The fundamental problem in transplantation is a shortage of transplantable organs. More than 90,000 candidates are on the national waiting list. It is estimated that about one third of kidney transplant candidates may have a willing, medically fit living donor, but the donor is incompatible because of an unfavorable blood type or the patient has antibodies to the donor’s tissue antigens.
In the past five to 10 years, researchers have developed several techniques to overcome incompatibility. One is desensitization, which involves performing extra manipulation of the immune system by removing the antibodies (plasmapheresis), blocking the antibodies (intravenous immunoglobulin), or suppressing antibody production (anti-CD20 antibodies). Desensitization does not always work, and the results achieved are not as good as with compatible donors and conventional immunosuppression. Still, it is better than waiting on the list. Another solution to incompatibility is called paired donation.
A successful paired donation
Below is a case illustrating the collaborative efforts between nephrology and urology at the Glickman Urological and Kidney Institute. Cheryl, whose blood type is O, wanted to donate to her older sister, Jackie, who is on dialysis and is a blood type A patient. Cheryl is highly motivated and is very healthy. Although she is blood type compatible with her sister, a direct transplant was not possible because Jackie had antibodies to tissue antigens on Cheryl’s kidney, a positive cross match test. At the same time in another Northeast Ohio community, Cindy wished to donate to her mother, Pat who was suffering from end-stage renal disease. Cindy was also highly motivated and healthy. Cindy is a blood type A and her mother Pat a blood type O making this combination incompatible.
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Both incompatible pairs enrolled in a paired donation registry jointly operated by the institute’s urologists and nephrologists. Medical information on the incompatible pairs was placed into the computer. A specialized program of the Paired Donation Network identified a match where Cindy could donate to Jackie and Cheryl could donate to Pat. Cindy’s tissue type antigens were compatible with Jackie and the two were the same blood type. Both Cheryl and Pat were blood type O with a negative cross match test, making transplantation possible. Both transplants occurred simultaneously and all are doing well.
