Posting in Cities
Georgetown surgeon matches seven donors and seven recipients, tackling renal disease as well as racial disparity.
The largest-ever single-city kidney exchange took place this summer in Washington. The seven-way exchange, which involved 14 patients, occurred at Georgetown University Hospital and Washington Hospital Center over four days in July. It was the brainchild of Dr. Keith Melancon, director of Georgetown’s Kidney and Pancreas Transplant Surgery, who used a procedure called plasmapheresis to address not only donor compatibility but racial disparity.
I caught up with Dr. Melancon recently, in the midst of planning for a second large-scale kidney exchange.
Why does D.C. have the highest per capita rate of kidney failure in the U.S.?
It’s because of racial dynamics. In D.C. proper, over 70 percent of the population is African-American, and there’s also a good number of Hispanic–Americans. Both groups have higher incidents of end-stage renal disease. If you are African-American, you have four to five times the chance of having kidney disease versus a person who is Caucasian. There is a very high rate of hypertension and diabetes in this population, and those are the two main reasons why people have kidney disease in this country.
Why is it so hard to find a donor who is a good match?
The best type of transplant is a donation from a family member or friend while they are still alive. The problem with African-Americans in particular and those from lower socioeconomic groups is that their friends and family members tend to come from the same socioeconomic level, so it’s harder for them to take all the time off work for testing, surgery and recovery. Also, the same problems leading to the patient having the disease—high blood pressure, obesity, high cholesterol-- will be higher in concentration in their communities. Then you have the problem of antibodies, which makes the prospect of getting a transplant more difficult because of higher incidence of rejection. With these patients in July, antibodies were so high that a traditional donor match was very difficult.
You’re focused not only on healthy kidneys but on the racial disparities that exist in this area of medicine. Will you elaborate?
Racial disparities contribute to much of the spectrum of disease that we see. Not only is kidney disease higher in certain ethnic groups, but there are differences in ability to access care. People who get transplants early in the course of their disease do much better than those who get transplanted later. You can chart how quickly a person can get to a transplant center, and it’s directly proportional to their socioeconomic status. Unfortunately, you can also see it’s in proportion to whether they are a minority or not.
This was the largest kidney transplant operation ever in one city. What kind of logistical problems did you face?
It was quite an undertaking. When I suggested it, people thought I was crazy. The hardest part was really figuring out who would be a good match for whom and moving the patients around so everyone had the best match situation. In some cases, a person wanted to donate to someone else and could not. A man wanted to donate to his wife, but she had built up antibodies to him through giving birth to their child, so she couldn’t take his kidney. But he still wanted to donate, so we matched him up with someone else. What made everything possible was the flexibility of all the recipients and donors. They had to come in many times and get blood drawn and redrawn. Everyone was anonymous. No one knew who was giving a kidney to whom. Then after it was over, when everyone was feeling better, they all met.
What are some of the technologies that enabled you to accomplish this?
One of the things that was most important to this process was a procedure called plasmapheresis. It allows us to remove the antibodies that would attack a new kidney. We put patients through this procedure so the body would accommodate the new organ. It’s very similar to dialyses in that their blood goes through a filter and then goes back to their body; the filter separates the liquid part of blood, which has antibodies in it. We throw that out and give them more liquid that doesn’t have antibodies. This is done over a period of three to four hours. They have to undergo this a few times before and after the transplant.
What was the cost?
A normal kidney transplant will cost $160,000. One done in this way (with plasmapheresis and extra medication)will increase the cost by about $100,000. However it’s still a savings versus the alternative. We already have universal health care for end-stage renal disease, and that’s been the case for the last 30 years. Dialyses costs $85,000 to $90,000 a year, so kidney transplant is always a benefit for the people and for the government.
And you’re planning to do it again?
Yes, we are actively planning another one. Every 17 minutes in this country, someone with kidney disease dies. Two of the people in the exchange were non-directed donors—they just came forth and wanted to donate to someone in need. It’s a very safe procedure for healthy people. I always like to make the plea that donation is something people should contemplate doing.
