Kidney transplant chain a Manitoba first

Living donor paired exchange surgeries done at HSC

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Being part of a national program that matches donors with recipients was a life-saver for a trio of Manitobans who recently underwent kidney transplant surgery.

This was the first time Manitoba has taken part in Living Donor Paired Exchange (LDPE) surgeries, which saw two chains with a total of nine kidney transplants take place in five provinces in February. Three Manitobans donated kidneys, and three Manitobans received kidneys, as part of the chains.

Several weeks after surgery, two of the participants were applauding the program. One was a donor who was incompatible with their chosen recipient - a close relative. The LDPE registry made it possible for a transplant to take place, by matching a compatible kidney from another person in Canada.

The identity of all participants in a transplant chain is kept anonymous, in order to protect their privacy.

"I offered my kidney, right there in the parking lot," said the donor, of that fateful day almost three years ago when the diagnosis of kidney failure was made.

"(But they) couldn't give me a kidney, because the blood type was wrong," said the recipient, who had been on dialysis three times a week. "The waiting list for me would have been four to five years (to receive a kidney from the deceased donor list). But then we found out about the paired exchange program where (s/he) could donate a kidney to someone else in Canada, and I would receive a kidney from another donor on this list."

While a person with a malfunctioning kidney may have a willing donor - a relative or a good friend - chances are the two are incompatible, due to differences in blood type, or antibodies that would cause the recipient to reject the donor's kidney. The national exchange program allows incompatible pairs of donors and recipients to join other people across Canada, moving healthy kidneys forward to people who are a match.

Dr. Peter Nickerson speaks with reporters at the March 7 press conference to announce the kidney transplant chain that included surgeries at HSC.

The larger pool of donors is making a big difference, said Dr. Peter Nickerson, Executive Medical Director, Organs and Tissues, Canadian Blood Services. "A kidney from a living donor is the best solution for someone requiring a transplant. In fact, we're finding that a preemptive transplant from a living donor is the best of all possible outcomes for the recipient."

Launched as a three-province pilot project in 2009, the LDPE - which operates as a partnership between Canadian Blood Services and transplant programs across the country - recently passed the 122 transplant mark, with all provinces participating. Not only do these transplants improve and save lives, estimates suggest the net benefit of a transplant over dialysis is approximately $50,000 per patient per year. Using those figures, transplants that have occurred through the LDPE have resulted in excess of $5 million in cost savings.

The two surgical chains in February were called "domino exchanges", because they were started by people who donated kidneys with no recipient in mind. These selfless individuals - called non-directed anonymous donors, or NDADs - have sparked two-thirds of the transplants done to date.

Non-directed anonymous donors play a role that is nothing short of heroic. They have literally given a stranger their life back, according to Dr. Nickerson.

"These altruistic people start a chain by offering a gift; a kidney with no recipient in mind," he said. "That kidney goes to a recipient on the list, while their partner donates their kidney to the next person down the chain. The chain ends when it reaches someone who is on the deceased donor wait list. We aim for chains that have five surgeries in them, for ease of scheduling."

A recent transplant chain in the United States received a lot of attention because it had 30 individuals donating or receiving a kidney. The LDPE program in Canada also performed surgeries on 30 pairs in the same time period, but because only five-pair chains were done at a time, it didn't receive the same publicity, said Dr. Nickerson.

"Canada is one of the few countries in the world with a national registry, along with the United Kingdom and Holland. We do smaller chains because it's simpler,"; he said. "The USA doesn't have a national donor matching system. In fact, it's something of a Wild West in the USA, with private organizations competing for recipients and donors. I'm travelling to a meeting in the USA at the end of March, as they want to learn about Canada's national registry."

About 500 living kidney donations are done annually in Canada. Since the inception of the Living Donor Paired Exchange Registry, operations increased by 10 per cent — approximately an extra 50 transplants a year.

"We figure by the time we get fully operational in the next year, we can double that again, to between 100 and 125 a year," said Dr. Nickerson at a press conference held on March 7. "We're very proud to have a system developed by Canadians, for Canadians."

Dr. Joshua Koulack and Dr. Tom McGregor performed the surgeries on the Manitoba donors and recipients in the two February transplant chains.

The February LDPE surgeries saw Dr. Tom McGregor performing the surgeries on the donors, and Dr. Joshua Koulack performing the recipients' surgeries. The doctors scrubbed up for each other's operations, working on a donor first, then moving the kidney as quickly as possible to a recipient who was prepped and waiting in a second operating room.

