Celebrating Adam Bingaman at Methodist Hospital in San Antonio

Working in kidney exchange has given me the opportunity to meet some remarkable surgeons, and one of them, Adam Bingaman, is being celebrated in in the San Antonio media:
Methodist Hospital Leads Nation in Live-Donor Kidney Transplants

Methodist Specialty and Transplant Hospital's Dr. Adam Bingaman

"Dr. Adam Bingaman, head of the live-donor kidney transplant program, joined the Texas Transplant Institute at Methodist Specialty and Transplant Hospital in 2007 and became the Director of Abdominal Organ Transplantation in 2012.
...
"For those awaiting a kidney transplant but lacking a live-donor match, the only chance for a kidney donation may be from a kidney-paired donor (KPD) exchange. This offers a transplant option for patients with a living donor who is both willing and medically fit but isn’t a compatible match with the recipient.

The donor’s information is entered into a nationwide database with those of other incompatible donors and recipients who are willing to exchange kidneys. It is here that the process of finding suitable exchanges occurs. Kidney-paired donation provides a means for all transplant centers to increase patient access to live-donor transplantation.

Methodist Specialty and Transplant Hospital’s Program

Launched in 2008, the paired-donor program at Texas Transplant Institute at the Methodist Specialty and Transplant Hospital has performed more kidney-paired donation exchanges than any other center. The program focuses not just on the kidney recipient, but on the donor as well. All transplants are performed in one integrated facility, with targeted care provided for the donor from initial screening to post-surgery follow-up for two years.

The program’s approach to building community partnerships enables patient access and follow-up care in less populated areas across Texas. The program’s team has forged relationships with nephrologists throughout the state and through dedicated clinics in Corpus Christi, Laredo, McAllen, Lubbock, Waco, Temple, and Austin. The transplant physicians and team members visit these locations regularly to check on patients who have either donated or received a kidney.

“We build relationships of trust,” Bingaman said. “Community partnering in underserved areas is very important to patient outcomes. Our goal is to integrate our services with those of a patient’s nephrologist, so that we provide a true umbrella of care.”

...

"The Texas Transplant Institute at Methodist offers an educational seminar three to four times a year. The series (and videos here) teach people how to “End Your Wait” with an education program explaining living kidney donation and how to go about finding a donor on their own.

“We give them tools that help their awareness about the need for a kidney transplant,” Bingaman said. “We started this program because more than 50% of kidney donations do not come from family members. They are from coworkers, church members, or someone in the extended social network.”

“We’ve already hit a crisis point,” Bingaman said. “If you have kidney disease and diabetes and maybe heart disease, after six years on dialysis, you probably won’t be healthy enough for a transplant. So your best bet is to find a living donor as early as possible.”

Sandholm on kidney exchange

Tuomas Sandholm writes:

"I just today updated my web page with my new papers.  Here are the main kidney exchange papers that I have been involved with.  This is not a complete list, but these are the main ones."

