When I started my medical career in nephrology in the late 1960s, the best treatment we offered patients with end-stage kidney disease was dialysis. Kidney transplantation once required special approval by hospital administration, but is now a standard of care. In 2020 alone, my colleagues and I at AdventHealth Orlando collectively performed 180 kidney transplants.
The calling
As a medical student, I was assigned a 16-year-old patient who had rapidly developed kidney failure. I sat with this boy's parents, watched him pass and right then knew I needed to learn as much as possible about kidney disease to help prevent such heartbreaking loss.
In the 1970s, while serving as director for a kidney dialysis physician training program in Miami, I met Dr. John Fleming, an internist from Florida Hospital (now AdventHealth). He had a teenage patient on dialysis in Orlando named Rochelle, and while he had some experience in nephrology, he wanted to learn more to better care for her.
Soon after he completed training, John invited my family to spend the weekend with him. We fell in love with the area and relocated to Orlando where I established my nephrology practice and began taking consults at what is now AdventHealth Orlando.
John's patient Rochelle became one of my first patients. We learned that Rochelle had a brother who was compatible for kidney donation. To give Rochelle a new lease on life, the hospital's administrator gave approval for us to perform the hospital's first kidney transplant in January 1973.
A few months later, the federal government launched the end-stage renal disease program under Medicare. Institutions that had performed a kidney transplant prior to this new legislation were automatically grandfathered in as a transplant center. We had already performed five, and thus AdventHealth's kidney transplant program was officially born, becoming one of the first community hospitals to offer this life-saving surgery.
The growth of transplantation
In the 1980s and 1990s, numerous medical advancements helped improve the effectiveness of kidney transplantation, including innovations in tissue typing, organ preservation and immunosuppressive drugs to decrease rejection.
One important development, and something I worked hard on, involved improving the organ procurement process. In the early days, one of our greatest challenges involved finding donor kidneys. I frequently made rounds in intensive-care units in case they had someone who might be a donor candidate.
Fortunately, the National Organ Transplant Act passed in 1984, which established the Organ Procurement and Transplant Network (OPTN). This network provided a national system for organ recovery and allocation, alleviating transplant physicians from this difficult task. The not-for-profit United Network for Organ Sharing (UNOS) received the federal contract to operate OPTN and has maintained that responsibility ever since.
During the mid-1980s, I became the founding medical director of TransLife (now OurLegacy), an organ procurement organization assigned by OPTN/UNOS to recover organs from hospitals in 10 counties of east central Florida. This new system improved access and enabled physicians to help more patients in need.
Despite the ever-increasing need for transplants, there were still a lot of kidneys discarded, and as a result, patients dying each day. In 2002, as chair of the organ availability committee of OPTN/UNOS, I led the establishment of the expanded criteria donor (ECD) allocation system allowing us to procure kidneys for higher-risk patients who are lower on the transplant list. This enabled us to salvage additional donor kidneys for patients who weren't expected to live long enough to make it to the top of the list.
The Kidney Donor Profile Index (KDPI) eventually replaced ECD. This new metric combines a variety of donor factors into a single number that summarizes the likelihood of graft failure after deceased donor kidney transplant. I continued to work through UNOS to ensure kidneys with a KDPI index of 85% or greater remain available to higher-risk patients who are lower on the transplant list.
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Looking to the future
Thanks to continuous innovation, more patients are able to receive the gift of life. Since 1988, over 515,000 kidneys have been transplanted in the U.S. Recently transplants from all types of donors rose from about 23,400 in 2019 to roughly 24,700 in 2021. While these numbers are impressive, there is still much work to do.
UNOS is leading an exciting new data-driven development called continuous distribution, in which several AdventHealth staff members are actively involved serving on UNOS committees. Continuous distribution leverages big data analytics to consider multiple factors, like medical urgency, expected post-transplant outcome, candidate biology, patient access and efficiency of organ placement, instead of only evaluating limited categories, such as blood type and location. It is a more flexible approach to allocating organs, and it ensures no single factor determines a patient's priority on the waiting list.
Furthermore, throughout my career, transplant researchers have been studying the feasibility of porcine (pig) kidney transplantation in humans, as this could significantly expand the availability of organs to meet growing patient need. While there are still significant hurdles and ethical concerns to address, this could be an important step forward.
As I reflect on the last 60 years, I believe we're in an exciting and promising era for transplant medicine. My greatest reward will always be the patients I served and the better lives we gave them through transplantation.
