"Fifteen years ago, we thought patients needed dialysis before transplant..."

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Advances in Kidney Transplantation

Thursday, January 10, 2013

Filed under:  Treatments & Techniques | Nephrology | Surgery

Living donor kidney transplantation has become a viable alternative for many patients.

“Fifteen years ago, we thought patients needed dialysis before transplant,” Phil Gauthier, M.D. transplant physician and Medical Director of the kidney transplant program at Porter Adventist Hospital. “Now, we know that patients need transplantation before dialysis. For that to happen, they need to be referred to a transplant program as soon as kidney disease is discovered. There is no need to wait for kidney dysfunction to reach a specific point for referral, particularly because the current waiting list is close to five years for people without a living donor transplant.”

As of September 2012, the waiting list stood at 93,566 for deceased kidney donation, yet only 11,087 deceased donor transplantations were performed between January 2012 and June 2012, according to the Organ Procurement and Transplantation Network (OPTN). Offsetting the disproportionate rate of transplantations to waiting list patients, living donor kidney transplantation has become a viable alternative.

“We take the screening process very seriously,” says Peter T. Kennealey, M.D., FACS, Chair of the Department of Surgery and Surgical Director of Kidney Transplantation at Porter Adventist Hospital. “If someone is able to be a living donor and can help his or her loved one or someone else, then that’s what we favor. We use the deceased donor list for those who do not have that option.”

When patients visit Porter Adventist Hospital or any of its seven additional outreach locations, they undergo standard diagnostic studies, including tissue typing, blood draws and computed axial tomography (CAT) studies, to measure kidney function and health. These same studies are performed for people in the tristate care area who want to provide a kidney as a living donor. Having such a regional multisite program coupled with use of national organ databases allows Porter Adventist Hospital patients the benefit of a widely cast net for living donations — the best source for transplantable kidneys, according to Ben Vernon, M.D., FACS, Medical Director of the Porter Transplant Center and multi-organ transplant surgeon at Porter Adventist Hospital.

The Far-Reaching Donor Net
As Dr. Kennealey explains, living donations can be direct, paired or part of a chain. Direct donations come from family members or friends who agree to donate kidneys. Paired donations occur when a would-be direct donor is incompatible with the recipient but provides a match to a different recipient with an incompatible direct donor.

The definitive lab test for kidney donation is a cross-matching test, which, according to the American Association of Kidney Patients, is designed to detect the presence of reactive antibodies in the donor’s blood that may cause the recipient to reject the donated kidney. Additionally, physicians ensure matching blood types. Dr. Vernon notes that recently, surgeons have performed blood incompatible transplants at Porter, but for the best possible results, Porter Adventist Hospital’s team typically transplants organs with matching blood types. In the event loved ones wish to donate a kidney to a close relation but are incompatible, other avenues may be pursued.

For incompatible paired donations, Porter Adventist Hospital’s active use of the National Kidney Registry and the National Alliance for Paired Donation provides a high likelihood of finding a compatible match elsewhere in the country. Once a match is found, each donor essentially exchanges recipients, providing a kidney to the recipient of the other donor. Paired exchanges may also be extended into multiple donations.

Chain donations occur similarly to paired donations but with farther-reaching possibilities. The longest donor chain ever recorded, according to the World Records Academy, was a 60-person chain providing kidneys from 30 donors to 30 recipients.

“Porter Adventist Hospital is forward thinking and progressive,” says Dr. Vernon. “Pairs and chains are new and the way kidney donation should work. Rather than do a blood group-incompatible transplant and accept a less ideal result at every step along the way, why don’t we invest a little more energy in finding a living donor kidney through exchange programs?”

State-of-the-Art Surgical Options
Once the donor evaluation process is complete, the transplant team at Porter Adventist Hospital utilizes both standard laparoscopic and LapaRobotic techniques to remove kidneys from living donors. After a particularly challenging general surgery case, Warren J. Kortz, M.D., Medical Director of the Living Donor Program at Porter Adventist Hospital, remembered something he heard at a demonstration for the robotic platform: “You see better and have better technical skill.” Once he committed to learn the platform seven years ago, he realized its potential in kidney removal, and has used the da Vinci Surgical System for these procedures since 2005.

The robotic platform enables Dr. Kortz more enhanced magnification than standard laparoscopes and 3-D visualization via a scope inserted through a port in the abdomen. Two instrument ports allow Dr. Kortz to resect the kidney, while another trochar is available for an assistant or surgeon to retract, suction blood or pass stitches through the abdomen as needed.

The da Vinci platform makes for a more comfortable, ergonomic surgical procedure for the surgeon. Its design allows complete intuitive control using natural movements of the arm, wrist and fingers from a specially designed chair at the console, resulting in less fatigue and stress on the surgeon and better outcomes for the patient.

“The bottom line is that this platform makes me a more confident surgeon,” says Dr. Kortz. “This really translates in allowing surgeons the ability to perform more complicated surgeries. It’s taken complex laparoscopic surgeries and made them easier and better because surgeons have more control. For kidney removal, there is less blood loss and trauma to the donor. There’s a level of safety and ease, and you get the same outcome as standard laparoscopy.”

Regional Outreach
More than 50% of Porter Adventist Hospital’s kidney transplant patients come from outside the Denver area, says Alan Qualls, M.B.A., Director of Transplant Services at Porter Adventist Hospital, which attests to the strength of its seven outreach clinics throughout the region. Initial evaluation and postoperative follow up may be performed by a member of the transplant team at one of those clinics. Potential living donors can have necessary tests done at a hospital facility most convenient for them.

After transplantation, the patient stays in Denver for one week for postoperative surveillance and immunosupression monitoring. Further care is coordinated with the patient’s referring nephrologist, in addition to follow-up clinic visits at the outreach facility in closest proximity.

Patients benefit from more than the convenience of Porter Adventist Hospital’s outreach program. All physicians on the transplant team come from top programs — such as Harvard Medical School, Duke University and Tulane School of Medicine, among others — with large transplant centers, providing direct patient care from the moment of admission to follow up.

“We don’t have residents or fellows in Porter Adventist Hospital’s kidney transplant program,” says Qualls. “All our physicians are full-time attendings. Patients do not have trainees working on them, only experienced surgeons and nephrologists. This results in less confusion because patients have direct communication with the specialists managing their care, not through residents or fellows.”

For more information about Porter Adventist Hospital’s transplant program, visit www.porterhospital.org/transplant.