"The start of one of the chains was an anonymous donor," said Dr. McGregor, who was recruited from Ontario to work with the transplant program in Manitoba. He performed laparoscopic surgery on the donors, a procedure he calls the gold standard for kidney donation, in that it is less invasive. "This started a chain of getting kidneys to people who would otherwise not get a match."

Two people in the February chains were 98 per cent sensitized, which meant that only two per cent of all possible donors in the world were a match. Some of the people had been on dialysis for up to 10 years before having their transplant.

Dr. Joshua Koulack, who performed the recipient surgeries in the February chains, said as the word gets out about the LDPE registry, the hope is that more Manitobans will step up to become donors.

"It's so rewarding to see a person after their transplant. They feel better almost immediately," said Dr. Koulack. "Renal failure is insidious, because people don't realize how much energy they've lost and how tired they're feeling. I've seen patients get up the next morning after surgery and tell me how much better they feel, now that they have a new kidney cleaning their blood."

Ensuring the donors and recipients were ready for their transplant was the task of the nephrology transplant team, including transplant nephrologists Dr. Leroy Storsley and Dr. Martin Karpinski, along with donor coordinator nurse Jody Sawatzky and recipient coordinator nurses Leslie Geiger, Jamie Combiadakis, Karla Farstad and Starr Beghin.

Drs. Storsley and Karpinski focused on the donor side of the February LDPE chains, ensuring the donors were physically and mentally ready for their operation and well informed of the risks.

"Having donors and recipients travel here from out of province was something new, and required significant cooperation and coordination," said Dr. Storsley. In one of the chains, three donor-and-recipient pairs underwent surgery in a 36-hour period.

Despite the pace, all the donors and recipients are doing well after their surgeries. Along with standard post-operative care, many of the donors and recipients are being tracked by studies looking at how well they fare. Drs. Karpinski and Storsley are part of Canadian consortium of physicians interested in living kidney donations.

"If you look at all the studies following people who donated a kidney, for 10 to 30 years, the studies show there is no higher risk in developing kidney disease," said Dr. Karpinski. "The only complication is a slightly higher chance of developing higher blood pressure. We know that donors will maintain 70 to 80 per cent of normal kidney function with their remaining kidney, and it's very unusual for a donor to develop kidney failure down the line."

Drs. Storsley and Karpinski work with both recipients and donors in the normal course of things, but were attached to the donor side only during the recent February LDPE chains. Working with living donors is one of the most rewarding aspects of their work.    

"Altruistic or non-directed donors are interesting people. Most are older, more mature, have a history of charitable acts and altruistic behaviours," said Dr. Karpinski. "Some identify a missed opportunity to donate to a relative, while others have had no direct contact with anyone on dialysis or who has chronic kidney disease. They're just fantastic people."

Donor nurse coordinator Jody Sawatzky at the March 7 press conference.

The concept of donating a kidney to a stranger, in order for your loved one to also receive a kidney from a stranger is one that takes a little getting used to, said Jody Sawatzky, donor nurse coordinator. The science behind kidney matching is complex, and it takes a computer system to line up the matches.

"It takes a year to work up a donor. We want to know if they're healthy now, and if they will be healthy years down the line after they donate a kidney," she said. "We also have to know if they’re mentally prepared to give up a part of themselves. But watching someone they love go to dialysis three times a week for 10 years is a big motivator. They want that person home, they want that person well, and it's amazing how well the donor and recipient pairs work together post-transplant to keep each other healthy and on track."

Prior to the existence of the LDPE registry, Sawatzky often had to deliver the bad news to potential donors; that they were not a match for their loved one and a transplant could not happen. With the LDPE registry now in place, she can offer them hope.

The Manitobans in one of the February chains praised the LDPE program.

"They told me I'd have 15 years to live if I was still on dialysis," said one of the recipients. Today, their new kidney is working beautifully, and they are on anti-rejection medication and more importantly, off dialysis.

The donor is amazed that nine people were willing to give up a part of themselves, to help nine others, and very thankful that the non-directed anonymous donors took part in the chain.

"The spirit of humans is amazing. I asked Jody Sawatzky if my kidney was working in the recipient, and burst into tears when I heard that it was. I needed to know my kidney was working in its new home," said the donor. "It came down to personal choice and the outcome is tremendous. I gave someone the chance to live a stronger, healthier, longer life."

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