3-way kidney swaps shorten waits for transplants

When Leo Cruz needed a kidney last year, his daughter, Maria Smythe, immediately agreed to help.

The 76-year-old retired mechanic from Yakima had already had one transplant, from a brother 19 years ago, but that organ was wearing out.

“I said, ‘I’m here,’ ” recalled Smythe, 50.

But when the father-daughter pair went for testing to get the surgery started, they learned it wouldn’t work. Cruz has O positive blood, while Smythe’s type is A positive, a mismatch that made a transplant impossible.

“I had six kidneys, from all my kids and grandkids, and not one was a match,” Cruz said.

Instead, doctors at Swedish Medical Center in Seattle offered a different idea: What if Smythe donated her kidney to someone else, in exchange for an organ for her dad?

“I asked him, ‘Are you willing? And we said, ‘Just do it.’ ” Smythe said.

That decision helped kick off a kidney swap involving six people in two states in what experts say is the first Pacific Northwest three-way paired exchange that links willing but mismatched donors with recipients in need.

The operations — three kidneys removed, three transplanted — took place on the same day, Dec. 8, in Seattle and Portland. So far, all six people are doing well in the complicated trade that included not only the father and daughter, but also two brothers in Seattle and two longtime friends in Sherwood, Ore.

“It was a really great thing,” said Dr. Lisa Florence, director of the kidney-transplant program at Swedish Medical Center. “It’s a testament to all of the surgeons in the transplant centers that they worked really well together.”

The multiple exchange is the first regional example of what transplant experts say could be a growing solution for the more than 101,000 people in the U.S. waiting for kidneys, including 2,380 in Oregon and Washington, federal figures show.

Kidney chains — including a link that featured 60 people and 30 organs — are becoming more common across the U.S. They typically begin with an altruistic donor, someone who doesn’t have a specific recipient in mind.

Paired kidney exchanges are different. They typically involve a donor who wants to offer an organ to a specific recipient, usually a friend or loved one, but is incompatible because of a mismatch in age, size, blood type or antigen sensitivity. Instead of giving to the original patient, the person donates to another patient who also has a mismatched donor.

“It’s where you have a recipient who has an incompatible but willing donor, but then they just kind of swap donors,” Florence explained.

There are national paired kidney-exchange programs, including one operated through the United Network for Organ Sharing (UNOS), the National Kidney Registry and the Alliance for Paired Donation. Patients can be enrolled simultaneously in all exchange programs in which their transplant centers participate.

But the logistics involved in transporting a kidney from Florida to Washington, for instance, mean that such national arrangements may often break down.

Of the approximately 6,000 live-donor kidney transplants that occur in the U.S. each year, fewer than 600 are unrelated paired donations, UNOS figures show.

Paired exchanges aren’t completely new in Washington state, where 36 such swaps have been performed since 2006, according to UNOS. Both Swedish and Virginia Mason medical centers have conducted two-way paired exchanges; Virginia Mason officials say they’ve completed five paired exchanges in the past two years.

But organizers say a three-way trade involving transplant centers in two states is novel, and that the practice is gaining new momentum because of a clinical trial sponsored by BiologicTx, a Totowa, N.J., biotechnology company that uses proprietary software to match donors and recipients based on medical criteria.

Previously, doctors would sketch out potential paired matches on paper, Florence said. Now, so-called computer “match runs” are conducted weekly, offering quicker and more accurate assessments of potential organ trades.

The firm’s MatchGrid software — which works something like an online-dating site for kidneys — has been used in transplant swaps across the country, including a six-way paired kidney donation conducted over two days in March at California Pacific Medical Center in San Francisco.

Larger swaps are possible when more paired donors are enrolled, noted Darrin Carrico, president and co-founder of BiologicTx.

“If you have 50 to 70 pairs, you can put the six-ways and 12-ways together,” he said.

Four Northwest transplant centers — Swedish and Virginia Mason medical centers in Seattle, Oregon Health & Science University (OHSU) in Portland, and Sacred Heart Medical Center in Spokane — are participating in the trial, which aims to find donors for the hardest-to-match patients. So far, there are between 10 and 12 pairs enrolled at the sites combined, Carrico said.

That includes so-called sensitized patients who have antibodies that react unfavorably to foreign tissue. The antibodies are usually acquired through blood transplants, organ transplants or, in women, pregnancies.

“If we try to give a kidney with those antibodies, it would be attacked by the person’s system,” Florence explained.

About 30 percent of people on the kidney-transplant-waiting list are sensitized, and some are highly sensitized, which can triple or quadruple the wait for organs from deceased donors.

That was the case for Trish Tulley, 46, a Portland realtor who was diagnosed with kidney disease at 18 and has had two previous kidney transplants. Tulley’s friend since high school, Kristi Pfarr, 47, a medical receptionist, was eager to help, but she was not a good match because Tulley is so highly sensitized.

Doctors at OHSU suggested paired donation. Pfarr said it took her a moment to adjust to the notion of giving her kidney to a stranger.

“My kidney was going into Trish, and that was going to be Trish’s kidney,” she said. “But then everyone said, ‘Isn’t that the same thing? She’s still getting a kidney.’ ”

The situation was similar for two Seattle brothers who declined to discuss their experience. John Michael Yasutake, 45, wanted to donate to his brother, who asked to remain anonymous.

And then there was Cruz and Smythe, who were mismatched because of conflicting blood types.

All three pairs agreed to participate in the BiologicTx trial that started last year. By fall, the MatchGrid software had matched them up.

“It was shocking,” recalled Tulley. “It literally could have been years and years.”

In the end, Smythe donated her kidney to Yasutake’s brother in Seattle, Yasutake’s kidney went to Tulley and Pfarr’s kidney was transplanted in Cruz.

The operations took place hours apart, with one kidney heading south in an organ-courier van to Portland and the other motoring north from Portland to Seattle. In the case of Cruz’s operation, his transplant was delayed because the kidney courier got stuck in Seattle traffic.

All of the donors and recipients recovered quickly and without problems, doctors said. The chief obstacle to conducting more paired donation exchanges is enrolling more people in the program, said Dr. David Scott, surgical director of the kidney-transplant program at OHSU.

“From the donor’s perspective, they can get their loved one transplanted and they also help somebody else get transplanted,” he said. “The downside is that you lose a little flexibility. You don’t know when the computer is going to generate that match that you’re going to be part of. You could wait three or four months. With highly sensitized people, it could be years.”

Tulley, Pfarr and other participants said they hoped that sharing their stories would inspire others to consider paired donation.

“It was my kidney. It’s not mine anymore,” said Pfarr, who plans to meet Cruz in person soon. “It’s in his body. I would want someone to do that for my dad if my dad was in that situation.”

Learn more about paired exchanges:

• Swedish Medical Center:  www.Swedish.org/transplant or 1-800-99ORGAN (1-800-996-7426)
• Virginia Mason: www.virginiamason.org/Living-Donation or donor information line at 1-800-354-9527, ext. 11201
• United Network for Organ Sharing, www.unos.org
• National Kidney Registry, www.kidneyregistry.org
• Alliance for Paired Donation: www.paireddonation.org