Sequenced coordination of donors in different states speeds new organs to sick patients

When surgeons at Stanford Hospital removed a healthy kidney from Yvette Aziz the morning of Oct. 6, and, that same afternoon transplanted a stranger's kidney into her husband, Fred, the procedures were part of an extraordinary cross-country chain of linked kidney donations involving 16 patients and eight kidney transplants at five hospitals over seven days.

The chain involving the Sunnyvale couple was one of the most extensive uses to date of a relatively new and logistically complex type of kidney donation in which multiple pairs of living kidney donors and recipients are matched via computer algorithm with compatible recipients and donors. Facilitated through a kidney donor registry, such donor chains accomplish transplants among donors and recipients who might be separated by hundreds or thousands of miles. The increasing use of donor chains — available as one option by Stanford Hospital's kidney transplantation program to recipients who have a living donor — has significantly expanded the possibilities for transplants and can reduce the time that patients must wait for a kidney transplant.

Fred and Yvette Aziz are gratified to have been part of the experience. "The chain is a wonderful idea," said Yvette. "There are a lot of people trying to get a kidney who can't. This is a way to get more transplants for more people."

For the Azizes, the success of the arrangement means something more personal: For the first time since 2004, when Fred's kidney problems began, they are planning to travel, starting with a family trip to their native Egypt.

"There are too many things I want to do now," said Fred. "Travel overseas, take my wife someplace nice. Go to Egypt, London, maybe Saudi Arabia." An engineer who worked at a Bay Area telecommunications company for 15 years until his failing health forced him to retire, he is thinking of going back to work. "Before the surgery I felt so weak," he said. "Now I have more energy. I want to go out and do things. I'm feeling strong."

The donor chain that enabled Fred's turnaround began Sept. 30 at UCSF Medical Center and ended Oct. 6 at UCLA Medical Center. In addition to the Azizes, the chain included patients at Cornell Medical Center in New York and Pinnacle Medical Center in Pennsylvania. It was the longest kidney-donor cluster to be successfully implemented in such a short period, according to Garet Hill, founder of the nonprofit National Kidney Registry, which coordinated the donations.

The registry works with 39 medical centers, and since the program began in February 2008, the registry has facilitated 73 kidney transplants. The transplants are accomplished either through paired kidney exchanges or donor chains. In paired exchanges, which Stanford also offers and has performed, a pair of individuals, usually relatives—one sick recipient and one healthy donor who are not immunologically compatible – are matched with another donor-recipient pair whose blood and tissue types permit transplants between the pairs. The exchanges are a closed loop among four people, or in larger arrangements they may involve six, eight or more people.

Donor chains, pioneered about five years ago, work in a similar fashion, matching compatible donors and recipients who don't know each other, but each chain begins with an altruistic, non-directed donor: someone who doesn't have a family member needing a kidney, but is willing to donate a kidney to any compatible recipient. A family member of that recipient then donates a kidney to another recipient in the cluster, and so on. The cluster ends when the last donor either donates a kidney to the deceased-donor waiting list, or becomes a so-called bridge donor, waiting to donate until a suitable recipient is identified. That starts a new cluster, and thus the chain can facilitate additional transplants.

"There's such a shortage of donors out there that when you have a donor, you want to make the best use of it," said Tania Makki, RN, recipient coordinator for Stanford's kidney transplant program. "These chains allow patients to be transplanted with a living donor, who may not have been otherwise."

According to the United Network for Organ Sharing, more than 80,000 U.S. patients are now waiting for kidney transplants, and the average wait time is five to seven years. Stanford has about 1,000 patients on its waiting list. Through donor chains, transplants can be arranged within months, and that can save lives, since kidney transplantation increases life expectancy compared with dialysis treatment.

Fred and Yvette heard about kidney donor chains in late 2007, after Fred was put on the waiting list for a transplant. Yvette was desperate to help her husband, who was on dialysis three days a week and was "going downhill," she recalled. "He was tired all the time. His skin color changed. He wouldn't eat. He couldn't sleep."

Yvette wanted to donate a kidney to her husband, but their blood types were incompatible. Complicating matters further, Fred's blood was sensitized against, or had antibodies against, roughly half the U.S. population.

Once Yvette learned about donor chains, she was immediately interested: "I told them if you want to do it, I'll donate right now," she said. After four months of tests at Stanford, and reviewing the small but real risks of donating a kidney, she was deemed healthy enough to donate. In February 2009, Marc Melcher, MD, an assistant professor of surgery who specializes in kidney and liver transplants, gave Fred and Yvette's information to the National Kidney Registry.

In September 2009, the registry contacted Stanford with a possible match for Fred and Yvette. The next step was to send their blood samples to the transplant centers involved in the cluster, to confirm the match.

The members of Stanford's kidney transplant team knew from experience that numerous factors had to be in place, and if any factor fell through—if any of the donors backed out, for example, or if anyone got sick—the whole chain could collapse. "You're always worried there might be a glitch and it won't go through. It's a rollercoaster of emotions," Makki said.

The long odds didn't dampen the Azizes' optimism. "When the doctors talked about the surgeries, they said, 'If, if, if…'" Fred recalls. "But I said I'm going to be positive."

By Sept. 25, 2009, all 16 patients in the donor cluster were cleared for surgery. The first operation took place at UCSF on Sept. 30. By Oct. 6, the remaining surgeries were still on schedule. Yvette went into surgery at 6 a.m. that day to donate her kidney, while a patient at UCLA was preparing to do the same. Both kidneys were shipped across the state on commercial flights, and that afternoon Melcher's team performed Fred's transplant. All 16 patients are recovering well.

While teamwork is important to the success of any organ transplant, it is particularly crucial in a complex donor chain, Melcher said. "We take a very team-oriented approach," he said. "Everyone has to work together: the nephrologist, the surgeons, the social workers, the nurse coordinators, the lab techs—everyone."

Melcher also praised the close collaboration among the five participating hospitals, with frequent communication among their nurses, surgeons, lab staff and more. "Remember, some of these institutions are competitors," he said. "But everyone worked together to do the best for our patients."

This effort didn't go unnoticed by the Azizes. "The whole team did a great job, from the lowest level to the highest. Their teamwork is 100 percent," said Fred, adding, "God bless every single person at Stanford."

The couple's oldest child, 23-year-old Amal, said she's looking forward to traveling with her parents to Egypt, and perhaps other destinations. After the heavy toll taken by her father's illness, she is glad to see him looking energetic again.

"This might sound corny," she continued, "but if it weren't for Stanford, my father might not be here today. They worked diligently to take care of him, and we're very thankful."

By Sara Selis.