October 6, 2008

First Paired Kidney Transplants Done Here

By Gustafson, Jeanne

Sacred Heart Medical Center has performed its first kidney transplant accomplished in a domino-effect scenario that involves two live donors and two recipients, triggering use of a matching approach hospital officials believe will boost kidney transplants here by 25 percent.

Separately, Sacred Heart says it plans to add pancreas transplants to its 27-year-old kidney transplant program.

Last week the hospital completed what's called a domino-paired kidney transplant, the first of its kind to be done in the Inland Northwest, says Dr. Richard Carson, a Spokane nephrologist and director of Sacred Heart's kidney transplant program.

That scenario began when a Spokane resident volunteered to be an "altruistic" kidney donor, meaning that he was willing to provide one of his kidneys to whomever needed it. Meanwhile, the wife of another Spokane man had offered to give up one of her kidneys for her sick husband, but found out that her organ wasn't a good match for her husband. So, her husband received a compatible kidney from the altruistic donor, and his wife, in turn, donated one of her kidneys to a Spokane Valley woman who had been on the waiting list for some time. In the end, two matches were made where before there were none, Carson says.

He says that the paired donor recipient matching method, which has been used nationally for about 10 years, should open the door to substantially more kidney transplants here.

The move comes amid other plans for growth within Sacred Heart's kidney transplant program, which serves Eastern Washington, North Idaho, and Western Montana.

The program plans to double the size of its medical staff to six physicians and move to larger quarters in the hospital complex. It currently is recruiting two surgeons and a second full-time nephrologist, Carson says.

By recruiting new surgeons, the program plans to add pancreas transplants to the program. Often, due to complications of Type 1 Diabetes, patients who need a kidney also need a pancreas transplant, and currently have to travel to Seattle to receive one.

Sacred Heart also hopes to launch a full pediatric transplant program. Currently, the program can offer kidney transplants to patients as young as 10 years old, but wants to be able to transplant kidneys in younger children as well.

The domino effect

While the idea of a domino-paired kidney donation is reasonably simple, making a match isn't, Carson says.

It can take weeks, using a specialized software, to cross match two sets of donors and recipients, then the transplant plans must be vetted and presented to the organ kidney transplant selection committee before the domino-paired surgeries can take place, Carson says.

"We also employ a human factor," he says. "We put together a list of potential donors then look at other factors in the medical decision," such as age, gender, and the urgency of the need.

"It's a complicated process, but it's rewarding," he says.

In each transplant cross-match, the donor and recipient are admitted to the hospital for surgeries scheduled one right after the other. One surgeon removes one of the donor's healthy kidneys in an operation that takes about three hours. Meanwhile, another surgeon and operating team has the transplant recipient prepped and ready to go into another surgical suite when the donor's organ is removed. Transplanting the organ into the recipient also takes about three hours.

The other cross-matched donor-recipient pair is scheduled for their surgeries within a week or so of the first pair, to ensure that the process is completed.

Carson says the paired-donor matching method is likely to play an important role here in future transplants, due to an increasing need for kidney donations. He says chronic kidney disease is on the rise, with diabetes and high blood pressure taking their toll on a population that already is aging. The preferred method of treatment for kidney disease is a transplant, but the supply of donated kidneys is woefully inadequate, Carson says.

Currently, about 76,500 people in the U.S. are waiting for donated kidneys, according to the United Network for Organ Sharing (UNOS), which manages U.S. organ-donor lists. Meanwhile, just 3,300 of the 11,500 kidney transplants performed in the U.S. during the first five months of this year were from deceased donors, meaning that the bulk of kidney transplants rely on live donors.

"Living donors have assumed a huge role, Carson says.

The lack of available donated kidneys has meant that more transplants involve kidneys that aren't as compatible with the recipient as doctors would like, he says. That, in turn, has spurred increased use of a practice called desensitization, in which a patient's immune system is suppressed to allow transplantation of a kidney that his or her body otherwise would reject Desensitization is expensive and can be risky for patients, so Sacred Heart limits its use of the practice, Carson says. He says he expects that paired- kidney donor matching will reduce the need for desensitization here.

"This is definitely going to replace the desensitization programs," says Carson, adding that Sacred Heart is pursuing domino- paired matches because they're safer than desensitizing patients who are at high risk of organ rejection. "We feel a safer and better way to go is through paired donor exchange," he says.

What makes the method possible is that kidney donations by living donors are on the rise generally, and more people are contacting Sacred Heart to donate a kidney because they've heard of living organ donation and want to do something good.

In the first paired transplant here, Carson says, a young Spokane man did just that, and underwent the medical and psychosocial testing that's required to be approved for donating. Dr. Katherine Tuttle, a nephrologist and head of the Providence Medical Research Program, says through that potential donor's physical testing, it was determined he needed to improve his own health before he gave up a kidney, and he did so. Carson says donors frequently must take care of medical problems unearthed in the evaluation process before they donate.

"We want the donors to be in perfect health. It's a big surgery that they don't need. We don't want to put them at risk for future problems," Carson says. He says typical health problems that donors can address before they donate are high blood pressure, excess weight, or slightly high blood sugar.

Though the notion of paired donorship has been around about a decade, over. the past five years or so larger programs at places such as John Hopkins University, in Baltimore, have taken the lead to develop programs to carry it out, Carson says. Though for now the matching method only is employed in a few places, LINOS is working toward establishing a national shared-donor program.

The national organ donor list is divided into regions, Carson says. There are four transplant programs in Washington, which are managed through a statewide procurement list. More than 1,000 kidney transplants have been performed through Sacred Heart's transplant program since 1981.

"Organs are allocated regionally first, but if there are no recipients, they are offered nationally," Carson says. The program here has received kidneys from as far away as Bermuda.

Instituting the matching method here has required little monetary investment, aside from buying a computer software program that compares potential donors with potential matches, Carson says.

If a paired match can't be found, the donor who had wanted to donate for a friend or relative could still donate to the general list of those in need, and in exchange, the program can move that person's friend or relative to the top of the waiting list for the next available organ.

"People who had incompatible donors would remain on the list for years. Now it opens the door for a whole new pathway" for donation, he says.

If a donor is approved, it becomes a matter of scheduling the donor and recipient at their convenience. If it's a paired donor exchange, and four schedules must be meshed, factors such as family and work commitments complicate the matter.

Sometimes, because of the complications of scheduling, a patient might have too urgent of a need to wait for all of the details to workout and would have to take another kidney if one became available sooner.

"It's a continuous evaluation process," Carson says. A person's relative health when they first got on the list could differ greatly from when an organ becomes available, he says.

Though each case is different, there's a scenario in nearly every transplant procedure that Carson says plays out over and over, regardless of how the donor and recipient were matched. When the doctor first visits a transplant recipient after the surgery, his or her first question is always "How is my donor doing?" Carson says. When the doctor first visits the donor after surgery, without fail the donor will first ask, "How is my recipient doing?"

Copyright Northwest Business Press Inc. Aug 28, 2008

(c) 2008 Journal of Business; Spokane. Provided by ProQuest LLC. All rights Reserved.