Johns Hopkins Leads First 12-Patient, Multicenter "Domino Donor" Kidney Transplant

Surgical teams at The Johns Hopkins Hospital, Barnes-Jewish Hospital in St. Louis and Integris Baptist Medical Center in Oklahoma City successfully completed Saturday the first six-way, multihospital, domino kidney transplant. All six donors — one man and five women, and six organ recipients – four men and two woman — are in good condition, according to Robert Montgomery, M.D., Ph.D., chief transplant surgeon at Johns Hopkins.

The procedure, kidney paired donation (KPD), takes a group of incompatible donor-recipient pairs (recipients coming to one of the three 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.

In Saturday’s so-called domino swap, a surgical team made up of nine surgeons, six anesthesiologists and 12 nurses began a cross-country set of operations with five incompatible pairs. An altruistic donor and a recipient who was next on the United Network for Organ Sharing (UNOS) organ recipient list started and ended the domino. 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 the UNOS recipient.

As part of this complex procedure, Johns Hopkins flew one kidney to Integris Baptist; Integris Baptist flew one kidney to Barnes-Jewish and Barnes-Jewish flew one kidney to Johns Hopkins.

“We have performed a six-way domino procedure at our hospital before,” says Montgomery. “But this is the first time we have done something this ambitious on such a grand scale involving two other hospitals. This will serve as a blueprint for national match in which kidneys will be transported around the country resulting in an estimated 1,500 additional transplants each year.”

The 12 surgeries — all of which must start at the same time — began at 7 a.m. Eastern time. The nine surgeons in charge included four at Johns Hopkins, three at Integris Baptist and two at Barnes-Jewish. All finished by 7 p.m. Eastern time.

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.

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 Johns Hopkins Department of Surgery; Scott Samara, M.D., Shea Samara, M.D., and William Miller, M.D., from Integris Baptist Medical Center; and Surendra Shenoy, M.D., Ph.D.. and Martin Jendrisak, M.D., from Barnes-Jewish Hospital.

-----
www.fayettefrontpage.com
Fayette Front Page
www.georgiafrontpage.com
Georgia Front Page

Hopkins Transplant Surgeons Remove Healthy Kidney Through Donor's Vagina

In what is believed to be a first-ever procedure, surgeons at Johns Hopkins have successfully removed a healthy donor kidney through a small incision in the back of the donor’s vagina.

“The kidney was successfully removed and transplanted into the donor’s niece, and both patients are doing fine,” says Robert Montgomery, M.D., Ph.D., chief of the transplant division at Johns Hopkins University School of Medicine who led the team that performed the historic operation.

The transvaginal donor kidney extraction, performed Jan. 29 on a 48-year-old woman from Lexington Park, Md., eliminated the need for a 5-to-6-inch abdominal incision and left only three pea-size scars on her abdomen, one of which is hidden in her navel.

Transvaginal kidney removals have been done previously to remove cancerous or nonfunctioning kidneys that endanger a patient’s health, but not for healthy kidney donation. Because transplant donor nephrectomies are the most common kidney removal surgery — 6,000 a year just in the United States — this approach could have a tremendous impact on people’s willingness to donate by offering more surgical options,” says Montgomery.

“Since the first laparoscopic donor nephrectomy was performed at Johns Hopkins in 1995, surgeons have been troubled by the need to make a relatively large incision in the patient’s abdomen after completing the nephrectomy to extract the donor kidney. “That incision is thought to significantly add to the patient’s pain, hospitalization and convalescence,” says Montgomery. “Removing the kidney through a natural opening should hasten the patient’s recovery and provide a better cosmetic result.”

Both laparoscopies and transvaginal operations are enabled by wandlike cameras and tools inserted through small incisions. In the transvaginal nephrectomy, two wandlike tools pass through small incisions in the abdomen and a third flexible tool housing a camera is placed in the navel.

Video images displayed on monitors guide surgeons’ movements. Once the kidney is cut from its attachments to the abdominal wall and arteries and veins are stapled shut, surgeons place the kidney in a plastic bag inserted through an incision in the vaginal wall and pull it out through the vaginal opening with a string attached to the bag.

Montgomery says the surgery took about three and a half hours, roughly the same as a traditional laparoscopic procedure.

The Jan. 29 operation is one of a family of new surgical procedures called natural orifice translumenal endoscopic surgeries (NOTES) that use a natural body opening to remove organs and tissue, according to Anthony Kalloo, M.D., the director of the Division of Gastroenterology at Johns Hopkins University School of Medicine and the pioneer of NOTES. The most common openings used are the mouth, anus and vagina.

Since 2004, successful NOTES in humans have removed diseased gallbladders and appendixes through the mouth, and gallbladders, kidneys and appendixes through the vagina.

Recently, Kalloo says, some medical experts have called for more studies to compare the safety and effectiveness of NOTES against traditional laparoscopies, which also leave very small scars, have been in use for many years, and are proven to be safer and less painful for patients than older “open” abdominal procedures. He supports more studies.

But, he adds, “natural orifice translumenal endoscopic surgery is the final frontier to explore in making surgery scarless, less painful and for obese patients, much safer.” An organ donor, in particular, is most deserving of a scar-free, minimally invasive and pain-free procedure.”

Additional surgeons from Johns Hopkins University School of Medicine who participated in the procedure were Mohamad E. Allaf, M.D., assistant professor in the departments of Urology and Biomedical Engineering and director of minimally invasive and robotic surgery; Andy Singer, M.D., Ph.D., assistant professor in the Division of Transplant Surgery; and Wen Shen, M.D., M.P.H., assistant professor in the Department of Gynecology and Obstetrics.

