Kidney donation chains provide life-saving chances for patientsBy Amy E. Nutt
December 27, 2009, 12:20PM
In March, when she was wheeled into the operating room at Newark Beth Israel Hospital, Beth Ard was doing a favor for someone she'd never met. But when her left kidney was removed and placed inside Lavoria Cure, Ard not only became the final donor in a life-altering series of six kidney transplants, she joined an army of volunteers that is radically improving the stingy mathematics of organ transplantation.
For many in the field of renal medicine, 2009 has been a kind of annus mirabilis, a year of wonders:
* In January, four people took part in a kidney swap in Pittsburgh.
* In February, six people donated kidneys in a 12-person chain in Baltimore, Oklahoma City and St. Louis.
* In March, six more donors, including Ard, a 55-year-old Monmouth Beach resident, were part of a kidney exchange that took place within 36 hours at two hospitals in New Jersey and one in New York.
Chain of Life - Kidney transplant chain helps six patients
The rate of exchanges - and the breathless press releases that accompany each "record-breaking" swap - have accelerated just in the past six months. This summer, Johns Hopkins University Hospital in Baltimore reported an eight-way exchange, and two weeks ago Georgetown University Hospital and the Washington Hospital Center, both in Washington, D.C., announced a 26-patient, 13-transplant chain completed over six days.
Encased in boxes of ice and cradled in the arms of paramedics, kidneys from living donors have been rushed by plane and ambulance to patients in every state this year. From Alabama to Maine, Mississippi to North Dakota, close to 5,000 transplants from living donors took place in the United States through September, according to the United Network for Organ Sharing. The number is likely to top 6,000 by the end of the year.
"It's absolutely picked up this year, geometrically," said Garet Hil, founder of the National Kidney Registry. "Our number last year was 21 transplants. This year we have 62 and counting. ... It's taking off."
INCREASED HOPE
Close to 90,000 patients will wait three to five years, on average, for a kidney from someone who has died. Many on the waiting list have friends or relatives who are willing to give them a kidney but whose blood or tissue type is incompatible.
Only recently have health care specialists figured out a way around the problem: the paired exchange. Those who are not a match for their relative or friend agree to donate a kidney to a stranger instead, in return for a compatible organ for their loved one. Kidneys from living donors tend to last twice as long as kidneys from cadavers.
In 2007, with advances in computer technology, the paired exchange gave rise to the kidney chain - and the field of kidney transplantation was changed forever.
Set in motion by an altruistic donor, one kidney given to a stranger sets off a domino series of exchanges among a pool of poorly matched pairs. Where once there was a single transplant, now there are 10 or 12, and involving kidneys not from cadavers but from living donors.
By paying the gift of a kidney forward, these living donors are dramatically increasing the hopes of tens of thousands of patients who are tethered to dialysis machines and whose only chance at a normal life is a transplant.
The National Kidney Registry maintains the largest national database of incompatible donor-and-recipient pairs. Like the NKR, which sifts through billions of possible pairings to create chains, other kidney exchange programs are reporting a spike in donations and transplants.
In a span of nearly two years - between February 2007 and December 2008 - the Alliance for Paired Donation in Maumee, Ohio, was responsible for 36 transplants. In 2009 alone, it has helped at least 41 patients receive new kidneys.
In March, when the New England Journal of Medicine published a report about a "daisy chain" of 10 transplants that took place over eight months, several hundred potential donors sought out the Alliance online and registered on its website for more information.
"We've definitely seen a big increase in interest," said Laurie Reece, the alliance's executive director. "Last year, 1,100 people sought out the alliance online, This year the number was nearly double, at 2,100."
The organization also doubled the number of its altruistic donors, to 20. "And in the past month alone, we've started work-ups on seven more," Reece said.
The New England Program for Kidney Exchange, in Newton, Mass., helped 16 patients get new kidneys this year. Last year the number was just nine. Ruthanne Hanto, the clinical program manager, believes the main reason for the increase has been the involvement of more hospitals.
'CHAIN WARS'
Attention-grabbing headlines haven't hurt. Neither has what sometimes seems to be "chain wars" between hospitals competing for the "longest" and the "largest."
When the New England exchange first began making computer matches in 2003, it had just seven medical institutions participating. Today it has more than 20.
"Anytime something is new, it takes longer for people to catch on," Hanto said. "They want to see the success of it before they buy into it."
