a patient who has a relative or friend willing to donate but whose kidney is not compatible by blood or tissue type. Once the altruistic donor kidney is matched up and transplanted, the kidney from the willing donor from the original incompatible pair goes to solve the problem of another incompatible donor-recipient pair and so on, theoretically endlessly, limited only by the number of recipients and possible, available matches.

The 10-way NEAD or "daisy chain" outlined in the NEJM article started at an Arizona hospital in July 2007. The majority of the subsequent transplants, including the most recent, 10th transplant in the chain, were performed at The Johns Hopkins Hospital.

NEAD builds on the concept of so-called domino kidney paired donation. Developed and pioneered at Johns Hopkins, domino KPD uses a kidney from an altruistic donor that goes into a pool that includes a finite number of incompatible donor-recipient pairs and a patient that's next on the United Network for Organ Sharing recipient list. Doctors and transplant coordinators can then match donors with recipients inside this pool, striving for the best possible match based on blood and tissue antigen testing. Although effective, this process is limited by the number of available incompatible pairs, good matches and available operating rooms because all the surgeries are performed on the same day.

"When an altruistic donor starts a kidney donation chain, it is no longer imperative that the transplants are done simultaneously," said Michael A. Rees, lead author of the study and medical director of the Alliance for Paired Donation, a consortium of transplant centers that maintains a database of incompatible donor-recipient pairs.

This is beneficial because the procedure does not require multiple surgeons and operating rooms. It also eases the complicated matching required when there are multiple donors and recipients needing same-day surgery.

"NEAD chains are the latest of a series of important breakthroughs in transplantation that will significantly increase the number of life-saving organs available to hard-to-match patients, many of whom die while waiting years for a kidney," Montgomery said.

Johns Hopkins surgeons performed one of the first KPD transplants in the United States, in 2001; the first triple-swap, in 2003; the first double and triple domino transplant, in 2005; the first five-way domino transplant, in 2006; and the first six-way domino transplant, in 2007. Johns Hopkins also led the first multihospital, transcontinental three-way swap transplant, in 2007.


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