Hopkins kidney surgeon stands out for his work, styleJohns Hopkins surgeon Dr. Robert A. Montgomery's medical research has helped jump barriers to kidney transplantation that 10 years ago would have seemed impassable.
By Arthur Hirsch, The Baltimore Sun
The opera singer who eventually became Dr. Robert A. Montgomery's wife would never have taken him for a kidney transplant surgeon the first time she saw him, not with the long hair and that outrageous mustache. Maybe a biker, she figured, and maybe she was onto something there.
When he heads for work at Johns Hopkins Hospital from his loft in Fells Point or the manse he shares in Bethesda with Denyce Graves, the internationally known mezzo soprano, Montgomery roars off in his 500-horsepower Shelby Cobra, painted white with a blue stripe down the center. Chances are he's in black cowboy boots, blue jeans and a dark shirt, and you probably wouldn't peg him for a kidney transplant surgeon, either, much less one who heads a team that is breaking ground in the field.
By all accounts it's all in character for Montgomery, all slightly outside the bounds of convention. The brawny car, the loft decor he calls "industrial gothic," the boar hunting trips. The rock music in the operating room. The wedding extravaganza that included a Masai ceremony on one continent and an airplane hangar dance party on another. And, oh yes, the medical research that has helped jump barriers to kidney transplantation that 10 years ago would have seemed impassable.
The problem of finding healthy kidneys to replace ailing ones is growing as kidney failure mounts with accelerating rates of high blood pressure, diabetes and obesity. At last count, more than 89,000 people in the United States were awaiting a kidney transplant, suffering the late stages of kidney disease on dialysis treatments several times a week. Finding kidneys for these patients — especially those whose blood and tissue types makes them hard to match with donors — is a complex puzzle of immunology and logistics, one that Montgomery has made key strides in solving.
These patients "need someone who will step up and take some risks for them, and Bob has done that," said fellow researcher and surgeon Dr. Stanley C. Jordan of Cedars-Sinai Medical Center in Los Angeles. "You need eccentrics, people who think about things in a different way."
"I'm much less conformist" than most, said Montgomery in a gentle, measured tone that seems out of sync with the macho accessorizing. "I'm more open to other ways of thinking and looking at problems."
As a kid, according to family lore, he once came home with a report card on which his fourth-grade teacher had written: "Bobby doesn't think the rules apply to him." He's been making idiosyncrasy work.
Peers and friends get a smile in their voice when they talk about this wild hair who managed to ascend the conservative ranks at Hopkins. You can almost hear them shaking their heads over the phone. That's Bob, famous party animal — "sucking the marrow out of life," as the Hopkins surgical residents used to say at their all-day pig roasts in Fallston.
Bob's the one who shows up at the black-tie surgical fellows' dinner at the Maryland Club in his black Nehru jacket. Maybe he doesn't have to worry about tuxedo formalities or the mustache trim. Not anymore, not with six titles to his name at Hopkins, including chief of the division of transplantation, director of the Comprehensive Transplant Center and director of the Incompatible Kidney Transplant Program. Not with the international speaking engagements, the documentary videographers showing up in his operating rooms on a regular basis.
In January, this native of Buffalo who was raised in Philadelphia turned 50, which means that for all his life surgeons have been transplanting human kidneys from living donors with increasing success, though not quite with his dramatic flair. Three surgeries at once? They pulled that off as a first at Hopkins a few years ago. That made news, but Montgomery and his surgical teams were just getting warmed up. In the past few years, his teams have performed a series of firsts involving living donor kidneys transplanted into five patients, then six, then a production involving four hospitals in four states, 16 patients and new kidneys for eight people.
Last year, his surgical team removed a kidney from a female donor as if he were delivering a baby. "Isn't it wild?" he said to a reporter at the time.
It was wild, and that vaginal nephrectomy, as it could be known, was a first in the world and might have been good advertising for more living donors — look, one less scar! — but it paled in comparison to the scientific complexity of the work that never gets on camera.
That would be the immunological work, where the real action in transplantation goes on. Ever since a British doctor during World War II identified the immune system as the culprit in skin graft rejection, the central battle in transplantation has been engaged in this extremely complex system of lymph nodes, bone marrow, two organs and an array of cell types. That's where Montgomery — who holds a doctorate in molecular immunology from the University of Oxford to go with his University of Rochester medical degree — is probably making his biggest mark.
In the lab and the clinic, doctors such as Montgomery tinker with the immune system and tell it not to do everything God intended. They might treat the patient with any number of drugs. They might treat the patient's blood to remove the plasma containing the antibodies, then pump in fresh plasma. They might do both in varying combinations, trying different drugs to stifle immune response, or "desensitize" the patient.