• Dickerson, J. and Sandholm, T. 2015. FutureMatch: Combining Human Value Judgments and Machine Learning to Match in Dynamic Environments. In Proceedings of the AAAI Conference on Artificial Intelligence. Extended version with appendix.
• Hajaj, C., Dickerson, J., Hassidim, A., Sandholm, T., and Sarne, D. 2015. Strategy-Proof and Efficient Kidney Exchange Using a Credit Mechanism. In Proceedings of the AAAI Conference on Artificial Intelligence.
• Dickerson, J. and Sandholm, T. 2014. Multi-Organ Exchange: The Whole is Greater than the Sum of its Parts. In Proceedings of the AAAI Conference on Artificial Intelligence. Early version in IJCAI-13 workshop on Constraint Reasoning, Planning and Scheduling Problems for a Sustainable Future (GREEN-COPLAS).
• Dickerson, J., Procaccia, A., and Sandholm, T. 2014. Price of Fairness in Kidney Exchange. In Proceedings of the International Conference on Autonomous Agents and Multiagent Systems (AAMAS).
• Dickerson, J. and Sandholm, T. 2014. Balancing Efficiency and Fairness in Dynamic Kidney Exchange. In Proceedings of the Modern Artificial Intelligence for Health Analytics (MAIHA) workshop at AAAI-14.
• Dickerson, J., Procaccia, A., and Sandholm, T. 2014. Empirical Price of Fairness in Failure-Aware Kidney Exchange. Towards Better and more Affordable Healthcare: Incentives, Game Theory, and Artificial Intelligence (HCAGT) workshop at AAMAS-14.
• Leishman, R., Stewart, D., Monstello, C., Cherikh, W., Sandholm, T., Formica, R., Aeder, M. 2014. The OPTN Kidney Paired Donation Pilot Program (KPDPP): Reaching the Tipping Point in 2013. World Transplant Congress (WTC). Abstract, presentation.
• Aeder, M., Stewart, D., Leishman, R., Sandholm, T., Formica, R. 2014. Early Outcomes of Transplant Recipients in the OPTN Kidney Paired Donation Pilot Program.
  World Transplant Congress (WTC). Abstract, presentation.
• Stewart, D., Leishman, R., Kucheryavaya, A., Formica, R., Aeder, M., Bingaman, A., Gentry, S., Sandholm, T., and Ashlagi, I. 2014. Exploring the Candidate/Donor Compatibility Matrix to Identify Opportunities to Improve the OPTN KPD Pilot Program's Priority Point Schedule. World Transplant Congress (WTC). Abstract, poster.
• Dickerson, J., Procaccia, A., and Sandholm, T. 2013. Failure-Aware Kidney Exchange. In Proceedings of the ACM Conference on Electronic Commerce (EC). Extended version.
• Leishman, R., Formica, R., Andreoni, K., Friedewald, J., Sleeman, E., Monstello, C., Stewart, D., and Sandholm, T. 2013. The Organ Procurement and Transplantation Network (OPTN) Kidney Paired Donation Pilot Program (KPDPP): Review of Current Results. American Transplant Congress (ATC). Abstract of talk.
• Leishman, R., Formica, R., Andreoni, K., Friedewald, J., Sleeman, E., Monstello, C., Stewart, D., and Sandholm, T. 2013. An Early Look at Transplant Outcomes from the OPTN KPD Pilot Program: Comparing Cold Times and DGF Rates with Other Living and Deceased Donor Transplants. American Transplant Congress (ATC). Abstract of talk.
• Stewart, D., Leishman, R., Sleeman, E., Monstello, C., Lunsford, G., Maghirang, J., Sandholm, T., Gentry, S., Formica, R., Friedewald, J., and Andreoni, K. 2013. Tuning the OPTN's KPD Optimization Algorithm to Incentivize Centers to Enter Their "Easy-to-Match" Pairs. American Transplant Congress (ATC). Abstract of talk.
• Dickerson, J., Procaccia, A., and Sandholm, T. 2012. Dynamic Matching via Weighted Myopia with Application to Kidney Exchange. In Proceedings of the National Conference on Artificial Intelligence (AAAI).
• Dickerson, J., Procaccia, A., and Sandholm, T. 2012. Optimizing Kidney Exchange with Transplant Chains: Theory and Reality. In Proceedings of the International Conference on Autonomous Agents and Multiagent Systems (AAMAS).
• Woodle, S., Daller, J., Aeder M., Shapiro, R., Sandholm, T., Casingal, V., Goldfarb, D., Lewis, R., Goebel, J., and Siegler, M. 2010. Ethical Considerations for Participation of Nondirected Living Donors in Kidney Exchange Programs. American Journal of Transplantation 10: 1460-1467.
• Awasthi, P. and Sandholm, T. 2009. Online Stochastic Optimization in the Large: Application to Kidney Exchange. In Proceedings of the International Joint Conference on Artificial Intelligence (IJCAI).
• Rees, M., Kopke, J., Pelletier, R., Segev, D., Fabrega, A., Rogers, J., Pankewycz, O., Hiller, J., Roth, A., Sandholm, T., Ünver, U., Nibhanubpudy, R., Bowers, V., VanBuren, C., and Montgomery, R. 2009. Six Nonsimultaneous Extended Altruistic Donor (NEAD) Chains. American Transplant Congress (ATC).
• Rees, M., Kopke, J., Pelletier, R., Segev, D., Rutter, M., Fabrega, A., Rogers, J., Pankewycz, O., Hiller, J., Roth, A., Sandholm, T., Ünver, U., and Montgomery, R. 2009. A Nonsimultaneous, Extended, Altruistic-Donor Chain. New England Journal of Medicine 360(11), 1096-1101.
• Abraham, D., Blum, A., and Sandholm, T. 2007. Clearing Algorithms for Barter Exchange Markets: Enabling Nationwide Kidney Exchanges. In Proceedings of the ACM Conference on Electronic Commerce (EC).

