Increasing the Odds
Increasing the Odds | Luis Campos, M.D., Surgeon Director of Kidney Transplantation, Methodist University Hospital Transplant Institute, MUHTI, National Kidney Registry,  NKR, UNOS, United Network for Organ Sharing,

UTHSC, Chancellor Steve Schwab, M.D., UTHSC. James Eason, M.D., Transplant Program Director, UTHSC, paired kidney donor, paired kidney exhange

Methodist University Hospital Transplant Institute Offers Paired Kidney Donor Program

Almost 90,000 people in the U.S. are waiting for a kidney transplant and on any given day 12 people die waiting for a kidney donor. Only some 11,000 receive kidneys a year. To respond to the increasing number and needs of their patients, the Methodist University Hospital Transplant Institute (MUHTI) in partnership with the University of Tennessee has formed a new alliance with the National Kidney Registry (NKR) to give patients better odds of successfully finding a kidney donor, according to Luis Campos, MD. Campos serves as the surgeon director of kidney transplantation at MUHTI.

“We are the only program in Tenn. that uses the National Kidney Registry and possibly the only one that uses any kind of paired donation,” said Campos. The Institute wanted to offer the NKR program to their patients for many reasons, he added. “The first is that we want to be able to have more living donors.  (Living donor kidneys) do better, last longer and the transplant surgeries are done in a controlled way so that recipients can be stabilized medically before getting the transplant.”

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“The second reason,” Campos continued, “is that we want to avoid having our patients placed on high-risk protocols designed to desensitize them. Certain recipients, having had pregnancies, a blood transfusion or previous kidney transplants, produce antibodies. When you cross match them with a potential donor, the match will be ‘positive’ which means that that donor cannot give that recipient a kidney (i.e. recipient is sensitized). As a result, the patient must be put on a list to receive a deceased donor kidney which can take anywhere from 3-10 years.”

The third reason he gave for offering the program was “the NKR can find kidneys sooner, due to a sophisticated computer matching program they developed.” The average wait time for NKR patients is 11 months for a living donor match, whereas the wait time for a deceased donor kidney is 48 months.

Lastly, Campos said, “The matching service is free to the donors and recipients.”

While NKR is not the oldest or the largest paired exchange program, they offer the best chances in terms of matching donors to recipients for a program the size of the Institute’s, explained Campos. “Presently, we perform 100 kidney transplants a year.”

“The paired kidney donation in concept has been around forever,” said Campos.  In times past, however, patients were reluctant to ask a living donor outside their family or circle of friends about their willingness to donate a kidney. While it has been done within major institutions with big programs, typically, there has been no ‘public’ asking of strangers for kidneys. “It has been our patients who have pushed us to explore new territory,” he added.

The National Kidney Registry was developed by a Wall Street businessman, Garet Hill, whose ten-year-old daughter’s kidneys failed. Although previous testing confirmed they were both Type A and compatible, thirty-six hours before her surgery was scheduled, he was told that his daughter would reject his donated kidney. Understandably, Hill was very frustrated by the very systems in place to help.

Though, ultimately, his daughter did receive a kidney from a distant cousin, Hill felt there had to be a faster and more effective way to match donors with kidney recipients and vowed to develop a new system, superior to the one which had failed his daughter and countless others – one that would pool all donors and recipients in a single database. “He challenged the medical profession, brought in the best IT and biostatistics experts and privately created a very good computer program,” said Campos.

Thus, the National Kidney Registry was born out of a father’s personal campaign to find live donor kidneys for people in failure, like his daughter, and he dedicated the resources required to create a computer program which resolves the complexities of matching up donors and recipients. NKR’s success is beyond expectation and growing. So far 288 transplants have been facilitated by NKR.

“Another thing the National Kidney Registry program has demonstrated is that you can actually procure the kidney, put it in preservation solution, and either walk it across the hall to the recipient or put it in a box and send it across the nation to a recipient – we have excellent results if the kidney is transplanted within up to 22 hours. The kidney starts working right away and the patient doesn’t need dialysis,” Campos pointed out.

