"Domino" transplants, as one of the newer methods in the medical field holds promise for creating more opportunities for patients to receive organ transplants.
A team of Johns Hopkins researchers, led by Robert A. Montgomery, M.D., chief of transplantation reported their successes with "domino" kidney donation in a paper published in the August issue of the British journal Lancet. The traditional domino procedure occurs when one patient undergoes organ transplant surgery, and his or her organ is then given to a second recipient.
Hopkins experience with domino transplantation in our Incompatible Kidney Transplant Program (InKTP) suggests that wider use of this strategy could almost double the number of kidney transplants in the United States. This is critical as the gap between the number of organ donors and patients needing transplantation has been an historic national problem.
Trends show that more and more patients have turned to living donation. At the same time, medical breakthroughs have made it easier for living kidney donation. The 1990s saw the advent of the minimally invasive living kidney surgery (laparoscopic donor nephrectomy) first performed at Hopkins. Our Incompatible Kidney Transplant Program was also developed to help sensitized patients – these are patients who suffer on the national waiting list longer than most patients because they have tissue type or blood type incompatibilities with potential donors.
It is through our InKTP program that many kidney patients who have incompatibility issues with their living donors can still be transplanted in a paired exchange, triple swap or other special treatment program. The InKTP team also evaluates living donors who fall into the "altruistic" category (sometimes also known as "Good Samaritan" or "non-directed" living donors). In looking for ways to help the most patients possible, Hopkins has found that domino transplants can maximize the benefits of donors’ altruistic acts.
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www.hopkinsmedicine.org/transplant/programs/Inktp.index.html |
Under the terms of the InKTP domino-paired donation program, a kidney transplant patient who has a willing but incompatible living organ donor is matched with an altruistic, compatible donor. The incompatible kidney from the recipient’s intended donor is then domino-matched with the next compatible patient on the United Network of Organ Sharing (UNOS) waiting list (Chart A). This strategy can be further used to enable a triple transplant by adding an additional incompatible donor-recipient pair to the chain (Chart B).
To date, Hopkins surgeons have performed two triple and one double domino-paired kidney transplant initiated by three altruistic donors who were able to provide eight recipients with compatible kidneys. According to Montgomery, if conventional allocation strategies had been used, only three of these recipients would have benefited from these altruistic donations.
UNOS reports that since the first altruistic donor came forward in 1998, 302 altruistic kidney transplants have been performed in the United States. Using a computer simulation program, Montgomery and his team calculated that 583 transplants could have been achieved if the domino-donation model had been in place.
Because there is currently no system in place for a national domino model, the concern is that altruistic donor kidneys often end up on an Internet donation site or at individual transplant centers and so are subject to variable ethical criteria. Altruistic donor programs have come under recent attack by critics who argue that altruistic donors may be vulnerable to coercion and have suspect motivations. Montgomery says altruistic donors at Hopkins go through the same rigorous and comprehensive psychological and social evaluation programs as any other person coming forward to be evaluated for living organ donation.
Most recently, the Johns Hopkins faculty have teamed up with transplant scientists, administrators and ethicists from various parts of the United States to set in motion the creation of a national policy to expand InKTP techniques and corresponding benefits.