Kidney exchange in San Antonio

Here's a news release from San Antonio, where Adam Bingaman is doing great things in kidney exchange:

SAN ANTONIO, Texas, Feb. 10, 2014/NEWS.GNOM.ES/ — Methodist Specialty and Transplant Hospital (MSTH), a campus of Methodist Hospital,  has performed its 250th  paired kidney exchange, setting a national record for a single hospital, while performing 10 lifesaving exchange transplants during the last week of January.

...

“Our philosophy is to help as many people as we can despite the challenges,” said Adam Bingaman, M.D., Ph.D., transplant surgeon and director of the program. “There are over 95,000 people on the kidney transplant waiting list and their chances of receiving a transplant are low, with an average wait of more than five years. Time is against people on dialysis – the sooner we can get them transplanted, the sooner they can return to good health.” Each year about 4,500 Americans die waiting for a kidney.

"The paired donor program at MSTH began in 2008 and has helped to pioneer the field of paired donation, successfully transplanting patients from across the U.S. and international pairs from Canada and Italy. The program’s success hinges on a team approach along with a world-class immunology laboratory. “Our group likes a challenge,” Bingaman said when talking about difficult-to-match patients who have travelled from near and far to receive exchange transplants in San Antonio. “We never get tired of giving folks their lives back, free from a dialysis machine.

"“A special emphasis is on blood type and antibody matching,” he continued. “We ensure each exchange recipient receives a kidney from a donor who is a complete or very close match, often making it unnecessary to utilize high-risk desensitization therapies to enable a transplant between incompatible pairs.”

Kidney exchange: stories of donors and recipients

Kidney exchange isn't just about the technology of matching and the logistics of arranging many surgeries, or difficult ones, it is also about the intensely personal stories of donors and recipients.  The news stories below open a window on some of those, from Vancouver British Columbia. to San Antonio Texas

Backing out was never an option for B.C. donor
"I was the last in the chain to do the donation," said Campbell, 48, of Qualicum Beach, B.C., who was scheduled to give one of her kidneys to a Montreal man days after her husband Steve got a kidney from an Ottawa donor. Organizers asked her repeatedly whether she would honour her commitment no matter what happened on the operating table to her husband, she recalled.

 "'And what happens if Steve doesn't do well, will you still be able to get on a plane and go?' They put a lot of faith in me not backing out."

  *********

FAITH, FREEDOM AND A KIDNEY: Healers in it for the long haul

""You have way too many antibodies. You're too big. You're too small. You're too tall. You're too short. There's always a reason to say, 'no.' A lot of times it's easier for hospitals to say, 'no,' Bingaman said. "It's much harder for them to say, 'yes.' " 

Kidney exchange in San Antonio

Adam Bingaman and his colleagues at the Methodist Specialty and Transplant Hospital,  in San Antonio, Texas, report on their stellar experience with kidney exchange (kidney paired donation). One key to their success is that they enroll compatible as well as incompatible pairs.

A. W. Bingaman, F. H. Wright Jr., M. Kapturczak, L. Shen, S. Vick, C. L. Murphey, "
Single-Center Kidney Paired Donation: The Methodist San Antonio Experience, American Journal of Transplantation, published online 30 April, 2012

Abstract: Many potential kidney transplant recipients are unable to receive a live donor transplant due to crossmatch or blood type incompatibility. Kidney paired donation increases access to live donor transplantation but has been significantly underutilized. We established a kidney paired donation program including consented incompatible donor/recipient pairs as well as compatible pairs with older non-human leukocyte antigen identical donors. Over a 3-year period, a total of 134 paired donor transplants were performed, including 117 incompatible pairs and 17 compatible pairs. All transplants were done with negative flow cytometry crossmatches and five were done with desensitization combined with paired donation. Kidney paired donation transplants included two-way and three-way exchanges as well as three chains initiated by nondirected donors. Of the sensitized recipients transplanted by paired donation, 44% had calculated panel reactive antibody levels greater than 80%. Transplantation of females and prior transplant recipients was significantly higher with paired donation. Only three episodes of rejection occurred and no transplants were lost due to rejection. These data highlight the potential of kidney paired donation and suggest that all transplant centers should be actively engaged in paired donation to increase access to live donor transplantation.

