All six patients met for the first time in the Finney Room on Harvey 8. From left, Jeremy Weiser-Warschoff, Paul Boissiere, Germaine Allum, Connie Dick, Julia Tower, Tracy Stahl.

A novel way of matching organ donors and recipients, one that has the potential to boost kidney transplants among those with willing but incompatible donors, caught the public's attention this past summer when Hopkins surgeons performed what is believed to be the first three-way, paired kidney swap. Paired kidney exchanges link together incompatible donor/recipient pairs. Each twosome gets a kidney and gives one up. Since 2001, four of these exchanges, each involving four people, have been performed here. This one took three pairs-two sisters, two friends and an engaged couple-to make the perfect matches.

The story begins with Tracy Stahl. For five years, Stahl, 39, had been suffering with progressive kidney failure. She had a willing donor in her sister, Connie Dick, with whom she shared the same blood type, B. But due to pregnancies and blood transfusions, Stahl had been exposed to foreign tissues and had developed harmful antibodies that would attack a transplanted organ. Plasmapheresis, a procedure that can strip some of the immune proteins out of the blood, had been unsuccessful. "I had reached the end of my rope," said Stahl.

Stahl was undergoing dialysis three times a week when her brother urged her to contact the Comprehensive Transplant Center. Doctors here knew that it was unlikely that a donor would ever be found for Stahl. But miraculously, as a tissue typing specialist searched the database, one surfaced. Her name was Julia Tower.
Tower had the universal blood type O, and her tissue type was compatible with Stahl's. "The odds were very unusual," said Robert Montgomery, director of the incompatible-transplant program. "It was a eureka type of moment when we found a donor for Tracy."

Tower had volunteered to donate a kidney to a friend, 13-year-old Jeremy Weiser-Warschoff but was incompatible with him. In fact, Tower, 57, believed that the boy deserved a younger kidney. She had fantasized about a healthy, handsome 30-year-old male donor, but Janet Hiller, the transplant coordinator who makes the matches, kept telling her, "We just don't have any."

Until, that is, Paul Boissiere arrived on the scene. Boissiere had volunteered to donate his kidney to his fiancee, Germaine Allum, but did not share her blood type. He was, however, compatible with Jeremy. Plus, he was healthy, handsome and exactly 30. Now, all that remained was for Allum to find her match. She did-in Connie Dick, Stahl's sister.

And so, with the circle complete, the simultaneous operations commenced at 7 a.m. on July 28. In each of six ORs were two surgeons, two anesthesiologists and two nurses. Hiller and co-coordinator Jennie Rickard moved from room to room, keeping everyone posted and ferrying the kidneys in three separate coolers. The donors were operated on first. "The logistics were staggering," said Montgomery, lead surgeon. "All the recipients had to be ready at the same time the donors' kidneys were out." By 6 p.m. that evening, all the transplanted kidneys were in place.

In recent years, the incompatible kidney transplant program has found ways to make some very difficult matches. Developed at Hopkins, the plasmapheresis treatments, which can remove harmful antibodies from patients who are sensitized to donors, now are also increasing compatibility among non-matched blood types. Through the altruistic donor program, people have stepped forward to donate kidneys anonymously to the most needy recipients, usually children. Like the altruistic donor program, the paired kidney exchange was the brainchild of a patient, who in this case, contributed the funds that cover the salary of matchmaker Hiller.

Some of the patients involved in the triple-swap transplant said they had investigated incompatible donor programs at other medical centers but had come up empty-handed. "We knew about paired donations from the beginning," said Linda Warschoff, one of Jeremy's parents. Elsewhere, she said, "there are no resources and infrastructure to do the matchmaking. If Johns Hopkins hadn't had a program in place, no one would have done it, even a two-way swap."

Typically in these cases, every effort is made to keep donors and recipients anonymous. "We do this for everyone's protection," said Montgomery. But on the floors post-transplant, the patients and their family members were beginning to figure out who was who. When staff asked the patients if they wanted to meet one another, all were game.

So, just before a morning press briefing on Aug.1, they gathered in a conference room on Harvey 8. The first to arrive were the two sisters, Stahl and Dick. Then came Julia Tower. It could have been an awkward moment, but Stahl, unhesitatingly, arose from her wheelchair to embrace her donor. It was an overture that set the tone for the subsequent encounters. "I looked into Tracy's eyes, and I just felt a bond," said Tower.
The patients speculate that they will always be friends. After all, said Allum, "we each have a piece of each other inside of us."

-Anne Bennett Swingle