Paired Kidney Exchange: A Major Breakthrough in Kidney Transplantation

By Matthew Cooper, M.D.
Director of Kidney Transplantation

Transplantation is about opportunity. The hardest part about choosing a career in transplantation is knowing the limits of perhaps the most ‘valuable’ valuable resource on this earth – lifesaving organs for those that desperately need them. Every day people die on the waiting list as that opportunity never comes, and the numbers of those added to that list grows exponentially.

We can never allow ourselves to think that there is no room for growth in transplantation. We can never be comfortable with the status quo and must continually reach for that next breakthrough, the next discovery, the next opportunity. The University of Maryland’s Division of Transplantation prides itself on being the place where people come for answers when others leave them with questions.

The University of Maryland has always been a leader in both surgical innovation and opportunities for patients in transplantation. Paired kidney exchange (PKE) is yet another opportunity we offer.  The program is designed for patients that have a living donor that is otherwise healthy and suitable for donation but incompatible with their intended recipient.  In years past we were forced to tell both the donor and the recipient that the only option was to wait an expected 3-5 years for a deceased donor transplant, knowing many would never see that day.

As more and more pairs were found to be incompatible we knew we had to find another opportunity.  Through paired kidney exchange we’ve turned ‘no’ into ‘yes’ and are excited about the possibilities. We’ve invested significant resources —  including designated clinical nurse coordinators — to maintain this specialty program and multiple assistants in our office to facilitate such procedures.

In recent months we’ve performed a four-way kidney exchange, involving eight people from four states, a two-way kidney exchange with a hospital in Minnesota and a third exchange involving a patient at Johns Hopkins, and we have more lifesaving kidney exchanges in the works.

The paired exchange program is an opportunity not all centers are able to offer, in part due to the complexity of the organization necessary to plan these procedures either within the institution or with other medical centers.   This may require flying an organ to another part of the country or operating very early in the morning or late at night to minimize the time the organ is waiting to be transplanted.   Also, there needs to be an institutional commitment, especially with the operating room, to provide space for these multiple transplants and/or odd timing for an operation.  We set high expectations for this transplant program, eliminate barriers for patients, and open the door for many to receive the Gift of Life.

This new program has brought great energy to the transplant division.  We’re seeing patients who either because of blood type incompatibility or high levels of antibodies to their donor now are finding matches after long years of waiting.  We’re seeing their intended donors (most of them close family members) excited about the chance to not only see their loved one free from dialysis but also having the opportunity to help another.  The ‘trickle down’ effect is a miracle itself.  Patients are now coming with potential donors for the PKE program that they never considered because of previous knowledge of blood type incompatibility.  Everyone is now an ‘opportunity’ for one another.

We take living donation very seriously.  We are bound by the principle of “Do No Harm” first and foremost.  Our standards of evaluation and safety of living donation are the highest in the country.  We place great value on the trust not only of the donor but of the recipient and their families who look to us to care for their Hero who comes offering this gift of new life.

We believe our standards must be even higher for donors in the PKE program, as they most often have never met the intended recipient of their donated kidney.  Ethically, while we maintain the privacy of all those involved in the exchange, we still demand the informed consent of all donors and recipients and answer all questions until it is clear and understandable.

We will continue to look for new and better answers for patients seeking to avoid the effects of end-stage renal disease.  We can no longer look at incompatibility with a living donor as an excuse to deny kidney disease patients the Gift of Life.  Paired kidney exchanges will become the standard of care across major transplant centers and will be a regular activity here at the University of Maryland, where we are committed to doing all we can to advance the state of the art in kidney transplantation for our patients.