Ann Marie Reynolds, a 32-year-old who has been in and out of hospitals fighting chronic kidney disease since she was a teenager, had a less than 1 percent chance of receiving a kidney without the University of Alabama at Birmingham's groundbreaking organ donation system that helped her and two other hard-to-match patients get kidneys in a three-way, incompatible kidney exchange earlier this year.
Even though UAB's incompatible transplant, desensitization program sometimes allows a transplant between a donor and recipient with different blood types, blood-type and tissue incompatibility can be barriers to a successful donor-recipient match. UAB's paired exchange and incompatible transplant programs are used in tandem to enable physicians and surgeons to identify and connect living organ donors with recipients and improve a recipient's ability to accept an organ with which he or she may otherwise have been incompatible.
Living Donor A may want to give a kidney to a friend, Recipient A; but they may not be compatible, and it may not be possible to make them compatible. Living Donor B may not be compatible with her son, Recipient B; but a transplant between Donor A and Recipient B might work. In Reynolds' case, a third donor and recipient were needed and identified, allowing three patients to receive a kidney.
UAB has been collecting incompatible donor-recipient pairs in a database and has the ability to identify connections among incompatible pairs to enable two or more recipients to be transplanted. UAB is one of three locations in the nation, and the only one in the Southeast, able to do this as a single center.
The UAB program began in earnest earlier this year, and by the end of 2013, UAB is expected to complete 28 to 30 paired exchange and incompatible kidney transplants as part of the program.
Bob Gaston, M.D., the Robert G. Luke, M.D., Endowed Chair in Transplant Nephrology in UAB's School of Medicine, says the programs will give more patients like Reynolds an opportunity that they otherwise might not have had.
"There was a time when, even if you came here with a willing donor, but you didn't match, that was the end of the story," Gaston said. "Approximately half of the people who contacted UAB and wanted to be a living kidney donor were incompatible with their recipient. We had to turn down willing donors. That's much less likely to happen now with this program. We have expectations that the numbers will grow substantially next year and in the coming years."
Jayme Locke, M.D., Reynolds' surgeon and the assistant professor of Surgery and Abdominal Transplant Surgery in the School of Medicine, says incompatible transplantation is an important innovation.
"Most programs are participating in some sort of paired exchange program; but by definition, they require that a completely compatible match be found," Locke said. "This still leaves a very large disenfranchised group of patients, or patients so highly sensitized that their hope of finding a completely compatible match is very slim, like Ann Marie Reynolds.
"We're fortunate here at UAB to be able to combine a paired exchange program with our desensitization program, and as a result, we're a bit unique in the Southeast because we're the only center that offers that at the moment."
Reynolds was able to bring in Vicky Junior, her sister's mother-in-law and fellow Anniston, Ala., native, a donor who did not match her, but did match with Hayneville, Ala., native Gwendolyn Goldsmith. Goldsmith's donor on her behalf was her sister Darnetta Goldsmith, whose donated kidney was given to Rockwood, Tenn., native Frank Peters. Peters' donor on his behalf was his wife, Amanda, whose donated kidney went to Reynolds.
This delicate dance was made possible because of extraordinary treatments and skills developed and honed by teams of surgeons, physicians and researchers in UAB's Kidney/Pancreas Transplant Program and the giving hearts of each of the donors.
"It's like Vicky told me - she wasn't doing this just for me," Reynolds said of Junior. "She was doing this because it helps other people, too. As a living kidney donor, this is what you can do for others. You can help multiple people. When you do, you're giving them life again. And the great thing is, all of this can be done right here in Alabama at UAB."
Building a program
As far back as a decade ago, UAB's kidney transplant program - led by Mark Deierhoi, M.D., professor of Surgery and co-director of renal transplant surgery; Mike Hanaway, M.D., associate professor of Surgery and director of the renal transplant program; and Gaston - began laying the groundwork to build a paired exchange and incompatible transplant program that would help patients so difficult to match.
New technologies evolved that enabled researchers and clinicians to specifically define harmful antibodies that are present in many previously transplanted patients. Vera Hauptfeld, Ph.D., director of the histocompatibility laboratory, was instrumental in making sure UAB was at the cutting edge in implementing these technologies that make it possible to measure how strong a patient's antibody response is. Then, that response can be eliminated or avoided, or its impact can be reduced by novel treatments.
"This was groundbreaking stuff that very, very few hospitals in the country were able to execute when we began putting our foundation in place 10 years or more ago," Gaston said. "We knew we needed this program because of the real need for kidney transplants in the state of Alabama; our waiting list is enormous. Plus, we have people from Mississippi, Florida, Georgia and Tennessee coming to us for transplantation. I have long referred to UAB as the Transplant Center of the South, and our capabilities have increased immensely due to the hard work and dedication of many of our researchers and physicians."
Vineeta Kumar, M.D., an associate professor of Medicine in the Division of Nephrology, has spent many days in UAB's histocompatibility lab in an effort to translate the advances in understanding antibodies to the clinical arena.
Kumar helped clinicians understand what these new tests meant, and she was instrumental in the clinical efforts at UAB as the new tests became more widely available. Jeremy Goodman, M.D., assistant professor of Surgery, also worked with Kumar to get some of the necessary testing off the ground in developing the laboratory support needed to make these incompatible kidney transplants possible.
