From the New York Times

The Kidney Swap: Adventures in Saving Lives

October 5, 2004
By DENISE GRADY and ANAHAD O'CONNOR

His eyes on a video monitor that displayed the inside of
Suzanne DeCample's abdomen, Dr. Lloyd Ratner gently guided
a hollow rod through an incision below her navel. Watching
his progress on the monitor, he advanced the tool toward
her left kidney and then passed another instrument, tipped
with a plastic bag, through the rod.

One of his favorite CD's played softly in the background,
the Jackson Five singing "ABC, easy as one, two, three."

"Getting jiggy with it," Dr. Ratner said, as he captured
the kidney in the bag, plucked it out and handed it off to
another surgeon, who slid it from the bag into a
gauze-covered ice bath.

In the operating room next door, surgeons were preparing
Ms. DeCample's brother, Buddy, for a transplant. He is 41;
she is 40.

But Ms. DeCample's kidney was not headed for her brother.
Instead, it was going to a stranger, Debbie Barnett, 40.
Mr. DeCample also got a transplant, but from Ms. Barnett's
stepmother, Jane Thomas, 54, whom he had never met. All
four operations were carried out simultaneously last
Wednesday morning in neighboring operating rooms at New
York-Presbyterian Hospital/Columbia University Medical
Center.

The reason for this kidney swap, or "paired exchange," was
simple: to lower the risk of rejection, kidney donors and
recipients must have compatible blood and tissue. Ms.
Barnett and Mr. DeCample did not match their own relatives,
but each had a match in the other's family. When a
transplant coordinator saw their medical records and told
the two families they might be able to help each other,
they seized the opportunity.

The surgery was carefully choreographed to meet two
conditions: the families could not meet or even know one
another's names beforehand, and all four operations had to
be done at the same time, to make sure no one backed out.

"If it weren't like this, I could give my kidney up and the
other donor could just walk out and not go through with
it," Ms. DeCample said.

The idea of swapping kidneys may sound bizarre, but it
makes perfect sense to people who are willing to donate a
kidney to help a loved one get free of dialysis. A healthy
person can safely give up a kidney, and last year 6,468
kidney transplants came from living donors. But family
members do not always have compatible blood or tissue.

When relatives want to donate but do not match, kidney
exchanges between families can help patients avoid long
waits on the transplant list and the serious decline in
health that often occurs in people who are on dialysis for
years at a time. In the United States, 60,000 people are on
the waiting list for a kidney, but last year only 15,000
got transplants. In the New York area, the wait is about
seven years.

In regions with long waiting times, kidney exchanges may
save lives.

In 2001, Dr. Ratner, then at the Johns Hopkins Hospital in
Baltimore, and other surgeons performed the first kidney
swap in the United States. Since then, about a dozen more
have been performed there, including two six-way swaps that
each involved three families. The recipient's insurance
usually pays for the donor's expenses.

Only a handful of other swaps have taken place at hospitals
around the country, Dr. Ratner said, in part because the
procedure requires a transplant program with enough staff
to find matching families and perform four operations at
once.

Transplant experts are trying to develop a nationwide
system to coordinate kidney swaps, but, Dr. Ratner said, "I
suspect that realistically, before all the details are
worked out, it will be two years before it's up and
running."

The leading causes of kidney failure are diabetes, high
blood pressure and a group of kidney diseases called
glomerulonephritis. Diabetes rates are increasing, and by
2010, about 100,000 people in the United States will be on
the waiting list for kidney transplants, Dr. Ratner said.

"We need novel strategies to make optimal use of live
donors," he said.

When doctors at Johns Hopkins first considered paired
exchanges, they consulted lawyers about ways to make sure
that one side did not renege after the other had already
given up a kidney, Dr. Ratner said. The lawyers ruled out a
contract because, he said, "you can't contractually oblige
someone to undergo surgery if they change their minds."

The group concluded that the only way to protect patients
from being cheated out of a transplant was to put them all
under anesthesia at the same time so that no one could back
out.

The doctors also decided that the families should not meet
each other before surgery, for two reasons. First, Dr.
Ratner said, if one family decides against the surgery, "we
don't want them to harass each other." Second, he said, the
doctors worried that a donor might take a dislike to a
recipient and say: " 'That guy is a jerk. I don't want to
give him my kidney.' "

Ms. Barnett, 40, who works part-time at a convenience store
near her home in Magnolia, Del., went on dialysis three
years ago when her kidneys failed because of a disease
called interstitial nephritis. Three times a week she would
drive to a dialysis center and spend four to six hours
hooked up to a machine that cleansed her blood. The
treatments exhausted her and left her little time to spend
with her 14-year-old daughter. (She also has a 20-year-old
son and two grandchildren.)

Ms. Barnett's name was on the transplant list, but she was
told to expect a six-year wait. Her husband wanted to
donate, but could not, because he had borderline diabetes.

Then, last spring, Ms. Thomas - the wife of Ms. Barnett's
stepfather - called and offered her a kidney, even though
the two women are not blood relatives and have known each
other only seven years.

"She needed it," Ms. Thomas said with a shrug. "That's what
families are supposed to do."

Ms. Thomas was healthy and passed all the kidney donor
tests except one: she had Type B blood. Ms. Barnett had
Type A.

The DeCamples were their mirror image: Suzanne was Type A,
her brother Type B.

Mr. DeCample went on dialysis about a year ago because of a
hereditary condition called polycystic kidney disease. Of
five siblings, two have the disease and two others,
including his sister Suzanne, are known to be free of it.
Their mother, who also has the kidney disease, received a
transplant from a cadaver donor eight years ago.

The DeCamples, who live in Blackwood, N.J., and Ms.
Barnett's family had consulted Thomas Jefferson University
Hospital in Philadelphia, and a transplant coordinator
there matched them up. They scheduled surgery with Dr.
Ratner, who worked there at the time, and followed him when
he moved on to New York-Presbyterian Hospital last summer.

By 8:30 on Wednesday morning, all four patients were
anesthetized. They occupied Operating Rooms 5, 6, 7 and 8,
two pairs directly across a hall from each other. Each
patient had a senior surgeon, with another assisting.

Each operation was expected to take three to four hours and
the strategy was to pace them, so that if surgeons ran into
a problem with a recipient and could not proceed, the donor
operation would also stop - and vice versa. But that would
not necessarily halt the other two operations, and so the
donors had been warned of a small chance that they would
give up a kidney and their relative would not get one.

People getting transplants rarely have their own kidneys
removed. Instead, they wind up with three kidneys. Cutting
one out would involve additional surgery, which is not done
unless there is a reason for it. So the transplant is
tucked into the pelvis, usually on the right side in the
front of the body, instead of in the kidneys' natural
location near the small of the back.

A vein and an artery from the kidney are stitched to the
patient's iliac vein and artery, and the ureter, the tube
that carries urine out of the kidney, is sewn to the
bladder.

Although an incision is required to open the recipient's
abdomen, the removal of the donor's kidney is less
invasive. The operation can usually be done
laparoscopically. Instead of cutting the patient open and
removing a rib, as was done in the past, surgeons now make
a few small incisions in the abdomen, to insert a camera
and slender cutting and dissecting tools. Guided by the
image on a video screen, they push the intestines and
pancreas out of the way, free the kidney from surrounding
tissue, tie off blood vessels, sever the ureter and widen
one incision to extract the kidney.