For years the gold standard was putting the donor and recipient asleep at the same time across the hall from each other and transplanting the kidney as soon as possible – reducing the cold ischemic time. Traditional thought was that the shorter time the kidney was outside the body, the better. This concept was turned on its ear when it was discovered that the old method does not produce better results, explained Campos.

“Delayed graft function is extremely low, which is amazing,” said Campos. “All of these kidneys have worked and none have been lost.”

Sadly, kidneys don’t last forever – the median survival time for a kidney transplant is 12-15 years, according to Campos. “We still don’t have the perfect immunosuppressant medications. Some actually produce renal failure over time. And there is also chronic rejection, which is different from acute rejection. We really don’t know why it happens or how to treat it.” Fibrosis occurs with chronic rejection and the kidney eventually stops working.

That doesn’t mean that some transplanted kidneys don’t last 20-30 years; some do even with a deceased donor kidney, but that is not the norm. It is not unusual for patients to undergo two, three, or even four transplants over a lifetime.

Renal failure will increase as the population ages, warned Campos, due to obesity, diabetes, and hypertension becoming more prevalent. Lack of access to primary care is also a huge issue for society. It is not unusual for patients to receive a diagnosis for all three conditions in an ER visit after neglecting their health, only to learn that they need a kidney transplant all at the same time, said Campos.

“We are very happy that we can offer this (registry) service to our patients. We have a small program but we have already identified two pairs

(of donor/recipients) and there are three more pairs that we are beginning to work up.

The paired kidney exchange works in the following manner. The donor offers a kidney to a recipient who has an immunologically incompatible donor.  Additional donor/recipient pairs enter the registry who are also incompatible, so being a part of the larger pool increases the odds that there is a compatible donor for each recipient.

Another way that paired exchanges can occur is for a chain to be initiated by an altruistic donor (a non-directed donor) who offers a kidney to an unknown recipient who proves to be a good match. This becomes a “pay it forward” practice for those individuals willing to offer the life-saving gift of a kidney to a stranger. They begin a chain that can result in multiple recipients being matched to compatible donors who enter the registry and save many lives in succession rather than just one.

Almost magically, the greater the number of pairs of donor/recipients entered in the registry, the possibilities multiply exponentially.

Transplant patients are on immunosuppressive medications for life and must manage their weight and practice good nutrition for optimal results. “We spend a lot of time educating our patients. Hypertension is the number one killer of transplanted kidneys,” said Campos, “so compliance is a big issue.”

Presently only 20 percent of the institute’s kidneys come from living donors (the national average is 40 percent). This was a strong incentive for the MUHTI to use the NKR. With use of NKR’s paired exchange kidney program, an increase of 20 percent (resulting in as many as 2,000 - 3,000 more kidneys) could become available from live donors.

UNOS (United Network for Organ Sharing) is a 501(c)(3) organization that presently manages deceased donor donations. Campos said it is possible that UNOS may develop a paired exchange program in time but no plan has been implemented to manage a living donor program and it could be years before they offer a matched live donor paired kidney program.

Probably few in the medical community are aware that MUHTI is the 6th oldest kidney transplant program in the country, having performed its first in 1970. Over 2,000 kidney transplants have been performed to date. “We are raising awareness that this program is still growing and thriving and available to those who need it in the community and beyond,” stressed Campos. “We are open 24 hours/7 days a week.”

MUHTI is also a unique transplantation program in the country, having the distinction of having 100 percent dedicated physicians, medical specialists and surgeons, nurses, nursing practitioners, and social workers who work together under the same roof at the Institute’s offices.

UTHSC Chancellor Steve Schwab, MD, and James Eason, MD, transplant program director worked together to make it a reality. “The collegiality is incredible; we have a unique bond,” Campos said. Most programs have a transplant division and a medical division that work together but the physicians belong to their respective medicine and surgery departments. At the Institute, they are one and the same. “Our hearts are in the transplant department,” claimed Campos.