Tuesday, April 6, 2010

The first kidney exchange in the U.S., and other accounts of early progress

The Student BMJ (a student run affiliate of the British Medical Journal) has an article interviewing the pioneering surgeons who conducted the first kidney exchange in the U.S., in 2000. (It's gated, but you can register for free.)

Anthony P Monaco and Paul E Morrissey: a pioneering paired kidney exchange
Transplant surgeons Anthony P Monaco and Paul E Morrissey performed the first paired kidney exchange in the United States
By: Prizzi Zarsadias
Published: 24 March 2010, Cite this as: Student BMJ 2010;18:c1562

The article is in interview form. Some highlights:
"When two patients found they were ABO incompatible with their live kidney donors it seemed that a long wait on the organ donor list awaited them. But by coincidence the donors were a match for each other’s recipient. Rather than lose this chance for both patients to receive a live kidney donation Anthony P Monaco and Paul E Morrissey saw an opportunity, and in 2000 they performed the first paired kidney donation in the United States. "

How did the first paired kidney donation come about?
Paul E Morrissey: We knew about paired donation from an experience in Korea. We had encountered articles about paired donation. Then these pairs simultaneously presented to us; it just clicked that we could exchange the donors. I wouldn’t attribute the idea to myself or Dr Monaco but to the entire team. We discussed it with 15 of our doctors and nurses, social workers, and various other people, and we agreed that it would be something that we would propose to the family.

How did the patients in the first exchange fare?
PEM: The surgeries were uneventful. One recipient had great kidney function. The second had recurrence of the original disease and a bad acute rejection shortly after the transplant and went back onto dialysis several weeks after the transplant. One outcome was not good. The other patient did fantastically. Any time that a living donation doesn’t work is sad. And in this circumstance, to have had a child make a donation for a parent and to have it work out for the person she donated to but not work out for the parent was sad and unfortunate.

What was the worst case scenario?
PEM: This would be close to it; the success rate for a live kidney donation is in the neighbourhood of 98% or so. This might happen once in every 50. It’s an extremely unusual circumstance for any living donation, and in this setting it adds to the unhappiness. There was a lot of hand holding for the recipient with the failed kidney but also for the donor. There was a lot of follow-up on a longitudinal basis. They are both alive and well today but who knows exactly what emotion they harbour, and I hope that the other patient is enjoying the outcome of her operation.
APM: The worst case scenario for any living transplant would be that the recipient or donor die because of surgery. We haven’t seen that, but that’s the risk in this scenario. We’ve had recipients who have died a week or two later, but that has not happened with swap transplants.
PEM: We inform the patients more of the adverse outcomes. It was, of course, at the forefront of our minds when we proceeded the second time.

During the first exchange did you envisage the technique’s success?
APM: We did not envision it, but we were not surprised that it has grown because it works well. There is a natural evolutionary process to extend it into other situations. We do swaps that involve not just ABO incompatibility; we also swap kidneys between pairs that are incompatible because of HLA antibodies. We are also currently working on a five-way swap.
PEM: The credit obviously goes to countless groups throughout the country that have pushed it forward. In particular the group in our organ procurement organisation, the New England Organ Bank, has really been a leader in taking this forward nationally but at the time that we did this, we didn’t have thoughts about expanding it beyond the reaches of our own programme. I think that they’ll continue to grow out of necessity.

The article begins with these biographical details:
Anthony P Monaco
Peter Medawar professor of transplantation surgery, Harvard University, emeritus director of the Beth Israel Deaconess Harvard Medical Center Transplant Program, and director of the Rhode Island Hospital Transplant Services
Biography—After graduating from Harvard Medical School in 1956 his career has spanned five decades. In that time he has published more than 470 papers and has held the post of editor of Transplantation for 32 years until 2001 and has been the special features editor for the same journal ever since. He is also a trustee of the New England Organ Bank.

Paul E Morrissey
Associate professor of surgery and transplant surgeon at Rhode Island Hospital and assistant medical director for the New England Organ Bank
Biography—Trained at the University of Massachusetts and held residencies and research fellowships at Yale and Harvard Medical Schools. He has been a transplant surgeon at Rhode Island Hospital since 1997 and has been surgical director of the Division of Organ Transplant since 2002. He has been awarded many honours, including the Thomas Murray award from the Rhode Island Organ Donor Awareness Coalition. "

As the article indicates, an earlier exchange had been carried out in S. Korea. Another country that has been active in kidney exchange is Holland, and a recent report of their experience is in the April 2010 issue of the American Journal of Transplantation: "Altruistic Donor Triggered Domino-Paired Kidney Donation for Unsuccessful Couples from the Kidney-Exchange Program" by Roodnat, J. I.; Zuidema, W.; van de Wetering, J.; de Klerk, M.; Erdman, R. A. M.; Massey, E. K.; Hilhorst, M. T.; IJzermans, J. N. M.; Weimar, W.

The New England Program for Kidney Exchange (the institutional descendent of that first U.S. exchange by Monaco and Morrissey) maintains a page listing Kidney Exchange:A Chronology of Scientific Contributions (scroll to the bottom of that page).

While I'm on the subject of important firsts, donating a kidney became much easier with the introduction of laproscopic kidney nephrectomies for donor kidneys (taking the kidney out via a small incision instead of a big one). Here's the article by Lloyd Ratner et al. reporting the first one:

Laparoscopic live donor nephrectomy.
Ratner LE, Ciseck LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR., Transplantation. 1995 Nov 15;60(9):1047-9.

"A laparoscopic live-donor nephrectomy was performed on a 40-year-old man. The kidney was removed intact via a 9-cm infraumbilical midline incision. Warm ischemia was limited to less than 5 min. Immediately upon revascularization, the allograft produced urine. By the second postoperative day, the recipient's serum creatinine had decreased to 0.7 mg/dl. The donor's postoperative course was uneventful. He experienced minimal discomfort and was discharged home on the first postoperative day. We conclude that laparoscopic donor nephrectomy is feasible. It can be performed without apparent deleterious effects to either the donor or the recipient. The limited discomfort and rapid convalescence enjoyed by our patient indicate that this technique may prove to be advantageous."

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