At the start of 1990, University of Colorado Hospital had performed 44 kidney transplants, all using organs from deceased donors. The hospital had many other patients on the transplant waiting list, which numbered 15,000 nationally that year. The number nearly quadrupled by 2002 and continued to grow in succeeding years.
In 1990, however, UCH began taking small steps toward expanding the pool of available donor organs by launching its Living Kidney Donor program. Patients on waiting lists stretching a few years or even many years could cut that time drastically by finding a willing donor, such as a spouse or relative, in good health with a compatible blood type.
Transplant surgeon Thomas Bak, MD, says laparoscopic surgery was a major factor in increasing the number of live kidney donor procedures. Of the Transplant Program’s 44 kidney transplants in 1990, just three involved living donors. That number initially grew slowly, but in 1997, 31 living donors accounted for a third of all kidney transplants at UCH. From 1998 to 2015, the overall percentage grew to a little more than 40 percent. And this year, the program reached a numeric milestone: 1,000 living kidney donor transplants.
The number tells only one part of the success story. The program’s one-year donor and graft survival rates for the most recently published public data in December 2015 were 100 percent, exceeding the national averages. The three-year rates for these measures were comparable to the national averages, noted Betsy Britz, RN, DNP, CNS, manager of Kidney and Pancreas Transplant Services for UCH.
The kidney transplant program, the largest in the Rocky Mountain region, is not resting on its laurels, however. The percentage of living kidney donor transplants at UCH is around the national average, but Britz adds, “We don’t want to be average.” She notes that 1,100 patients at UCH alone are on a waiting list for a kidney. Increasing the number of living donors is the only way to shorten it.
“That’s the most important goal we have,” said Deidre Ellis, RN, MBA, executive director of Transplant Services for UCH. “The number of deceased donor organs is finite and growing at a minuscule rate compared to the need. We must increase the number of living donors to save more lives.”
Ellis noted the hospital showed its commitment to that goal with the appointment of Elizabeth Pomfret, MD, PhD, as chief of Transplant Surgery starting July 1. Pomfret is a strong proponent of living donor transplantation.
“Elizabeth Pomfret’s selection to lead our transplant program was critical and it was driven by our commitment to living donation,” Ellis said.
The emphasis on living donors is not simply a numbers game. Living donor procedures improve outcomes for recipients. The donor organs start to work more quickly than those from a deceased person, and they generally last longer, said Thomas Bak, MD, associate professor of Transplant Surgery with the University of Colorado School of Medicine.
“The recipient’s survival with a good quality of life is longer with organs from living donors,” he said.
It’s a classic win-win. Healthy donors live very well with one kidney (see accompanying story in this issue), while the organs they donate can change the lives of recipients.
“Most times it works beautifully,” noted Heidi Monroe, RN, CNS, clinical nurse specialist and educator for Transplant Services at UCH. “Living donation allows us to transplant patients before they get very sick or have to go on dialysis.”
Ellis points to the hospital’s transplant experience as one reason to believe it can bring those benefits to a larger number of patients. It’s a strong reputation earned across decades of work.
Much of the difficult transplantation groundwork had been plowed by 1990 when the hospital began tracking its living donor procedures, noted Bak. The first successful human kidney transplant, involving identical twins, had been performed in 1954 by Joseph Murray, MD, at Peter Bent Brigham Hospital (now Brigham and Women’s) in Boston.
Living kidney donor transplant at UCH actually began in 1962 with Thomas Starzl, MD, who gained greater notoriety – many at the time described it as infamy – with his pioneering efforts in liver transplantation. Kidney transplantation didn’t fare much better in the early days.
“One-year kidney graft survival rates in the early 60s were about 4 percent,” Bak said. However, by the mid-80s, the introduction of high-dose steroids, Imuran and cyclosporine as anti-rejection drugs had boosted survival rates dramatically, he added.
In 1988, Igal Kam, MD, who trained under Starzl at the University of Pittsburgh, arrived at UCH and revitalized the transplant program, which had gone dormant after Starzl’s departure. When living donor transplants began at UCH, Kam, later joined by Michael Wachs, MD, and Mark Stegall, MD, performed open kidney transplant procedures. The surgery involved making a roughly 6-inch incision in the patient’s side, then cutting muscle and removing a rib tip. Chronic pain and hernias were frequent complications – and obvious deterrents to people considering becoming living donors.