How not to communicate about kidney exchange

Kidney exchange, aka kidney paired donation is a great opportunity, but it has to be communicated to patients and donors. The state of the art is practiced by surgeons like Dr. Adam Bingaman in San Antonio, who makes sure that patients and donors hear about all options before they even begin to be tested for compatibility. That way, if they are incompatible, they're not surprised to hear they still have options.

Other hospitals only mention kidney exchange after testing donors and finding them incompatible with their intended recipient. Here's a few sentences of a story that makes that clear:

"After testing, Hendon received a letter from UCLA saying she was not a good match.

“I was so sad, almost devastated,” she said. “Then at the bottom of the letter, in tiny letters, it mentioned I could still be involved in a kidney exchange. I called them the next day and they seemed surprised that I still wanted to do it and started the process.”

"Once she was approved, it was not long before she was notified that they had a recipient waiting for her kidney."
*********

The donor in question participated in this nonsimultaneous extended altruistic donor (NEAD) chain.

Misc. kidney transplantation

In Texas, where everything is the biggest, the Texas Transplant Physician Group says they are the biggest "in Texas AND the United States."
"Our Living Paired Donor Kidney Transplant team made history in November, 2010, with the world's largest paired donor kidney transplant donor chain--with 16 transplants completed over three days. The 17th donor's "bridge" kidney was used to start another chain in December--extending the record-breaking chain to 23--still the largest single center kidney donor chain in the world! The kidney recipients ranged in age from 17 to 69 and all were transplanted with fully matched kidneys without the need for desensitization therapy. Dr. Adam Bingaman, Kidney and Pancreas Transplant Surgeon and Director of the Live Donor Kidney Transplant Program with Texas Transplant Physician Group is planning to extend the chain further in January, 2011.

"Read the local and national coverage this donor chain generated in our Kidney News section."

*********************

A story in the LA Times about a procedural error gives some insight into transplant procedures: Wrong patient got kidney at USC
"USC University Hospital halted kidney transplants last month after a kidney was accidentally transplanted into the wrong patient, according to a spokesman for the program that coordinates organ transplants in Los Angeles.

"The patient who received the wrong kidney escaped harm, apparently because the kidney happened to be an acceptable match, said Bryan Stewart, spokesman for the program, OneLegacy, which was notified of the error by the hospital.

"The hospital, which performs about two transplants a week, confirmed in a statement that it had voluntarily halted transplants Jan. 29 after a "process error" was discovered. The hospital did not detail the nature of the error and declined to answer questions. It said no patients were harmed.
...
"In general, immediately after a kidney is removed from a donor, it is placed in a plastic container with a screw-on lid. That container, labeled with an identification number, is then placed inside three sterile plastic bags, which are placed on ice in another container.


"The nurses in the operating room and the surgeon must check for the ID number on the kidney and compare that with the patient ID number," Klintmalm said.

"It is the operating room surgeon's responsibility to make sure the numbers match," he said. "You sign forms before you start the surgery."

****************
Flip Klijn writes: "Recently, several towns in the Netherlands started discussing the possibility to ask citizens directly whether they are willing to sign a donor form (i.e., to give permission for organ transplants at the time of decease) when they visit the city hall to pick up a driver's license or a passport. In Amsterdam, both left-wing and right-wing political parties seem to agree that this is a good idea: http://www.metronieuws.nl/regionaal/gemeente-amsterdam-ja-tegen-nieuw-plan-donoren/SrZkcu!QfBmXR4HMGY/

(There are already similar proposals in Rotterdam and The Hague. And probably for the US this is not something new.) In another city (Breda) they stopped asking "because citizens apparently did not like to be asked" (according to the city hall): http://www.bredavandaag.nl/nieuws/politiek/40539/2010-12-14/gemeente-breda-negeert-motie-d66