In New Jersey 20 years ago, there were just five living-donor transplants, according to the United Network for Organ Sharing. Last year, there were 157. For 2009 the number is projected to break 200 for the first time. The Saint Barnabas Health Care System, which includes Newark Beth Israel, executed five chains last year with 110 donors. This year, it has completed 13 chains with 135 donors, and there are plans for more transplants before December is over. The 12-person, six-way chain in which Ard and Cure took part was completed in March and documented by The Star-Ledger in June. All 12 donors and patients are well, and none has had any serious setbacks.
LESS OF A WAIT
Hope Preston wants to become a part of a new chain. The 57-year-old school librarian from Morris County doesn't need a kidney. She wants to give one away. When she read in The Star-Ledger about the six-way paired exchange earlier this year, she made a quick decision: She wanted to be a nondirected donor.
"I've always been an optimistic person, involved and engaged," she said. "I'm very happy where I am in my life. If I wasn't happy I wouldn't be thinking about doing this. I'm so fortunate. I'm healthy. It seems unfair not to share this bounty with people who aren't so lucky."
So Preston contacted Hil at the National Kidney Registry.
"A lot of people in the New Jersey area are coming through the center," said Hil, who quickly added Preston to his database.
In the past few months Preston, a wife and the mother of two grown children, has had her DNA tested and her blood cross-matched, has undergone a thorough physical and a day of psychological testing, and has been cleared to take part in a chain that, it is hoped, will unfold this week.
"Our numbers are doubling every six months," Hil said. "We've broken the one-year barrier for wait time for a paired exchange transplant. The average wait time has dropped from 10 years to under one year. By the end of next year we will be down to an average of less than six months."
The National Kidney Registry has started 10 chains over the past 12 months, Hil said, and the average length has doubled, with most chains completing 10 or more transplants.
However, Hil has concerns. He says some medical institutions may be sacrificing patient outcomes in the interest of publicity.
He points to the 13-way swap at Georgetown University Hospital and Washington Hospital Center, announced as "the world's largest kidney exchange." Three of the donors were altruistic, which is why Hil disputes the claim that it set a record:
"Three nondirected donors means three chains, not one chain. They appear to have timed the start of these three chains to drive a good headline."
This is the "dark side of paired exchange," Hil says: "Some transplant centers actively hold back nondirected donors and pairs at the local hospital instead of joining with other hospitals to get more, and better matched, transplants."
The result, he said, is that fewer people, overall, receive kidneys, and the transplants are not as well-matched, with many recipients required to undergo a desensitization process called plasmapheresis that rids the recipient's blood of organ-rejecting antibodies. (Five of the 13 transplant recipients in the Georgetown/Washington chain required plasmapheresis.)
"Where they got 13, we could have gotten 30 or more if they had participated in our national program," Hil said.
DECISIVE ACTION
Keith Melancon, director of the kidney transplant program at Georgetown, did not dispute that more transplants might have taken place if his three nondirected donors had each started a separate chain, but his mission, he says, is to rapidly help an under-served population: minorities. Of the 20 living kidney transplants Georgetown has facilitated this year, 16 recipients were minorities.
"I don't want people to think we're making large exchanges for media attention," Melancon said. "I'm watching patients die on dialysis. I'm interested in getting those patients transplanted by any means possible, as fast as possible."
To make his matches, Melancon relied on just 40 pairs, along with three altruistic donors, the first of whom contacted him in August.
Hil maintains the best matches, and the fastest matches, come from the largest pool of pairs, the largest number of nondirected donors and the most-advanced software. The National Kidney Registry has 1,351 nondirected donors and 147 active pairs.
"The best opportunity for those patients is to join a national program like ours," he said. "We have a computer system. He had a (magnet) board. Our system can look at 10 billion possibilities in 30 seconds. It's a numbers game." Had Melancon used the National Kidney Registry, "he would have gotten more people transplanted faster with less desensitization," Hil said.
Despite the disagreement, Hil acknowledges Melancon is "taking decisive action to move the ball forward in paired exchange."
"If the publicity raises awareness," he said, "then people are being helped. The more attention we bring to the process, the better it is for everyone."
Chain of Life, published in June, is a three-part multimedia series by The Star-Ledger
Part 1: A gift of hope unfolds
Part 2: A dozen surgeries in 36 hours
Part 3: Donors and recipients meet
http://www.nj.com/news/index.ssf/2009/12/kidney_donation_chains_provide.html
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