First 16-patient, Multicenter 'Domino Donor' Kidney Transplant

"All Johns Hopkins patients are in good condition and are recovering as anticipated," according to Robert A. Montgomery, M.D., Ph.D., director of the Johns Hopkins Comprehensive Transplant Center.

The procedure, kidney paired donation (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 even 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," says Montgomery. "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, the first on June 15 and the last, July 6."

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, says Montgomery, and also ties up too many operating rooms.

He says this new model 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 started the domino effect. Altruistic donors are those willing to donate a kidney to any needy recipient. Just like falling dominoes, the altruistic donor kidney went to a recipient from one of the incompatible pairs, 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 who had been on the United Network for Organ Sharing (UNOS) waiting list.

One of the donors in this procedure was the Pamela Paulk, the vice president of human resources at The Johns Hopkins Hospital and Johns Hopkins Health System. Paulk, a long-time supporter of kidney donation, decided to donate to a friend and colleague who 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," says Paulk, whose surgery took place on June 22. Paulk joins roughly 100,000 Americans since 1988 who have generously 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, says Montgomery. For an up-to-date perspective from Paulk, please visit http://pameladonates.blogspot.com

As part of this complex procedure, Johns Hopkins flew one kidney to Henry Ford, one kidney to INTEGRIS Baptist and one kidney to Barnes-Jewish, In exchange, Henry Ford, INTEGRIS Baptists and Barnes Jewish each flew a kidney to Johns Hopkins.

The 16 surgeries were performed on four different dates, June 15, June 16, June 22 and July 6. The 10 surgeons in charge included four at Johns Hopkins, two at INTEGRIS Baptist, two at Barnes-Jewish and two at Henry Ford.

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.

Nearly 100 medical professionals took part in the transplants, including 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.

The other surgeons who participated in the surgery were Mohamad Allaf, M.D., Andrew Singer, M.D., and Dorry Segev, M.D., from the Johns Hopkins Department of Surgery; Scott Samara, M.D., and Shea Samara, M.D., from INTEGRIS Baptist Medical Center; Surendra Shenoy, M.D., Ph.D., and Martin Jendrisak, M.D., from Barnes-Jewish Hospital; and Dean Kim, M.D., and Lauren E. Malinzak, M.D., from Henry Ford Hospital.