Nov 30, 2009
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Conspicious chick, You seem very adamant about your beliefs on this issue, and to help support your strong feelings, I would like to make a few factual corrections to your post. The mortality rate is 1-3 in 10,000 for living donors. Everyone with end-stage renal disease (ESRD) can receive medicare, regardless of age. Medicare covers dialysis for all US citizens. The reason many recipients do not receive medicare is because many people receive kidney transplants pre-emptively, before their condition deteriorates. However, Medicare does cover the cost of their immunosuppresant drugs for years after surgery (the number of years is continually increased). The rejection rates for kidney transplants used to be 20%, however they have fallen off dramatically in recent years with better immunosuppressive medications. The rejection rate has been reported as low as 3%. A long-term study showed that kidney donors are LESS likely to suffer from kidney associated illnesses than non-donors. I don't have my paper citing the source, but I assure you I read over the study and it is fundamentally sound. This is due to the stringent regulations and assessments on being eligible to donate. Furthermore, this study tracked people who have donated decades ago, which is not a good measure since the donation surgery has improved tremendously, becoming a minimally invasive procedure. I think people who donate are heroes - our patients tell us this everyday. I agree the system could be improved, however, without a fundamental change, there would still be a tremendous shortage even if the system were perfectly managed within today's framework. I think we should challenge our fundamental assumptions about what is right and wrong about a HEAVILY REGULATED system that allows compensated kidney donation. I think the estimated 100,000 people on the waiting by 2010 will agree.
Currently, the recipient's insurance pays for evaluation and surgical costs related to living donation. If the donor is compensated, you can bet the insurance companies are going to refuse to foot the bill for anything. Some would suggest the federal government or Medicare (same thing) 'pay' the donor, based on the savings versus the cost of dialysis. However, not all would-be recipients are on dialysis, and not all recipients are on Medicare. Plus, not every transplant is successful. If the graft fails within the first year (happens more than the public knows - the media, strangely, shies away from those stories, prefering the warm-fuzzy tales of above), the entire transplant actually COSTS Medicare (and the taxpayer), or the insurance company big money compared with dialysis. There is an erroneous assumption that living donation is akin to donating blood. However, some have DIED, and others have been permanently maimed (nerve damage, hernias, etc), and still others suffer depression, anxiety, anger and PTSD for which the transplant centers offer NO aftercare or support. In fact, the recipient's insurance doesn't cover it either, so guess whose pocket that comes out of? For those that manage to avoid the short-term consequences... well, we have no idea. The medical community is quick to take the proffered organs but they've never bothered to track or study living donors in any comprehensive manner. What we do know is that nearly 200 since 1993 have ended up on the waiting list themselves and untold others suffer from hypertension, cardiac issues, and severely reduced kidney function. One-kidneyed people have to avoid the contrast dyes of MRIs etc. and chemotherapy could cause the remaining kidney fail, putting the living donor at higher risk of missed diagnoses or losing a battle against cancer. It's time the media stops glorifying organ transplantation as a miracle cure-all, and living donors as 'heroes'. The system is deficient and broken, and the organizations in charge (OPTN, HRSA, DHHS) need to be held responsible. www.livingdonor101.com
It certainly sounds offensive at first pass, but as you think through it, selling your organs could make sense. First of all, the organ donor is the ONLY person in the entire exchange that gains nothing, yet puts himself at considerable, but manageable risk. The rich already pay for organs by gaming the system. Why did Steve Jobs get a liver transplant in Tennessee? He had the money and resources to game the system. Completely legal. With a financial incentive, more donors will come forward. Selling the organs of a deceased family member could help offset burial costs or lost income for the survivors. Of course, this creates a different set of problems, especially around protecting the rights of the donor. But, having a legitimate market would be better than what happens today.
Your story about the 7-Way Kidney Exchange highlighted the tragic shortage of human organs for transplant operations. At least 9,000 of the 105,000 Americans on the national transplant waiting list will die before they get a transplant. Most of these deaths are needless. Americans bury or cremate 20,000 transplantable organs every year. There is a simple way to put a big dent in the organ shortage ? give donated organs first to people who have agreed to donate their own organs when they die. Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs. Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition. LifeSharers has over 13,000 members at this writing. Please contact me - Dave Undis, Executive Director of LifeSharers - if your readers would like to learn more about our innovative approach to increasing the number of organ donors. I can arrange interviews with some of our local members if you're interested. My email address is firstname.lastname@example.org. My phone number is 615-351-8622.