Rare Quadruple Kidney Swap Raises Ethical Concerns

CHICAGO _ Pierre Kattar Jr. could not donate a kidney to his father because of incompatibility, so he gave one to Niral Patel, whose mother had wanted to give him a kidney but could not. Instead, Patel’s mother gave her kidney to Alice Smith.

So it went last Thursday at Northwestern Memorial Hospital, where four kidney donors and four kidney recipients gathered for a rare set of operations known as a domino paired exchange, the largest of its kind ever performed in the region. Doctors announced the success of the surgeries Tuesday.

Such arrangements are becoming more common as doctors seek creative ways to get kidneys to people who need them. Just Saturday, surgeons at Johns Hopkins Medical Center in Baltimore performed a six-way paired exchange, the largest ever done.

The operations at Northwestern and Hopkins come as some transplant officials push for a national program to increase paired kidney donor exchanges. Last year, the National Organ Transplant Act was amended to clear the way for the program.

In 2007, surgeons performed more than 16,000 kidney transplants, 6,000 of which used organs from living donors. Some experts say the linked surgeries could make as many as 2,000 additional kidneys available every year for transplant.

Hopkins transplant surgeon Dr. Robert Montgomery described the operations as “one of the most significant breakthroughs in transplantation in the last decade.”

More than 30 percent of kidney patients know someone willing, but unable to become their donors because they are not a suitable tissue match, said Dr. Matthew Cooper, associate professor of surgery at University of Maryland Medical System, incoming chair of the United Network for Organ Sharing (UNOS) living donor committee.

But despite widespread support, some raise concerns ranging from ethical issues to whether UNOS is pushing ahead too quickly.

Dr. Steve Woodle, a Cincinnati transplant surgeon who is a member of the Paired Donation Network, said he questioned whether UNOS was the best agency to oversee a national exchange program and whether the necessary resources are available. UNOS has faced criticism for not doing enough to protect living donors.

Woodle and others also say some patients waiting for a deceased donor organ could even be disadvantaged by a national program. Donors with blood type O are best suited for triggering a domino exchange because their organs can be donated to more patients. But using them as donors for people of other blood types means that type-O patients on the waiting list, who can only receive organs from type-O donors, will have fewer options, Woodle said.

Others express ethical concerns about how the donors could be affected.

“The larger these pairs, the greater pressure on the donor,” said Donna Luebke, a living kidney donor who helps coordinate an Ohio-based group that advocates for living donors. “If they back out, it doesn’t collapse just one surgery, it can collapse four. The more people you bring in, the more people that donor feels responsible for.”

Transplant officials recognize the need to offer a way out for people who don’t want to become donors _ even if they have to stretch the truth and say they are not medically suitable.

“We need to be able to medically disqualify people when they don’t want to do it on psychological or emotional grounds,” said Arthur Caplan, director of the Center on Bioethics at University of Pennsylvania.

Kattar admitted fears about the surgery but said being a part of a complicated operation gave him extra motivation to take the risk.

“It became more than just about my father, and that actually helped me to go through with it,” Kattar said. “I thought, `Now they’re really counting on me, if one person backs out, you got 7 people that are … out of luck.”

The surgery last week brought together a donor who works at Northwestern’s transplant center with three sets of kidney patients and the family members who volunteered to become their living donors but were medically incompatible. Also included was a patient who was waiting for a kidney from the deceased donor list.

The transplants were performed over a 12-hour period Thursday, involving three operating rooms and 32 doctors, nurses and staff members, said Dr. Joseph Leventhal, one of the surgeons and the director of the hospital’s living donor kidney transplant program.

The four-way exchange was triggered by the failure of a more typical direct donor-to-recipient transplant.

Doug Penrod, 61, of Chicago, who has worked in transplant medicine for 20 years, most recently at Northwestern, decided last year to donate a kidney to a friend’s father. However, the intended recipient became too ill for the surgery, prompting Penrod to consider other options.

“I’ve seen the good that comes with a transplant,” Penrod said. “I told the program director, `Hey, I’ll give it to anybody, let’s get this rolling, let’s get this done.’”

Northwestern’s living donor kidney transplant program then set out to determine how to best use Penrod’s kidney. In the weeks before Thursday’s surgery, they located three parent-child pairs and an eighth patient, drawn from the center’s kidney waiting list.

Though none of the donors and recipients met each other or were told about each other’s identities before the procedure, the eight patients met for the first time on Friday as they recuperated at the hospital.

Penrod’s kidney went to a Chicago woman whose daughter, Griselle Ortiz, 25, came from Puerto Rico to donate to Pierre Kattar, Sr., 60, a Lebanese-born native of Chicago. Kattar said that despite the language barrier between him and Ortiz, he was able to thank her through a translator.

“I told her that she really helped me and my family,” Kattar said. “It was across all racial lines and it was beautiful to see that all these people of different backgrounds can exchange organs.”

Kattar’s son flew from his home in Washington, D.C., to donate his kidney to Niral Patel, 25, of Westmont, Ill., who was receiving his fourth kidney transplant after suffering from polycystic kidney disease. Kattar and Patel said they hit it off after the surgery when they learned each one owned an iPhone, and have been sending each other text messages in the days since meeting.

“I thought I would never meet the recipient of my kidney and I didn’t care,” Kattar said. “It was about saving my father.

“When I met Niral it was like, wow,” Kattar Jr. said. “It set in that I did for Niral and his family what someone else did for my father and my family.”

Completing the exchange, Niral Patel’s mother Vina, 54, donated her kidney to Smith, 65, of Joliet, who had been receiving dialysis treatment for 5 years.

“My heart was full of joy,” Patel said of meeting Smith. “I was so glad my body part helped someone’s life.”

Penrod said he was moved to discover that patients he had worked with for years at the transplant center, including Kattar Sr. and Patel, were among the recipients in the exchange procedure.

“Hopefully this is going to enable them now to have a better life with their family, to be able to do more things,” Penrod said.

___

(c) 2008, Chicago Tribune.

Visit the Chicago Tribune on the Internet at http://www.chicagotribune.com/

Distributed by McClatchy-Tribune Information Services.

For reprints, email tmsreprints@permissionsgroup.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.