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Featuring Robert Montgomery, Professor of Surgery, Chief of Division of Transplantation, Director of the Johns Hopkins Comprehensive Transplant Center
My name is Robert Montgomery and I’m a transplant surgeon at Johns Hopkins Hospital and I’m the Director of the Comprehensive Transplant Center.
The two most common causes of renal failure in the United States are diabetes and high blood pressure. There are a lot of other diseases that are much less common that can cause renal failure. When somebody develops renal failure their kidneys aren’t doing the job that they need to do; they are not cleansing the blood. And without that cleansing the person will die. Thankfully we have dialysis and dialysis can take the place of a kidney, but it doesn’t do as good a job. So what happens is when someone’s on dialysis for a very long period of time, they tend to get a lot of wear and tear on their body and they can develop heart problems, strokes, high blood pressure, and a lot of other medical problems that are greatly increased by dialysis and that’s where transplantation comes in because transplantation – when you actually give them a kidney – that kidney can do what their old kidneys use to do. It’s a better replacement than dialysis and they are much more likely to live longer and to have a better quality of life. I mean, let’s face it, dialysis is really difficult. You have to be hooked up to a machine, usually for three to four hours, three times a week. Many people are unable to work when they are on dialysis. A lot of my patients are on disability. There’s a recovery phase for a lot of patients after dialysis that can extend anywhere from a few hours to a day. And it’s not…they can’t travel and there are a lot of limitations on their lives.
But when they receive a transplant, they have to take some additional medications, but they have a normal life again. And most transplant patients will tell you that they feel normal and that they are able to do all of the things they were able to do before.
Right now in the United States, the average time to wait on the list for a kidney transplant is between three and five years, and in fact, there are some areas where it’s considerably more than that. During that waiting time, almost a third of the patients will die waiting. And transplanting patients earlier is very important because dialysis, while it is life preserving, it produces a lot of wear and tear on the body and it increases the likelihood of patients having other serious medical problems. As a result of that, the longer they wait the more likely they are to die waiting. So earlier transplantation becomes very important and that’s really where live donation has a significant impact, because if you have a live donor, you can essentially receive your transplant as soon as you’re cleared to have a transplant, and avoid that waiting period.
When a patient sees me in clinic and has just been told that they are going to need a kidney transplant, my job I think, is to, first of all, reassure them that they are going to be okay and to be confident. To be confident in my ability to help them and in what I’m telling them - that they will be okay that we have things we can offer them. Where they are at that moment is not how life is going to be. It’s going to be a lot better and I think that reassurance and that confidence helps someone tremendously who is – you know – who has been given news that seems very frightening. It’s very important to make sure they understand what kidney disease is and what their options are and what they should expect, or can expect in the future.
There are a lot of patients who, either because of blood type incompatibility or tissue incompatibility, are unable to receive a kidney from a willing donor – a loved one usually. And we’ve come up with a number of different approaches – a number of different options for patients to be able to have their donor donate either directly to them or to someone else so that they can receive a kidney.
One of them – one of these options is called a domino kidney paired donation. What that involves is - we have over 100 people every year in the United States who come forward and say, “I want to give my kidney to anyone who needs it.” So they don’t have anyone in mind and they come to a transplant center and say, “Look, you know, I want to donate one of my kidneys.” What that has allowed us to do is to start these dominoes. So that person, we call them altruistic donors or non-directed donors, can give to someone who has an incompatible donor and that incompatible donor can give to someone else. You create these chains of transplants. This is a concept that we came up with in the…about five or six years ago and we have done these very long chains. You can either do all the transplants in one day, and we did an eight way domino, or transplanted eight people with eight donors, at multiple different institutions, shuttling kidneys around on airplanes. That’s the biggest one that has been done.
Or, you can do…you can create the chain one link at a time. We have chains now that have extended over 20 transplants. So a domino paired donation is a way to match up people who have an incompatible donor with other pairs that are incompatible in order to produce a chain of compatible transplants. There are a lot of these being done now throughout the country. We’ve set off a chain reaction.
There are certain patients who are hard to match because they have been exposed to foreign tissue, either through pregnancy, previous transplant or a blood transfusion and they develop these harmful antibodies that can cause a new kidney to be rejected. The other type of incompatibility is a blood type incompatibility. So we all make harmful antibodies against blood types that are not our own for reasons that we don’t completely understand, but if we put an organ into some that’s a wrong blood type without preconditioning their body to receive it, it will be rejected right away. So there are essentially two types of incompatibilities: Someone can be incompatible by tissue or by blood. And we’ve developed multiple different procedures to either get around those incompatibilities or remove the harmful antibody so the person can receive an incompatible organ from their loved one.
Plasmapheresis is a way of removing harmful antibody that can attack a transplanted kidney. People develop these harmful antibodies – we usually think of an antibody as something good, but in this case, it’s not – they develop this antibody as a result of expose to foreign tissue. So that can be through a pregnancy – women are a lot more likely to develop a sensitization to other people’s tissue – previous transplant or a blood transfusion. And essentially what plasmapheresis does is we pass a patient’s blood through a machine and the machine filters out these harmful antibodies and we have to do a number of treatments before the transplant and by doing that, we’re able to use a live donor kidney that that patient would have rejected immediately and get excellent outcomes. In fact, the patients are twice as likely to live to eight years after this treatment than if they didn’t receive the treatment.
We’re a transplant center in a hospital that has a tremendous depth of expertise, that is a leader in the field in terms of research and innovation and new developments, but we don’t forget the human part of what we do. We’re doing a lot of really interesting things here – a lot of interesting protocols, allowing people to receive a transplant who wouldn’t otherwise or who wouldn’t at other institutions. We do it one transplant at a time and we do it with a sense of humanity.