Let’s get small
Bak began his fellowship in Transplant Surgery at UCH in 1998, in time for the beginning of laparoscopic kidney transplant procedures, a major breakthrough for living donor programs. Surgeons make a small incision around the donor’s belly button and expand the stomach cavity with gas. They create two port sites, one for a camera and another for instruments. With a sleeved hand, they rotate the kidney, dissect and staple the vessels and remove the donor organ, which is generally only about 4 inches in width, Bak said.
At that point, the recipient team goes to work, flushing the donor kidney with iced preservative fluid, trimming tissue and beginning to sew it in, all within a few minutes, Bak said.
The positive impact of laparoscopic surgery has been enormous. Monroe said the complication rate for living donor kidney transplant surgery is only about 2 percent nationally; at UCH it’s less than that. Hospital stays before laparoscopy typically stretched to four or five days; today, they are two or three.
Success isn’t automatic, however. The foundation of the Living Kidney Donor program at UCH – indeed, all of Transplant Services – is an experienced team that maximizes the chances of a good outcome by managing the process before, during and after the procedure. The work is multidisciplinary and includes transplant surgeons and nephrologists supported by nurse coordinators, social workers, dietitians, pharmacists and inpatient nurses and OR staff.
“It’s a well-oiled machine that handles every phase of the donation,” said Jamie Berry, RN, quality improvement clinical specialist with Transplant Services. Berry noted that an individual who wants to donate an organ goes through a battery of medical, surgical and psychosocial evaluations to ensure a good outcome.
“The goal is to keep donors educated and informed during every step of the process,” Berry said. That occasionally includes giving potential donors surprising and unpleasant news, she added.
“We’ve identified renal failure, kidney masses and poor kidney function in people who want to be donors,” she said. “We’ve had to tell them they might actually need to be transplant recipients. We help those patients as well.”
Before the process can even begin, however, the team must also ensure that the donor gives his or her consent freely, Monroe added.
“The donor cannot feel forced, pressured or coerced,” she said. “It’s important to look at that before the decision is made.” The Transplant Services’ social work team plays an important role in ensuring that, Monroe said. In addition, an Independent Living Donor Advocate has the sole responsibility of consulting with the donor and protecting his or her interests and rights as well as the independence of the decision, she added.
The 1,000-transplant milestone is cause for satisfaction, but Monroe and Berry, each of whom have double-digit years of experience with Transplant Services, look forward for ways to improve the program.
“Our overall goal is to increase the number of living donors while keeping patients safe,” Berry said. “We are doing that through more donor awareness and education and outreach to the community.” She noted the team concentrates on patient safety by having a dedicated team for quality and process improvement.
That work includes developing age-appropriate patient education materials, helping donors manage postoperative pain, joining in multidisciplinary analyses of procedural complications, protecting the anonymity of donors who request it, ensuring blood types are double-checked, providing acknowledgement and thanks to living donors, and more.
By the numbers
Meanwhile, the effort to increase the number of living kidney donor transplants continues. The hospital is one of many transplant centers nationwide participating in the Organ Procurement and Transplant Network’s kidney paired donation program, including the Alliance for Paired Kidney Donation. The aim is to create a large pool of potential donors and identify those who are medically compatible. That provides an option if a donor isn’t a match with his or her intended recipient.
Britz said the hospital has been involved with paired donation since 2007, but has increased its activity. For example, it recently joined forces with the National Kidney Registry’s paired exchange program, which has helped to facilitate some 1,700 transplants since 2008.
“Paired donation connects us to a national pool of living donors and gives us a chance at a better hit rate for genetic matches,” Ellis said.
The people, yes
The hospital is also working to expand its reach into the communities of the state and region, educating people about the importance and benefits of living donor transplant. In addition, patients in communities a long distance from UCH or those who have limited transportation options can get their initial testing done close to home, with the Transplant Services team providing consultation, Britz said.
“Living donors are healthy people who are working,” Ellis said. “It’s important that we accommodate their time constraints.” She added that people considering becoming living donors can enter their basic medical information electronically, saving them time if they are ruled out for donation.
But those who cannot donate can help by becoming “donor champions” who explain the benefits of living donation to others, Ellis added.
“We’ve made great advances in our processes and procedures,” she said. “We are now focusing on how to introduce the topic to help more people who need transplants and to bring more living donors to the process.”