To be sure, Montgomery is working with tools developed by others, at Hopkins and elsewhere — the drugs, the blood treatments, the laparoscopic surgical technique and the logistically complicated practice of "kidney paired donation," not performed in this country until 2000 in Massachusetts. Hopkins physicians did their first in 2001.
Simply put, kidney paired donation is a way to get around the problem that arises when a donor is not a good match for the intended recipient. What then? Then the names of donors and recipients, along with their blood and tissue types, are fed into a computer database in hopes of finding better matches. Sometimes those matches are with strangers thousands of miles away. In a simple two-way swap, for instance, the donor in pair A gives to the recipient in pair B and vice-versa. The more pairs in the database, the more possible matches.
A donation "chain" is a bit different. This would start with one donor giving a kidney to no one in particular, setting in motion a succession of donor-recipient couplings. At the end, a kidney would be left that could start another chain or go to a patient on the list for a kidney from a deceased donor.
Montgomery didn't invent any of this, but he and his research and surgery teams have combined these elements in novel ways and pushed things further. Among other things, they've built on work done at Hopkins in the 1990s and overseas to leap the blood-type barrier between donor and recipient. Montgomery's research has also refined the categories of "sensitized" patients — meaning those with heightened immune responses who are difficult to match with donors — arguing for specific procedures that would work best for each group.
Jordan's review article in the September issue of the journal Nature called the blood-type work a "major advancement … a development that will probably dramatically increase the rates of living donation."
Dr. Bryan Becker, president of the National Kidney Foundation, called Montgomery a "transplant systems engineer," leading work that has been a "tremendous step forward."
Imagine our highways and flyways thick with legal traffic in live kidneys, iced and packed in foam containers, bound for far-flung operating rooms, making transplants possible for kidney failure patients who otherwise would have little prospect of finding a matching donor. Montgomery imagines that, and hopes the existing regional compacts among hospitals can be expanded to a national matching system.
The U.S. government, along with the Organ Procurement and Transplantation Network and other organizations, is scheduled to begin a pilot national program this year.
"I guess I'm a zealot on this," Montgomery said. "There's no reason why we shouldn't be doing this. … It could be saving lives."
Among patients waiting for a kidney transplant, roughly one-third fit the profile of Montgomery's program for people who — because of blood type and tissue sensitivities — are the most difficult to match with donors. They tend to wait longer than the average of five years for a kidney match.
Montgomery has been working the project hard for years, publishing research, performing surgeries and presenting his work at conferences. Shadow him on a busy day and you think of that old variety act in which the performer tries to keep plates spinning on bamboo poles to the frantic surge of "The Sabre Dance." In this case, it's the Brazilian Girls, 10,000 Maniacs, U-2 or Third Eye Blind playing on Montgomery's MP3 in the OR.
On two successive days this winter — all right, they were busy ones — he had a four-hour kidney removal in the morning followed by a three-hour kidney transplant in the afternoon. In between, he was reviewing summaries of research being considered for a national conference, meeting with a surgical fellow about patient care, doing rounds, and talking with an assistant about his schedule of speaking engagements, travel and surgeries.
The logistics of his professional and personal lives rival the complexity of the giant kidney-swap diagrams that decorate his office: arrows zigzagging from one box to another, each box representing another life.
This month and next, for instance, his wife is in Nashville, Tenn.; Ankara, Turkey; Cincinnati; and Warsaw, Poland. Montgomery plans to join her in several cities and has speaking engagements in Boston, Italy and San Diego, to say nothing of the Bonnaroo rock concert in Manchester, Tenn., which Graves is not attending.
Graves interrupted a trip to Eastern Europe last winter to watch her then 5-year-old daughter Ella in a dance recital in Montgomery County and attend a Hopkins event. Then she flew back to continue her performance tour.
Ella is Graves' daughter from a previous marriage. Montgomery was married in his early 20s and has two children from that marriage — one in college, one in high school — and a little boy from a relationship that unfolded when Montgomery was separated from his first wife.
Montgomery and Graves, an imposing, elegant woman raised in Washington, say their first marriages were casualties of their intense focus on their work and that they mean to not have it happen again. Sometimes they join each other on the road. They check in a lot by phone and e-mail.
Next month in Warsaw, Graves will reprise the role of Carmen, the Gypsy, for which she's become famous. Suitably, she and Montgomery met on a United Airlines flight out of Washington Dulles International in June 2006. She and Ella were heading back to Paris, where she lived. He had a connecting flight in Paris en route to a speaking engagement in Sardinia.
In the terminal, he had noticed the stunning woman in a black-and-white print dress. Graves hadn't noticed him until she and Ella sat next to him. He'd planned to spend the flight organizing slides for his talk, but when the battery on Ella's laptop died and with it the DVD she was watching, Montgomery spared Graves a small crisis by volunteering his laptop. They started talking.
"I was touched by his openness and generosity," Graves said. By the time the flight ended, they knew quite a bit about each other. She told him that she was raised without a father; he told her about being apart from his children.
