From Nature.com, by Andrea Aguilar
SMYD2 is a novel epigenetic regulator of cyst growth
Kidney Transplant News
U.S. doctors are discarding donated kidneys that could keep people alive for years, simply because the organs are not top-quality, a new study claims.
"Suboptimal" kidneys from older donors with health problems perform much better than expected, and would preserve a patient's life much longer than dialysis, said lead researcher Dr. Sumit Mohan, an assistant professor at Columbia University's Mailman School of Public Health.
About 73 percent of lower-quality kidneys received by Columbia patients were still functioning five years after transplant, Mohan and his colleagues found.
"To our surprise, yes, they did worse than the best-quality kidneys, but they didn't do that poorly," Mohan said.
By comparison, the five-year survival rate for kidney patients on dialysis is about 35 percent, Mohan said.
"If I don't get a kidney, my alternative is to stay on dialysis," Mohan said. "Even getting a suboptimal kidney provides a huge survival advantage."
Unfortunately, about 1 in 5 donated kidneys winds up in a trash can in the United States, Mohan said, even though the United Network for Organ Sharing shows more than 97,000 people are now on the waiting list for a kidney transplant.
These kidneys are discarded because biopsies of donated organs reveal scarring or other problems that make them less than ideal, Mohan said.
When is a donor kidney good enough?
Some low-quality kidneys are rightfully discarded, Mohan said, but he suspected that many donor kidneys could still provide years of good function.
To test this idea, Mohan and his team reviewed 975 kidney transplants that occurred at Columbia University Medical Center between 2005 and 2009.
Kidneys from living donors provided the best outcome for patients, with 91 percent still working five years after transplant regardless of whether the organ was damaged, the researchers found.
Living donors undergo intense screening to make sure they are healthy enough to donate a kidney, Mohan explained. In addition, kidneys from living donors are not damaged during organ preservation and transport.
"You should take a living donor kidney regardless of anything else you know about that living donor," Mohan said. "It's always going to be better than a deceased donor kidney."
But high-quality kidneys from deceased donors functioned well, with nearly 82 percent still working after five years, the researchers found.
Surprisingly, most lower-quality kidneys also remained viable for nearly as long as the best kidneys, with 73 percent still working five years after transplant, the study showed.
By eight years after transplant, 62 percent of optimal kidneys and 53 percent of suboptimal kidneys from deceased donors still functioned, Mohan said.
The findings were published online July 6 in the Journal of the American Society of Nephrology.
Are biopsies the best way to decide?
The problem?
Doctors rely too heavily on biopsies in judging whether they will accept a kidney for transplant, said Mohan and Dr. Richard Formica, director of transplant medicine at the Yale School of Medicine.
Biopsies of donated kidneys are often reviewed by pathologists who are not kidney experts, Mohan and Formica explained. These general pathologists are not as capable as specialists of performing a nuanced review of each organ's quality.
In addition, biopsy results can vary depending on where the tissue sample is taken from the kidney, and might not accurately reflect the overall quality of the kidney, Formica added.
Finally, many biopsy samples are frozen, and the freezing process can distort what a pathologist sees under the microscope, Formica said.
"I don't think the way we do biopsies currently in assessing whether or not organs get transplanted gives the clinicians the ability to make an informed decision," Formica said. "That's the problem with biopsy."
Mohan and Formica couldn't say whether the problem extends to other donated organs, such as hearts or livers.
Doctors might be choosier regarding kidneys because patients can be kept alive through dialysis, whereas a person needing a new heart or liver will die without the donation, Formica said.
Lower the bar to save more lives?
"People don't realize if I turn down a kidney that's coming for somebody, it's not that that person is going to sit on the waiting list forever just waiting for the perfect kidney," Mohan said. "There's a significant possibility they're going to die before the next kidney shows up, because the mortality rate on dialysis is so high."
Mohan believes that transplant doctors should rely more heavily on a donor's medical records to decide whether a kidney is viable, and use biopsies solely to help evaluate truly questionable donations.
"If you know age of the donor, the gender, the race, the clinical history, you pretty much already can guess 9 times out of 10 what the biopsy is going to show you," Mohan said. "Looking at a bad biopsy shouldn't sway you further away from using that kidney."
The U.S. organ donation system also should consider changing the way it distributes donated kidneys, to provide people further down the waiting list the option of taking a less-than-perfect kidney if it suits them, said Formica, secretary of the American Society of Transplantation.
"If you're 65 or 70 years old, waiting six years for a kidney isn't really an option," Formica said. "You're either dead or you're not going to have any more fun in your retirement. However, if you could get a kidney that was not perfect but was good enough, if you could get that kidney in two years and then get to take that Danube River cruise you always wanted. That's not a bad trade."
