Surgeons In the Newss

The Logistics of Life-Saving: First Kidney Swap Performed at NewYork-Presbyterian/Columbia

The first kidney swap in New York State was performed at NewYork-Presbyterian Hospital/Columbia University Medical on September 29, 2004. Only a handful of kidney swaps have been performed nationwide to date. "A kidney swap, or paired exchange, essentially involves taking patients who have potential donors who are medically suitable and willing, but blood group incompatible, and swapping donors so that two patients can get kidney transplants where previously neither would have been able to," says Dr. Lloyd Ratner, Surgical Director of the Renal Transplant Program at NewYork-Presbyterian/Columbia.

Kidney swapping is part of a new program Dr. Ratner has recently spearheaded at NewYork-Presbyterian/Columbia, The Incompatible Kidney Transplant Program. Ideally, to be eligible for transplant, kidney donors and recipients should have compatible blood and tissue, but often family members do not meet these criteria. Patients can now successfully receive kidneys from someone with a different blood, or donors whom they have antibodies against. However, it is safer, easier, and less costly to receive a kidney from someone of a compatible blood type or who is immunologically compatible. A creative solution, kidney swaps can arrange the perfect opportunity for a family member who is immunologically incompatible with his/her own blood relative to form a suitable exchange with another family.

"We had one patient who needed a kidney transplant and he was blood group B. His sister, who wanted to donate to him, was blood group A. We had another woman who needed a kidney transplant who was blood group A, but her stepmother, who wanted to donate to her, was blood group B. So we basically swapped donors," explains Dr. Ratner. "To make sure that no one backs out once their loved one gets a kidney, both donors have to undergo anesthesia and have the surgery at the same. Since we normally do the donor and recipient operation simultaneously, that means we must have all four patients being operated on simultaneously. We need four hospital rooms, four surgical teams, four sets of anesthesiologists, etc. The logistics need to be synchronized perfectly."

During the swap, the four patients underwent surgery in neighboring operating rooms. The two donors and two recipients were complete strangers, who could potentially provide each other with a new extension on life. Dr. Ratner oversaw the swap, working with attending surgeons Drs. Mark Hardy, Marc Bessler, and Roman Nowygrod. Dr. John Birkhoff assisted with both recipients. Once the donor kidneys were successfully removed, they were slipped onto ice and passed on to the surgeons in the adjacent rooms who were waiting to perform the transplants.

When asked about the particular challenges of a kidney swap, Dr. Ratner responds, "The transplants themselves are routine and straightforward, but there are a fair amount of tricky logistical issues involved. We try and maintain the anonymity between the two sets of donors and recipients. Let's say someone decides they want to back out at the last minute; we don't want the other family harassing them or trying to coerce them into donating. We also don't want them to meet beforehand because what if they don't get along? One person might say, 'I don't want to give my kidney to that jerk.' A meeting could wind up scuttling the whole thing. They can meet afterwards, only if all four parties agree—as they did in this case."

In addition to the logistical challenges, the choice of the institution is critical. "Not every medical center can field four transplant teams simultaneously," explains Dr. Ratner. "NewYork-Presbyterian/Columbia has the manpower and resources to do this. One of the reasons I came here was to establish the Incompatible Kidney Transplant Program. We are always on the lookout for patients who have incompatibilities and we are hopeful that this will be the first of many successful swaps we will perform."

Dr. Ratner believes the great benefit of this procedure is that it provides two patients with transplants where previously neither of them would have been likely to receive a live donor transplant. "With the kidney swap our goal is to make optimal use of live donors and get people off the transplant waiting-list and back to their normal productive lives. The reality is there aren't enough organs to go around for transplantation, so we have to be creative and come up with new strategies to get as many organs transplanted as we safely can." A second kidney swap is scheduled to be performed at NewYork-Presbyterian/Columbia in mid-October 2004.

For further information regarding the Incompatible Kidney Transplant Program, which includes the donor swaps, blood group incompatible kidney transplants, and transplants despite the presence of donor-specific antibodies, please contact Dr. Lloyd Ratner, or Joan Kelly, Transplant Coordinator, at 212.305.6393.