"He shared some insight on what it was like to be a father," Graves said.
"I told everyone about this encounter," she said. "I said, 'I met the most fascinating man.'"
Five days later, they saw each other again when he stopped in Paris on his way back from Sardinia.
"I knew she was going to be someone who would be very important in my life, but I didn't know what," Montgomery said.
The connection was sustained through visits, e-mail, phone calls. Graves moved to the United States, and last summer they were married.
Saying they were merely "married" seems a bit like saying Queen Elizabeth "took office." It was a production of operatic proportions. In June, there was a family ceremony in a small chapel at the National Cathedral. In August, they indulged Montgomery's longtime enthusiasm for African culture by traveling to Kenya for an all-day ceremony among the Masai tribe, in which they were draped in multicolored traditional garb and had their faces daubed with red paint made of ochre and animal fat. In mid-September, their five-day blowout included another ceremony at the National Cathedral, this one for 150 guests, preceded by a party for more than 100 people at an airplane hangar in Leesburg, Va., featuring the Brazilian Girls, the style-blending electronic dance music trio that is one of Montgomery's favorite bands. Montgomery is said to have danced with abandon.
"Denyce doesn't do anything small," Montgomery said. But the Africa part was his idea.
One late afternoon in December, Graves called Montgomery at Hopkins from Slovenia, where she had finished her day's rehearsals for a performance at the Ljubljana Opera House. She just wanted to say goodnight, to see how Montgomery's day was going. He couldn't answer the phone, though, as he was in Operating Room No. 1 in the Carnegie Building, up to his wrists in the abdomen of Wendy Crowder, a 40-year-old woman from Dunnsville, Va.
A nurse picked up the phone from the shelf in the operating room where Montgomery had placed it more than two hours before. He was busy chasing tiny blood leaks on the surface of Crowder's newly transplanted kidney with a cauterizing instrument, raising an aroma of cooking meat.
Crowder fit Montgomery's specialty in hard cases, as tissue sensitivity tests showed that she would be compatible with just 1 percent of the population. Hopkins found a reasonable match through swaps involving patients in two other states. A kidney from her husband, Jeff, was removed that morning and flown to Portland, Maine, in exchange for a kidney that matched someone at St. Barnabas Medical Center in Livingston, N.J., who was related to a donor whose kidney was a reasonably good match for Wendy Crowder. Her donor's kidney was driven down that afternoon from New Jersey packed in ice, pale, hovering between life and death.
Montgomery has removed and transplanted about 1,000 kidneys, but he said he's not over the charge of that moment when, having sewn kidney to artery, the clamps are released to let the blood flow. If all goes well the organ pinks, pulses. It's alive.
For that vivid moment the body has not rejected the organ. Still, the patient has miles to go. They're never really out of the woods, Montgomery said. The months after surgery are critical, then the patients stay on immune-suppressing medications for the rest of their lives.
Later in a hospital lobby, he told members of Crowder's family to be prepared for complications. "Transplantation can be a little bit of a roller coaster," he told them.
Crowder and her husband say they knew the risks but felt there was little choice. The mother of three who had been working as manager of a doctor's office described life on dialysis: "It sucks."
Sitting in a chair in her hospital room days after the surgery, she described Montgomery in words that would embarrass the grandest medical ego. While he doesn't sugarcoat the risk, she said, "he just radiates this calmness. … It's almost as if he's floating above you when he talks to you."
Montgomery is quick to acknowledge that this work is, frankly, strange. On the one hand, there is that moment of the kidney's awakening: "It's mystical … Frankenstein stuff. … It's something I never take for granted."
On the other, he spends much of his time performing surgery on perfectly healthy people, the donors, a "unique phenomenon in medicine." Then, to save the recipient's body, he fights it.
"There's tremendous drama," he said. "There are tremendous saves, and there are patients who die. It's not like being a plastic surgeon or a dermatologist. It's a different deal."
Dr. Robert A. Montgomery
Title: Associate professor of surgery; chief of the Division of Transplantation; director of the Incompatible Kidney Transplant Program at Johns Hopkins Hospital
Born: January 22, 1960, in Buffalo, N.Y.
Marital status: Married to opera singer Denyce Graves
Home: Bethesda and Fells Point
Education: University of Rochester School of Medicine, Rochester, N.Y.; Balliol College, University of Oxford
Passions: Fast cars, rock and roll, food, red wine
http://articles.baltimoresun.com/2010-05-22/health/bs-md-hs-hopkins-kidney-surgeon-20100522_1_kidney-transplant-montgomery-denyce-gravesPHOTO:
Kidney surgeon Robert A. Montgomery with his wife, opera singer Denyce Graves, in their Bethesda home. (Gene Sweeney Jr., The Baltimore Sun / December 23, 2009)
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