12/03/08

 

BY DIANE ROGERS

	Norbert von der Groeben
	Marc Melcher and Stephan Busque (standing) led the Stanford portion of a four-hospital kidney transplant chain. One organ went to Allan Soriano after his wife, Josephine, donated one of hers to another patient.

Twenty-four hours after she donated one of her kidneys at Stanford Hospital, Josephine Soriano picked up the bedside phone and called her husband. He was on the floor below her, and he, too, was recovering from kidney surgery. "We each said something like, 'Are you OK?'" Soriano recalled a couple of days after her surgery.

Both were doing fine—walking, eating and joking with doctors—but they also had some questions. Josephine Soriano didn't know where her donated kidney had gone, and Allan Soriano didn't know whose kidney he had received.

In a first-of-its-kind collaboration in the Bay Area, transplant surgeons from Stanford Hospital and California Pacific Medical Center joined specialists from Ronald Reagan UCLA Medical Center and New York-Presbyterian Hospital/Weill Cornell Medical Center in a set of carefully orchestrated surgeries that started on the morning of Nov. 19. "All the donors were under anesthesia at the same time," said Marc Melcher, MD, assistant professor of surgery who specializes in kidney and liver transplants. "Otherwise, with the time differences, you can imagine that a donor could back out after others in the chain had already donated their kidneys."

First, the surgeons extracted kidneys from three donors who did not know one another. Two of the kidneys made transcontinental trips on commercial flights, triple-bagged and packed in ice, and one kidney was shipped within the state of California. Later that day, the kidneys were implanted in three recipients who, again, were total strangers.

Patients and physicians who've participated in these transplants are excited about their potential because, first, the kidneys come from living donors—and will last double the time of a deceased-donor organ. Moreover, a "leftover" donor remains from the daylong series of surgeries. The remaining donor waits at one of the institutions, ready to donate a kidney when a compatible recipient is found. That means the chain of kidney donations could be "never-ending."

"By getting multiple universities together and cooperating, you can maximize the number of [donor-recipient] pairs that are possible and get more people transplanted," said Melcher, who is spearheading the effort at Stanford.

These chains of live kidney donations are a response to the growing list of sick patients who have to wait years for transplants. The United Network for Organ Sharing reports that more than 82,000 patients nationwide are waiting for kidneys. At Stanford, there are about 950 such patients.

The chain was the idea of New York software developer Garet Hill, whose daughter lost kidney function when she was 10. He wanted to donate a kidney to her, but their blood types were incompatible. A cousin was found to be a match and donated a kidney. But Hill wanted to help other families, so last year he founded the National Kidney Register (kidneyregistry.org) to match donors and recipients. "We went live in October 2007, and started our first chain on Valentine's Day 2008, when three transplants were done at Cornell," he said. The registry now works with 15 academic medical centers and has some 600 non-directed donors on its lists.

Stanford's Melcher and Mojgan Haririfar, manager of the adult kidney transplant program, attended a presentation Hill gave at CPMC in September, and came away believers. "With his program, you have the extra variable—the non-directed altruistic donor—which adds significantly more permutations and possibilities," Melcher said.

The chains are an outgrowth of "swaps" or "paired donations," in which 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. But the exchanges stop there, among four people. Chains, by comparison, begin with an altruistic donor who is "non-directed"—willing to donate a kidney without knowing anything about its intended recipient—and they end with a leftover donor, who waits to make a life-saving gift. "These donors," Hill said, "walk on water."

He could be talking about Josephine Soriano. The 39-year-old contract recruiter for Yahoo watched the health of her husband go downhill the past two years from a condition first detected in 1985. Stanford physicians put Allan on the list for deceased-donor kidneys, but the Sorianos knew it could be eight years before he'd be eligible for an organ.

"I said, 'We've gotta do something'," Josephine Soriano recalled. "I had heard about the chains, and for me it was, like, 'Of course I'd do this, because in the end, Allan's going to benefit.' It was only later that it dawned on me that other people would also benefit."

The Sorianos had long conversations with Soo-Yee Kong, Stanford's living donor coordinator, with Melcher and with Stephan Busque, MD, head of Stanford's kidney-pancreas transplant program. Then Melcher registered the Sorianos on Hill's Web site; matches were found in a matter of weeks. In preparation for the surgery, Allan, a 44-year-old engineer, tracked down Yahoo news groups, corresponded with kidney recipients in Ireland and Spain and studied a huge red binder about post-operation medications.

Allan felt confident about how the chain would work, but he was worried about his wife, who had never been hospitalized. It helped to know that Busque and Melcher would be performing a minimally invasive procedure that used three 1-centimeter "ports" to insert laparoscopic tools and another 8-cm incision to remove the kidney. There were "points when I became nervous," Josephine said, though she never doubted her decision. "God made me relatively healthy," she said. "It was a no brainer."

The Sorianos arrived at the hospital on the morning of Nov. 18. They shared a room that night, and at 6:15 the next morning, Allan watched as Josephine was wheeled out to an operating room. Her procedure took about four hours, his almost three hours. Within 24 hours, they were chatting by phone, separated because their surgeries required different levels of care. "We're glad we're past the surgery, but this is just the beginning of the next phase for Allan," Josephine said. "He'll be on meds for the rest of his life, so it's a longer journey for him."

Allan said his wife's sacrifice had made him want to tell others about the experience. "The donors don't have to do it," he said. "But we want to get the word out that they can."