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.