While so many advancements have been made in the field of renal medicine over the last twenty years, there is still no escaping the fact that renal failure is a life-changing illness.
In 1950, the first kidney transplant from a cadaver was performed, the transplanted kidney functioning for 53 days before being rejected by the patient’s body and removed. In 1954, the first successful kidney transplant operation was performed.
One of the newborn twins was dying from total kidney failure, so one kidney was taken from the healthy twin and transplanted onto the ailing one. The major reason for optimism here was through the lack of likely rejection of the transplanted organ as they were identical twins, rejection at the time being the major reason for kidney transplant failure
Curiously, while today we see ‘live’ donation of kidneys and parts of livers (the liver being the only organ in the body capable of regeneration, where a donation of 25% of a liver can grow to full size and functionality) as relatively ‘commonplace’, back in the 1950s live donation created considerable moral and ethical conflict for doctors and surgeons.
The Hippocratic oath taken by all medical students does not actually contain the phrase “first, do no harm”, but it underpins the whole ethos of the medical profession. Consequently, they struggled with the scenario where to save one patient, they had to ‘harm’ another.
As mentioned, rejection of the transplanted kidney was a hurdle that proved difficult to overcome. Initially, high doses of radiation were used to destroy the body’s defense mechanism against ‘foreign bodies’, though sadly such levels of radiation were so high that many patients died from radiation poisoning. However, the discovery of Imuran as an immunosuppressant, originally developed to fight leukemia, plus the development of tissue typing in 1960, along with the same lines as blood typing, saw a giant leap taken in the number of more successful kidney transplants.
Kidney transplants today
Jump forward to 2015 and for the first time, the number of kidney transplants in the U.S. exceeded 30,000 for a one-year period. However, this doesn’t solve the problem that currently over 120,000 patients are on the waiting list for a kidney transplant in the U.S.
While the success rates for kidney transplant operations are high, according to the Mayo Clinic:
- Failure of the transplanted kidney is reported in about 4 percent of deceased-donor kidney transplant recipients within one year after transplant and in 21 percent of cases five years after transplant.
- Among living-donor kidney transplant recipients, failure rates are about 3 percent at one year and 14 percent at five years after transplant.
What surprises many is that even if successful, a kidney transplant still has a limited lifetime. On average:
- A kidney transplant from a deceased donor has an average lifetime of 8-10 years.
- A kidney transplant from a living donor has an average lifetime of 15 years.
On average, 80% of kidneys transplanted are currently from deceased donors and 20% are from living donors.
Kidney Paired Donation
Once the ethical hurdles relating to living kidney donation had been overcome, and further advances had been made in terms of anti-rejection medication – ciclosporin today being the most well-known – the number of living kidney donations increased dramatically. However, it was not until 2010 that the Organ Procurement and Transplantation Network (OPTN) was first piloted as a means to pair non-compatible organ donors with compatible recipients, thus allowing for kidney paired donation.
Kidney paired donation involves individual pairs of kidney donors and recipients who are initially not a match, but as a group, matches can be created.
The simplest kidney paired donation involves two couples. As can be seen in the diagram at the beginning of this article, here recipient R1 has a kidney donor D1, but D1’s kidney is not a match for R1.
Similarly, recipient R2 has a donor, D2, whose kidney is not a match for R2. However, where D2’s kidney is found to be a match for R1 and D1’s kidney is a match for R2, two transplants can still take place.
In the first instance of a kidney paired donation, according to the HRSA:
Rebecca Burkes of St. Louis had intended to be a living donor for her fiancé, Mr. Crowder, and Cathy Richard of Henniker, N.H., had planned to donate to her sister-in-law, Ms. Niedzwiecki — only to find that both were medically incompatible with their intended recipient. But in the first paired donation arranged through a national pilot program of the Organ Procurement and Transplantation Network (OPTN), Ms. Burkes was able to donate to Ms. Niedzwiecki and Ms. Richard became a donor for Mr. Crowder.
At the time, OPTN’s President said:
Paired donation is helping the transplant community help people who otherwise could not get a living donor transplant. We’re proud to be able to coordinate these for the first time using a national network for potential matches among 77 participating transplant programs.
Kidney paired donation has become a partial solution to the perennial problem of a shortage of available kidneys suitable for donating.
Unlike the totally philanthropic anonymous donation of a kidney to an unknown recipient, OPTN and paired kidney donation ‘piggybacks’ of the altruistic desire for a kidney donor who will do anything to see their initially intended recipient of their kidney, usually a husband or wife, brother, sister or a very close friend, regain their health.
Prior to 2010, if the intended donor and recipient turned out not to be a suitable match owing to tissue incompatibility, that would be the end of the story.
As you will see from the diagram above, kidney paired donation need not take place solely between two pairs of donors and recipients. The remarkable thing about paired kidney donation is that not every transplant has to happen on the same day.
From a practical point of view, a kidney earmarked for transplantation can remain viable for up to 30 hours once removed from a living donor. In addition, in 2007 the first transplants took place where donors and recipients were not operated on in the same hospital, which paved the way for the creation of the OPTN.
To take this to an extreme, according to uwhealth.org, a series of 34 transplants took place in 26 hospitals across the U.S. over a three-month period.
What kidney paired donation has also proved highly successful with is helping patients with high antibody levels (sensitized) who struggle the most to find a match and in fact 16 of the 35 recipients in the above chain were highly sensitized.
Kidney paired donation has helped over 10,000 people regain their health from life-threatening and certainly a life-shortening renal failure, which is remarkable in itself. However, it does not change the fact that there is still a massive shortage of kidneys and why the waiting list for a transplant has over 120,000 people on it.
One other way to reduce the size of this waiting list is for more people to make it clear on their driving license that they wish to be an organ donor, and for more people to make it clear to their next of kin, friends, and relatives that in the unfortunate event of their death, they wish to be an organ donor.