-----
www.fayettefrontpage.com
Fayette Front Page
www.georgiafrontpage.com
Georgia Front Page

Kidney Transplant Survival can be Long-Term for People with HIV

A Johns Hopkins study finds that HIV-positive kidney transplant recipients could have the same one-year survival rates for themselves and their donor organs as those without HIV, provided certain risk factors for transplant failure are recognized and tightly managed.

“Kidney transplantation is a viable and necessary option for HIV-positive patients with chronic kidney disease, especially since kidney disease is taking such a large toll on this group,” says Jayme Locke, M.D., a resident in the Department of Surgery at Johns Hopkins University School of Medicine, and lead researcher of the study described in the January issue of the Archives of Surgery.

Traditionally, HIV patients were not considered transplant candidates because survival rates after transplantation were thought to be greatly compromised by the disease, which cripples the body’s immune system. Transplant patients also take drugs that suppress their immune systems in order to prevent organ rejection, a regimen thought to further threaten their already fragile immune systems.

Locke says their study results are in part a reflection of newer antiretroviral therapies that have reduced HIV death rates by 80 percent. Indeed, people with HIV now die like most other people, of chronic diseases, rather than from the opportunistic infections that once took a grave toll. Kidney disease, for example, accounts for more than 10 percent of HIV-related deaths.

For the study, Locke and her team looked at the one-year kidney survival rates and one-year patient survival rates of 36,492 HIV-negative and 100 HIV-positive kidney transplant recipients listed on the United Organ Sharing Network (UNOS) list who received transplants between January 2004 and June 2006. They excluded those under 18 and anyone who had multi-organ transplantation.

The chances of survival were the same in both groups. However, kidney survival rates in these two groups showed that HIV-negative recipients had a 94.6 percent survival rate, compared to 87.9 percent in people with HIV. (People can survive on dialysis even if their transplanted kidney fails.)

However, when the investigators broke down the results into subgroups, they learned that some of the kidneys transplanted into HIV-positive recipients were relatively late getting to full function. This so-called delayed graft function (DGF) reduced kidney survival by 30 percent. When this group was removed from the rate comparison, both HIV-positive and HIV-negative groups had equal kidney and patient survival rates, says Locke.

According to Locke, this is significant because DGF can be avoided by controlling certain negative risk factors such as advanced organ donor age, deceased-donor kidneys (vs. live-donor kidneys) and long cold ischemic times (the time the kidney is without blood flow before transplant).

Other researchers who contributed to this study from Johns Hopkins University School of Medicine include Robert Montgomery, M.D., Ph.D.; Daniel S. Warren, Ph.D.; and Dorry Segev, M.D., of the Department of Surgery; and Aruna Subramanian, M.D., of the Department of Medicine.

-----
www.fayettefrontpage.com
Fayette Front Page
www.georgiafrontpage.com
Georgia Front Page

Study Shows Machine Perfusion Significantly Improves Transplant Results

/PRNewswire/ -- A landmark study published December 31 in the New England Journal of Medicine (NEJM) demonstrates that use of a specially-designed machine to store kidneys for transplantation offers significant benefits in kidney survival and function when compared to those stored in a traditional "ice box", or cold storage. Unlike the icebox, the LifePort(R) Kidney Transporter monitors the temperature and vascular performance of the organ in real time, while preserving it by pumping the kidney continuously with a cold solution, even while the organ is being transported to its intended recipient.

"This important study confirms the critical role that transportable machine perfusion can play in improving kidney transplant outcomes," said David Kravitz, Chief Executive Officer of Organ Recovery Systems, the manufacturer of LifePort. "It also demonstrates that LifePort should have a central place in all transplantation programs, to help ensure the best possible patient outcomes."

The international trial enrolled kidney pairs from 336 consecutive deceased donors in Europe and randomly assigned one kidney to machine perfusion and the other to static storage. Results showed that the odds of a delay in kidney function post transplant were reduced by almost half when machine perfusion was used compared with static cold storage. Delay in kidney function, or DGF, is a factor that is known to adversely affect the long-term outcome of kidney transplantation. The study also showed that the LifePort kidneys were 48 percent less likely to fail within the first year post-transplant compared to those kidneys stored in the traditional box of ice prior to transplantation. This is the first randomized, prospective study to directly compare the two methods of storing and transporting organs for transplantation.

"For the first time in the United States, the number of those waiting for a life-saving transplant has passed 100,000," said Joseph Vassalotti, MD, Chief Medical Officer of the National Kidney Foundation. "Any new method like the one demonstrated in this study, that will help maximize the available organs and potentially reduce the need for re-transplantation, is vitally important for patients and the professionals who care for them."

More than 1.5 million people worldwide suffer from end stage renal disease, for which a kidney transplant is the preferred treatment option. With a continuing global shortage of organs for transplantation, it is important to find ways of increasing not just the number of kidneys available but also the quality of organs for transplantation to improve the long-term outcome for recipients. By improving the quantity and quality of organs for transplant, both improvements in clinical outcomes and cost savings to health systems are likely to occur.

The LifePort provides a sealed, sterile, protected environment where a physiologic solution is gently pumped through the kidney at cold temperatures to minimize damage while the organ is outside the body. The LifePort is lightweight and portable allowing organs to be perfused and evaluated from the time of recovery until transplant. It can travel unaccompanied by land or air, safely transporting the kidneys across town or between states.

About the Machine Preservation Trial

The Machine Preservation Trial was an investigator-driven study, run by an independent Scientific Steering Committee across The Netherlands, Belgium and Germany, with Eurotransplant (an international organ exchange organization) collaborating as study coordinators. The Machine Preservation trial was sponsored by Organ Recovery Systems of Chicago, USA, manufacturers of the LifePort Kidney Transporter.

-----
www.fayettefrontpage.com
Fayette Front Page
www.georgiafrontpage.com
Georgia Front Page