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PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY August 2013 | Archived Issues

Cedars-Sinai's First Paired Kidney Exchange: Another Instrument in Transplanting the Untransplantable

In a way, KM was a typical kidney transplant patient at Cedars-Sinai. He had three previous kidney transplants, all of which had failed, and as a result his immune system was highly sensitized to organs from other people.

One glimmer of hope emerged as he languished on the deceased-donor waiting list. The patient had a willing and healthy living donor. However, despite undergoing intensive desensitization treatments, KM remained persistently sensitized to his potential donor, effectively eliminating the option of receiving a kidney from this individual.

"Incompatibility" can be as simple as incompatible blood typing with a donor (i.e., blood type O recipient with a blood type A donor), but for many of the patients at Cedars-Sinai, immunological incompatibility with elevated sensitization to HLA antigens, remains the largest obstacle to transplantation.

It is estimated that nearly 30 percent of patients on the kidney transplant waiting list are highly sensitized like KM. The desensitization protocol developed at Cedars-Sinai has enabled many of these patients to be transplanted successfully. Paired kidney exchange (PKE) is a strategy that has evolved in the U.S. over the past 10 years and generates compatible donor/recipient matches by exchanging or "swapping" organs between donor and recipient pairs that would otherwise be immunologically incompatible.

On June 14, Cedars-Sinai participated in its first successful paired kidney exchange, enabling the successful transplantation of two highly sensitized recipients. KM was found to be compatible with an altruistic living donor. Under PKE, KM's donor would then be available to provide a kidney to a second transplant recipient, who although also highly sensitized was compatible with KM's donor.

Under the guidance of Stanley Jordan, MD, and other members of the Transplant Nephrology team, the two highly sensitized recipients underwent desensitization treatment prior to the exchange, readying them for transplant. After many weeks of coordination, planning, and participation from members of the Cedars-Sinai nursing and operating room staff, four simultaneous operating rooms — two donor rooms and two recipient rooms — enabled the safe exchange of two living-donor kidney transplants.

Gerhard Fuchs, MD, and Christopher Ng, MD, performed the living-donor nephrectomy operations, and J. Louis Cohen, MD, and Donald Dafoe, MD, served as the implanting surgeons. The exchange occurred uneventfully and smoothly. The first words uttered from KM in recovery were barely audible, but clear. "How is my donor?" he asked the transplant staff, as the nurses hastened to replenish his IV fluid intake, trying to keep up with his torrential urine output.

Several months after the transplant, both donors and recipients are doing well.

Ellen Shukhman, RN, Kristen Cisneros, RN, the living-donor coordinators who planned much of the efforts in this first paired exchange, and Irene Kim, MD, the director of the Paired Exchange Program, are busy strategizing the next PKE.

Cedars-Sinai is a participant in the National Kidney Registry, the largest kidney exchange network in the United States, and the team is eager to coordinate the next PKE. After all, the Cedars-Sinai kidney transplant team is dedicated to any strategy that enables the gift of life.