July 20, 2009

16 patients, 8 ‘new’ kidneys, 4 hospitals: Johns Hopkins surgeons lead largest-ever ‘domino donor’ kidney transplant

Surgical teams at The Johns Hopkins Hospital in Baltimore, Barnes-Jewish Hospital in St. Louis, INTEGRIS Baptist Medical Center in Oklahoma City and Henry Ford Hospital in Detroit successfully completed the first eight-way multihospital domino kidney transplant. The transplant involved eight donors (three men and five women) and eight organ recipients (three men and five women). “All Johns Hopkins patients are in good condition and are recovering as anticipated,” said Robert A. Montgomery, director of the Johns Hopkins Comprehensive Transplant Center.

The procedure, kidney paired donation, or KPD, takes a group of incompatible donor-recipient pairs (recipients coming to one of the four hospitals with a willing donor who is not compatible by blood or tissue) and matches them with other pairs in a similar predicament. By exchanging kidneys between the pairs, it is possible to give each recipient a compatible kidney. In this way, each recipient receives a kidney from a stranger, and transplants are enabled that otherwise would not have taken place. Involving multiple hospitals created more possibilities for matches, but it also made the procedure more complex.

“We performed a similar, six-way domino procedure involving three hospitals earlier this year,” Montgomery said, “[and] we managed to perform all those surgeries on the same day. However, adding two more recipients, two more donors and another hospital meant that we needed a multihospital team of eight anesthesiologists, 16 nurses and nine surgeons. The logistics being that much more complicated, we decided it was best to spread the surgeries over several days.”

Aside from sheer logistics, performing large numbers of transplants on one day puts a lot of strain on the doctors, nurses and staff at each hospital, Montgomery says, and also ties up too many operating rooms. This new model, he says, will serve as a blueprint for a national KPD program in which kidneys will be transported around the country, resulting in an estimated 1,500 additional transplants each year.

An altruistic donor—one who is willing to donate a kidney to any needy recipient—started the domino effect. Just like falling dominoes, that donor’s kidney went to a recipient from an incompatible pair, that recipient’s donor’s kidney went to a recipient from a second pair and so on. The last remaining kidney from the final incompatible pair went to a recipient on the United Network for Organ Sharing waiting list.

One of the donors in this procedure was Pamela Paulk, vice president for human resources at The Johns Hopkins Hospital and Johns Hopkins Health System. (See accompanying story.)

Paulk, a longtime supporter of kidney donation, decided to donate to a friend and colleague who had lost function of his kidneys three years ago. “I always knew I was going to donate. I was just waiting for the right time, and this was the right time,” said Paulk, whose surgery took place on June 22.

Paulk joins roughly 100,000 Americans who, since 1988, have donated a kidney to needy recipients, according to data from the UNOS Web site. As encouraging as that sounds, 84,000 people in the United States alone are currently listed by UNOS as needing a kidney. With only about 6,000 people donating kidneys annually, we are a long way from eliminating this problem, Montgomery says.

As part of the complex procedure, Johns Hopkins flew one kidney to Henry Ford, one to INTEGRIS Baptist and one to Barnes-Jewish; in exchange, each of those hospitals flew a kidney to Johns Hopkins.

The 16 surgeries were performed on four different dates, June 15, 16 and 22 and July 6, with nearly 100 medical professionals—immunogeneticists, anesthesiologists, operating room nurses, nephrologists, transfusion medicine physicians, critical care doctors, nurse coordinators, technicians, social workers, psychologists, pharmacists, financial coordinators and administrative support people—taking part.

The other surgeons who participated were Mohamad Allaf, Andrew Singer and Dorry Segev, at Johns Hopkins; Scott Samara and Shea Samara, at INTEGRIS Baptist Medical Center; Surendra Shenoy and Martin Jendrisak, at Barnes-Jewish Hospital; and Dean Kim and Lauren E. Malinzak, at Henry Ford Hospital.

Johns Hopkins surgeons performed one of the first KPD transplants in the United States, in 2001; the first triple swap, in 2003; the first double and triple domino transplant, in 2005; the first five-way domino transplant, in 2006; and the first six-way domino transplant, in 2007. Johns Hopkins also performed the first multihospital transcontinental three-way swap transplant, in 2007, and the first multihospital transcontinental six-way swap transplant, in 2009.