Could 'reused' transplanted kidneys solve the waitlist problem? Some docs think so
Las Vegas resident Vertis Boyce has always liked to travel to visit friends and family. But for the past 9½ years, her travel has been limited by her need for dialysis treatments. Boyce experienced renal failure in 2008 due to a combination of high blood pressure and a genetic disposition.
"Traveling was an inconvenience because I always had to set up appointments for dialysis in each city that I would visit," Boyce said.
Things changed for the better however last July, when Boyce, 70, received a kidney transplant after being on the waiting list for nine years. Boyce's procedure was one of more than 34,700 organ transplants performed in the U.S. in 2017, marking a new record.
But what made Boyce's transplant nearly unique was the fact that she was the third person to have the same kidney, thanks to a procedure that had been performed only a few times since it was first introduced in the U.S. nearly a decade ago.
Boyce's kidney came from a 25-year-old man who had received it in a transplant in 2015. A 17-year-old girl who had died was the source of the kidney, which was functioning well inside the first recipient until he died in a car accident in 2017.
Such transplants have not been widely performed because of the procedure's complexity, as well as the fact that the damage a kidney usually sustains after an initial transplant makes it a poor candidate for a second procedure.
But the team that performed Boyce's surgery is hopeful the technique can reveal the potential for reusing viable kidneys to become a standard medical practice at transplantation centers and help reduce the shortage of available organs.
Normally if a transplant recipient unexpectedly dies or when the organ is rejected, the donated kidney is discarded. In 2013 more than 16% of all kidneys recovered from deceased donors were discarded, according to the U.S. Renal Data System.
"I didn't want to see a high-functioning kidney get wasted," said Dr. Jeffrey Veale, a transplant surgeon at Ronald Reagan UCLA Medical Center. Veale has performed three procedures during which a donor's kidney was reused in another patient.
He said as many as a quarter of kidney transplant recipients die with a functioning kidney.
After a kidney is transplanted, scar tissue can form around the organ; that makes reusing it more difficult because the surgeon can't attach it to vital blood vessels.
Veale addressed that problem by removing the second donor's iliac blood vessels that go into the leg and sewing them into Boyce.
"I sewed the first donor's kidney along with the second patient's vessels, and they all kind of work together to help the third person get off dialysis," Veale said.
Arguably the greatest factor in the procedure's success was the health of the kidney, which was in good enough shape for a second transplant despite being inside the first recipient for two years, during which the patient underwent a daily regimen of toxic anti-rejection medications.
Yet Veale was confident the procedure he performed could be duplicated by others more frequently.
"Without even trying I was able to do three in 2017," Veale said. "Could you imagine if we had all 230 transplant centers doing this?"
Others did not sound as optimistic about the procedure's potential. "It is not a common practice, but it's really the amount of time from the first transplant that will dictate whether that kidney can be reused or not," said Dr. Lorenzo Gallon, professor of medicine and surgery and director of the Transplant Nephrology Fellowship program at Northwestern University's Feinberg School of Medicine in Chicago.
In 2012, Gallon was part the Northwestern Medicine transplant team that conducted the first successful removal and implantation of a kidney from one patient to another after the organ failed in the first recipient. The findings of the case were published in the New England Journal of Medicine.
In that case, the kidney came from a living donor and three weeks passed between the first and second transplant.
"For a short period of time, I think there is the possibility of reopening the window (to re-transplant the kidney) when someone dies," Gallon said, adding that scar tissue can begin to form around the newly transplanted kidney within four weeks. "Unfortunately, this is how the body reacts to foreign organs."
Kidney transplants by the numbers
20%Growth in number of organ transplants from 2012 to 2016—UNOS48% lowerThe five-year risk of mortality among those who received a kidney from a deceased donor, compared with a patient on dialysis. —Transplantation661,000Number of Americans who have end-stage renal disease in the U.S.—Mayo Clinic$32,000Average per-patient cost for a kidney transplant in the U.S.$89,000Average per-patient cost of hemodialysis in U.S. for a total of $42 billion annually—University of California at San Francisco
Whether or not re-transplantation happens more frequently, the need to meet the rising demand for kidney donors has experts re-thinking the current organ donation framework to increase efficiency and access for waiting patients.
Currently, more than 95,000 people are waiting for a kidney transplant, according to the not-for-profit United Network for Organ Sharing, which administers the country's organ transplantation network.
The average wait time to receive a kidney in the U.S. is three to five years, but the wait can be up to seven years in some parts of the country. An estimated 4,500 people die annually waiting for a transplant, according to the Living Kidney Donors Network.
Gallon said one possible way to address lengthy wait times is for hospitals to create target lists of patients who will benefit from receiving a kidney transplant sooner compared with other patients. The national waiting list system gives first priority to those who've spent the longest time on the list.
Another solution would be using kidneys that in the past would have been discarded because they came from a patient suffering from certain treatable or manageable diseases even if the transplant recipient had the same disease, like HIV or hepatitis C.
"Obviously that doesn't increase the number (of organs) drastically but it increases it a little bit," Gallon said.
It's a problem that is expected to only get worse in the coming years as the country's elderly population increases. The percentage of adults ages 30 or older who will develop chronic kidney disease is projected to increase from 13.2% currently to 16.7% by 2030, according to a 2015 study published in the American Journal of Kidney Diseases.
Other proposals have called for the government to compensate living kidney donors to encourage more people to donate. A 2016 study published in the American Journal of Transplantation estimated a program that had the government compensate kidney donors would save taxpayers an estimated $403,000 a year per kidney dialysis patient for a total savings of about $2.6 billion annually.
Some of the demand for transplant kidneys in recent years has been offset by the opioid epidemic, which has driven an increase in deceased donor organs as a result of the record number of individuals who have died from drug overdose. Organ transplants that came from overdose death rose from 1.1% of all donors in 2000 to 13.4% in 2017.
The crux of the kidney shortage, according to Dr. John Friedewald, medical director of kidney and pancreas transplantation at Northwestern Memorial Hospital in Chicago, lies in being able to successfully harvest donated kidneys and preserve them long enough to be transplanted.
A 2016 study by the United Network for Organ Sharing found the discard rate for deceased-donor kidneys more than tripled from 5.1% in 1988 to 19.2% by 2009, the most recent data available.
"We have been fairly successful in getting people to sign up to be organ donors," said Friedewald. "One of the challenges we have is getting the organs out and keeping them healthy until we can get them into the next person."
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