Kidney paired donation conference: financing kidney exchange

A conference in Philadelphia today will take a look at a so far unresolved aspect of kidney exchange: how to finance it. Since transplantation is far cheaper than dialysis, this shouldn't in principle be a big problem, but there are still lots of kinks to iron out in determining who pays for what. I spoke to a similarly constituted group in Minneapolis in 2007...
Kidney Paired Donation Conference, Philadelphia, Pennsylvania, WEDNESDAY, OCTOBER 27, 2010

8:00 a.m. Welcome and Opening Remarks, Chris Pricco, Chief Operating Officer, Complex Medical
Conditions, OptumHealth Care Solutions

8:05 a.m. Introduction and Conference Overview, Dennis Irwin, MD, National Medical Director, Transplant Solutions, Complex Medical Conditions, OptumHealth Care Solutions

8:15 a.m. Kidney Transplantation: Alternative Donors, Lloyd E. Ratner, MD, New York-Presb - Columbia
Campus

8:35 a.m. The Unmet Need for Kidney Transplantation as Viewed by the National Kidney Foundation,
Bryan Becker, MD, University of Illinois-Chicago

8:55 a.m. The OptumHealth/UnitedHealthcare Experience with End Stage Renal Disease, Kidney
Transplantation and the Unmet Need, F. Gregory Grillo MD, National Medical Director, Kidney
Resource Services, OptumHealth Care Solutions

9:15 a.m. The United Network for Organ Sharing (UNOS) Pilot, Kenneth Andreoni, The Ohio State
University Hospitals

Representation and Overview from UNOS Coordinating Centers

9:45 a.m. Ruthanne L Hanto RN MPH, New England Program for Kidney Exchange

10:00 a.m. Dorry Segev, MD, PhD, Johns Hopkins Hospital

10:15 a.m. Michael Rees, MD, PhD, Alliance for Paired Donation

10:30 a.m. Jeffrey L. Veale MD, Ronald Reagan UCLA Medical Center

Successful Single Center Experience with Paired Kidney Donation

10:45 a.m. John Friedewald, MD, Northwestern University Hospital

11:00 a.m. Adam Bingaman, MD, PhD, Texas Transplant Institute

11:30 a.m. National Kidney Registry, Garet Hil, National Kidney Registry (Invited)

11:45 a.m. Kidney Paired Donation from the Donor’s Perspective, John Milner, MD, Loyola University
Medical Center

12:00 p.m. The OPO perspective, Speaker TBD

12:15 p.m. Summary of the recent Living Kidney Donor Follow-Up: State of the Art and Future Directions
conference, Alan Leichtman, MD, University of Michigan

12:30 p.m. National Marrow Donor Program (NMDP): 23 Years of Experience in Establishing and
 Managing a Successful Program for Matching Willing Donors to Recipients, Jeffrey W. Chell,
MD, Chief Executive Officer, National Marrow Donor Program

1:30 p.m. Facilitated Discussion, Clifford Goodman, PhD, Vice President, The Lewin Group

4:00 p.m. Closing Remarks

Note: OptumHealth reserves the right to make any necessary changes to this program. Efforts will be made to keep presentations as scheduled. However, unforeseen circumstances may result in the substitution of faculty or content. Last Updated: 10/05/10

Single-hospital kidney exchanges in Texas and Illinois

A recent letter to the editor in the New England Journal of Medicine reports on the kidney exchange ("kidney paired donation") program at Methodist Specialty and Transplant Hospital in San Antonio, TX.

Bingaman AW, Wright FH, Murphey CL., "Kidney paired donation in live-donor kidney transplantation," N Engl J Med. 2010 Sep 9;363(11):1091-2.

"Our center established a KPD program enrolling all consenting recipient candidates who had incompatible donors as well as compatible pairs with donors over the age of 45 years. Since we initiated the program in March 2008, we have performed 83 KPD procedures, including 22 two-way and 13 three-way exchanges.
...
"If the productivity of our KPD program were to be replicated on a national level, it would potentially result in approximately 2000 additional
live-donor transplantations annually and reduce the number of patients on the waiting list. The increased use of this procedure would also probably avert many difficult desensitization therapies. No recent advance in transplantation has achieved such an apparent increase in access to live-donor transplantation, especially in sensitized patients.
"We believe that all transplantation centers should consider the development of an effective KPD program in order to give patients with incompatible donors a full range of options to achieve successful transplantation."

