New Procedure Allows Kidney Transplants From Any Donor

[Guest Nicole]

Clint Smith, at home in New Orleans, had a procedure that altered his immune system to allow his body to accept a kidney from an incompatible donor. It “changed my life,” he said. Credit William Widmer for The New York Times

 

In the anguishing wait for a new kidney, tens of thousands of patients on waiting lists may never find a match because their immune systems will reject almost any transplanted organ. Now, in a large national study thatexperts are calling revolutionary, researchers have found a way to get them the desperately needed procedure.

In the new study, published Wednesday in The New England Journal of Medicine, doctors successfully altered patients’ immune systems to allow them to accept kidneys from incompatible donors. Significantly more of those patients were still alive after eight years than patients who had remained on waiting lists or received a kidney transplanted from a deceased donor.

The method, known as desensitization, “has the potential to save many lives,” said Dr. Jeffery Berns, a kidney specialist at the University of Pennsylvania’s Perelman School of Medicine and the president of the National Kidney Foundation.

It could slash the wait times for thousands of people and for some, like Clint Smith, a 56-year-old lawyer in New Orleans, mean the difference between receiving a transplant and spending the rest of their lives ondialysis.

The procedure, Mr. Smith said, “changed my life.”

Researchers estimate about half of the 100,000 people in the United States on waiting lists for a kidney transplant have antibodies that will attack a transplanted organ, and about 20 percent are so sensitive that finding a compatible organ is all but impossible. In addition, said Dr. Dorry Segev, the lead author of the new study and a transplant surgeon at the Johns Hopkins University School of Medicine, an unknown number of people with kidney failure simply give up on the waiting lists after learning that their bodies would reject just about any organ. Instead, they resign themselves to dialysis, a difficult and draining procedure that can pretty much take over a person’s life.

Desensitization involves first filtering the antibodies out of a patient’s blood. The patient is then given an infusion of other antibodies to provide some protection while the immune system regenerates its own antibodies. For some reason — exactly why is not known — the person’s regenerated antibodies are less likely to attack the new organ, Dr. Segev said. But if the person’s regenerated natural antibodies are still a concern, the patient is treated with drugs that destroy any white blood cells that might make antibodies that would attack the new kidney.

The process is expensive, costing $30,000, and uses drugs not approved for this purpose. The transplant costs about $100,000. But kidney specialists argue that desensitization is cheaper in the long run than dialysis, which costs $70,000 a year for life.

Although by far the biggest use of desensitization would be for kidney transplants, the process might be suitable for living-donor transplants of livers and lungs, researchers said. The liver is less sensitive to antibodies so there is less need for desensitization, “but it’s certainly possible if there are known incompatibilities,” Dr. Segev said. With lungs, he said, desensitization “is theoretically possible,” although he said he was not aware of anyone doing it yet.

In the new study, 1,025 patients at 22 medical centers who had an incompatible donor were compared to an equal number of patients who remained on waiting lists for an organ or who had an organ from a deceased but compatible donor. After eight years, 76.5 percent of those who received an incompatible kidney were still alive, compared with 62.9 percent who remained on the waiting list or received a deceased donor kidney and 43.9 percent who remained on the waiting list but never got a transplant.

The desensitization procedure takes time — for some patients as long as two weeks — and is performed before the transplant operation, so patients must have a living donor. It is not known how many have someone willing to donate a kidney, but doctors say they often see situations in which a relative or even a friend is willing to donate but is incompatible.

“Often patients are told that their living donor is incompatible, so they are stuck on waiting lists,” for a deceased donor, Dr. Segev said.

In recent years, an option called a kidney exchange has helped some in this situation. Patients who have incompatible living donors can swap donors with someone whose donor may be compatible with them. Often, there are chains of patient-donor pairs leading to a compatible organ swap.

That process can be successful, said Dr. Krista L. Lentine, the medical director of the living donation program at the Saint Louis Center for Transplantation, but patients often still cannot find a compatible organ because they have antibodies that would reject almost every kidney. In those cases, “desensitization may be the only realistic option for receiving a transplant,” said Dr. Lentine, who was not involved with the study.

Dr. Jeffrey Campsen, a transplant surgeon at the University of Utah Health Sciences Center who also was not a study investigator, said his group focused on exchanges and had been fairly successful. But he also comes across patients whose donors do not want to participate. “There is a hurdle if the donor and patient have an emotional bond,” he said.

The new data showing the success of desensitization “lets people get behind it,” Dr. Campsen said, adding, “I do think it is something we would consider.”

Mr. Smith, the New Orleans patient who went through desensitization, had progressive kidney disease that slowly scarred his kidneys until, in 2004, they stopped functioning. His sister-in-law, Allison Sutton, donated a kidney to him, and he had a transplant, but after six and a half years, it failed. He went on dialysis, spending four days a week hooked up to dialysis machines for hours. It was keeping him alive, he told his friends, but it was not a life.

Then a nurse suggested that he ask Johns Hopkins about its desensitization study. “I was like, whatever I could do,” he said. He discovered that he qualified for the study. But he needed a donor.

One day, his wife, Sheryl Smith, was talking on the phone to a college friend, Angela Watkins, who lives in Augusta, Ga., and mentioned that Mr. Smith was praying for a donor. Mrs. Watkins’s husband, David Watkins, a judge in state court, had been friends with Mr. Smith in college and the two wives, also college friends, had kept in touch over the years.

Mrs. Watkins told her husband about the conversation, and they asked themselves if they should offer to donate.

“We talked and researched and prayed,” Judge Watkins said. Finally, he said, they came to a conclusion. “We have a moral obligation to at least see if we would qualify.” And he thought that he should be the one to go first. If he did not qualify, his wife could be tested.

Mr. Smith warned his old friend that donating was an enormous undertaking. “He said, ‘You can’t grasp what you are doing.’ I heard him but it didn’t register,” Judge Watkins said. “I told him, ‘I have something you need, so what’s the big deal?’ ”

Of course, it was a big deal. Although Judge Watkins had prepared by getting himself in top physical shape, it still took about six months to recover from the operation.

That was four years ago, and Mr. Smith’s new kidney is still functioning and he is back to his active life, forever grateful to his friend.

“Every night,” he says, “during my nightly prayers with my wife, I thank God for bringing David and Allison to me and for giving me the gift of life.

“But for David giving me this gift, I would still be in that dialysis chair.”

Correction: March 9, 2016 
Because of an editing error, an earlier version of this article misstated the role of Dr. Krista L. Lentine, the medical director of the living donation program at the Saint Louis Center for Transplantation, in the study of kidney transplants. She was not involved.

Source:http://www.nytimes.com/2016/03/10/health/kidney-transplant-desensitization-immune-system.html?ref=health