More information
For more on transplant trends, visit the United Network for Organ Sharing.
From The Indian Express, Mumbai
Unlike regular kidney transplantation where the patient receives the kidney through a larger muscle cutting process, robotic surgery is conducted with only a small incision and involves no cutting of muscle.
MAHARASHTRA became the third state in the country to record a successful robotic kidney transplant after Gujarat and New Delhi. The kidney transplant surgery, conducted on July 2 at HN Reliance Foundation Hospital and Research Centre, (HNRF), Mumbai, saw a woman donating a kidney to her husband. Unlike regular kidney transplantation where the patient receives the kidney through a larger muscle cutting process, robotic surgery is conducted with only a small incision and involves no cutting of muscle. The Da Vinci robot is used in a specific way to ensure tremor free movement of the instrument thus causing no damage to the graft kidney. This ensures minimal chances of infection and faster recovery of the patient and the donor.
Andheri resident Leena Murlidharan (55) donated the organ to her husband C N Murlidharan (59) after he was admitted to the hospital with renal failure. “The family was apprised about the latest robotic technology and its benefits, including lesser risk of infection, lesser pain, and a faster return to normalcy. Higher magnification and finer scaled movement of robotic instruments ensured greater precision in this act,” said Shruti Tapiawalla, consultant at HNRF.
Doctors said that the particular robot has been in use previously for other surgeries but was used for the first time for a transplant. A team of doctors led by Dr Inderbir Gill, Head of Department, Urology and Robotics, HNRF, and MD, Distinguished Professor and Chair, USC Institute of Urology, University of Southern California conducted the surgery. “The cost of this transplant is not much higher than a regular transplant process which is worth Rs 5-6 lakhs,” Tapiawala added.
“It has been a privilege to perform Mumbai’s first robotic kidney transplant at the hospital considering it is the first of its kind in Maharashtra. The team worked together and we are thrilled the patient and the donor are doing well and the operation was a great success,” Gill said.
Gill added that robotic surgery allows kidney transplantation to be performed with great precision, minimal blood loss, and lesser chance of post-operative infection. “This is an advanced procedure performed in very few centers in the world,” he added.
Murlidharan had been on dialysis for the past one-and-a-half years. He said, “The robotic surgery involved much lesser pain. I was initially reluctant, but the doctors convinced me about the benefits. I am happy that I went ahead with it.” Narrating her experience, Leena said, “I decided to give my kidney for my husband’s normal life,” who added that she did her own research about the surgery before going ahead with it.
Patients suffering from chronic renal diseases tend to prefer renal replacement compared to dialysis for various reasons. Only three centers in India including Mumbai have performed these transplants as of now.
Living with PKD
That’s why a nurse from Lifespan is hoping to raise awareness, hoping to get a retired Providence firefighter a living donor soon.
"It's been difficult for him because he's the type of guy who's always a go, go, go person,” said Nancy Thibault of her husband of 11 years, Raymond.
Raymond said he found out he had an inherited form of kidney disease, polycystic kidney disease, when he was in his 20s. His mother had it too.
"I just kind of put it off. It didn't really bother me until two years ago," he said.
That's when his health started going downhill.
"A lot of fatigue, I was getting tired, nauseous," he recalled.
Raymond’s kidneys were failing and for more than a year now, he has been on dialysis three days a week, every week, for about four hours a day.
His 10-year-old son, Ray, explained how dialysis works: "It's like a machine that the blood goes through and filters his blood because his kidney doesn't work."
About six months ago while talking about the importance of living kidney donations, the Thibaults met Sheila Drew, a nurse at Lifespan. Five years earlier, she had donated a kidney to a Coventry woman.
“ I said, 'Well, I work at a hospital. We have a transplant center. Somebody must need my kidney,'" she recalled.
That was after she tried to donate one of her kidneys to a little Massachusetts girl in need but a better match was found. Drew then offered to donate to someone in need in Rhode Island. That person turned out to be Carol Ryan of Coventry in August 2012. They met in the hospital just days after the operation.
"And the two of us just looked at each other and there was a flood of tears,” said Drew. “I didn't know the woman from anywhere but I knew we're sharing body parts."
Since that time, Drew and Ryan have been good friends. And Drew has become a zealot about others becoming living donors.
"Sheila's an amazing person and actually it inspired us there's actually people out there that are willing to donate and it's sort of given us a little bit of hope," said Nancy Thibault.
So, the Thibault family hopes and Drew continues to preach.
"Wherever I can I tell my story," said Drew.
To qualify as a living donor, you must be at least 18 years old and in excellent health. Recovery can last up to three months. Drew said she bounced back much sooner than that. She has lunch often with the women she now refers to affectionately as "Kidney Carol."
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