And here's a news report of another exchange at Northwestern Memorial Hospital.
All eight patients OK after four-way kidney transplant (Chicago Sun Times, Sept. 23, 2010)

"Arlene Hoffman was Jane Delimba's postal carrier for only about three months. But when Hoffman bumped into Delimba at a Wal-Mart seven years later and learned she needed a kidney transplant, Hoffman didn't hesitate to offer one of her own.

"The two weren't a compatible match.

"Still, Hoffman's generosity helped make it possible for four people, including Delimba, to receive kidney transplants last week in what's known as a "four-way paired exchange."

"In simultaneous operations that took place last Thursday at Northwestern Memorial Hospital, four living donors each gave up a kidney, and four people whose kidneys were failing each got one. All eight patients, ranging in age from 28 to 74, are doing well."

And from another story about that exchange: "Northwestern Memorial transplant surgeons performed their first paired exchange in 2006. To date, the hospital has completed 38 paired exchange transplants. "

Misc. kidney exchange news

A May 17, 2010 story: Innovative Transplant Procedure at Emory Opens Door to More Patients in Need

"The Emory Transplant Center at Emory University Hospital in Atlanta has recently opened its innovative Paired Donor Kidney Exchange Program, providing greater hope for patients in need of kidney transplants."
...
"Dr. Newell and his team this past month completed the third paired donor exchange surgeries involving a total of six patients - three donors and three recipients - from Texas, Colorado and Georgia. As part of this, as well as one of the two previous exchanges, Emory partnered with the Texas Transplant Institute in San Antonio, the largest independent paired donor program in the country. The program is led by Adam Bingaman, MD, a former Emory trainee who completed both his residency in general surgery and his PhD work at Emory School of Medicine. "To get the ball rolling initially on our program here at Emory, one of the first things we did was partner with the Alliance for Paired Donation," says Dr. Newell. "APD maintains a database of patients who have incompatible donors from over 50 other transplant centers, and the Alliance runs a computer program once a month to find matches between them.
"After about a year, we decided to focus on developing our own database rather than depending on APD's, and we naturally approached Dr. Bingaman about collaborating," says Newell. "Now, building our own listing of donor-recipient pairs remains paramount, an effort expedited by weekly meetings and consultations. Whenever new candidates are added, the data is shared with Dr. Bingaman's program, further increasing each patient's chance of receiving a compatible kidney from a living donor.""

Here's a paper in the June 2010 American Journal of Transplantation:
Ethical Considerations for Participation of Nondirected Living Donors in Kidney Exchange Programs
E.S. Woodle, J. A. Daller, M. Aeder, R. Shapiro, T. Sandholm, V. Casingal, D. Goldfarb, R. M. Lewis, J. Goebel and M. Siegler ; for the Paired Donation Network

ABSTRACT Kidneys from nondirected donors (NDDs) have historically been allocated directly to the deceased donor wait list (DDWL). Recently, however, NDDs have participated in kidney exchange (KE) procedures, including KE 'chains', which have received considerable media attention. This increasing application of KE chains with NDD participation has occurred with limited ethical analysis and without ethical guidelines. This article aims to provide a rigorous ethical evaluation of NDDs and chain KEs. NDDs and bridge donors (BDs) (i.e. living donors who link KE procedures within KE chains) raise several ethical concerns including coercion, privacy, confidentiality, exploitation and commercialization. In addition, although NDD participation in KE procedures may increase transplant numbers, it may also reduce NDD kidney allocation to the DDWL, and disadvantage vulnerable populations, particularly O blood group candidates. Open KE chains (also termed 'never-ending' chains) result in a permanent diversion of NDD kidneys from the DDWL. The concept of limited KE chains is discussed as an ethically preferable means for protecting NDDs and BDs from coercion and minimizing 'backing out', whereas 'honor systems' are rejected because they are coercive and override autonomy. Recent occurrences of BDs backing out argue for adoption of ethically based protective measures for NDD participation in KE.

Paying It Forward
Tulane surgeons performed what is believed to be the first “domino” paired-donor kidney exchange in Louisiana at Tulane Medical Center. Three patients in dire need of a kidney transplant received new organs from people they had never met.