Circle of organ donation

A trend-setting case of a three-way-swap kidney transplant, which signals how such pairing can be the way forward

Circle of organ donation

Timely organ transplantation is critical in saving a life. Patients diagnosed with heart or liver disease often require urgent transplantation for the diseased organ as the only means of treatment. Long waiting times for a suitable donor may be detrimental and can result in a loss of life. Patients with kidney disease, on the other hand, can be treated with dialysis for some time, in case a donor is not readily available. Hence, there is more time to prepare and find an appropriate donor in such cases. However, the number of people who require kidney transplants are more than the number of willing donors

An ideal kidney donor should be of the same blood group and have immunologically compatible tissues; i.e., the patient should be negative for antibodies against the human leukocyte antigens (HLA) of the donor. This is determined by a test called tissue cross-match, which should ideally be negative. In India, kidney donors are often family members. Most individuals are hesitant to donate their organs; however, they find it acceptable to donate to a family member and are more willing to donate to a loved one.

Here is an interesting story of how multiple lives were saved because multiple donors agreed to donate outside their families.

48-year-old Mohamed was suffering from kidney disease for over five years and was being medically treated. When the time came for a kidney transplant, Dr Sajith Narayanan, Senior Consulting Nephrologist, Aster MIMS, Calicut, set about to look for a kidney transplant donor and carried out some basic tests. Mohamed was O negative. However, his wife, Bushara, was B positive and could not be a suitable donor. Tests also revealed that Mohamed had a heart condition that required coronary angioplasty. Since transplantation is advised only six months after such a procedure, Mohamed had to undergo dialysis in the interim period.

Simultaneously, 36-year old Sunitha Kumari was also in need of a kidney donor. She had been diagnosed with kidney disease during pregnancy four years ago and had been on medications for the first few years. She had recently started undergoing dialysis as her condition was worsening. Her husband, Anil Kumar, was willing to donate his kidney to her. However, while they both were B positive, there was cross-match positivity, and the donor-recipient pair was also not suitable.

B-positive, 40-year-old Aboobaker was also in need of a kidney transplant. He had already received a donor kidney 14 years ago in Coimbatore. However, this kidney was failing now, and a second transplant was required. His wife, Nadira, was ready to be the donor and turned out to be O negative. O being the universal donor, Nadira would be able to donate to Aboobaker and the couple could complete the donor-recipient pair.

However, the innovative team of doctors at Aster was trying to save multiple lives and realized that should Nadira be willing to donate to Mohamad (who was also O negative), Bushara to Sunitha Kumari, and Anil Kumar to Aboobaker, then 3 lives could be saved.

Nadira was first approached and asked whether she would be willing to donate to Mohamad instead of Aboobaker. She willingly agreed and the plan for a 3-way kidney swap was initiated. A tissue crossmatch was done for all the three pairs and turned out to be negative. The 3-way swap was then carried out after a government committee approval and all three pairs are doing well post-transplantation.

‘Approximately 40-50 kidney transplantations are performed every month in Kerala alone. Each hospital maintains its own registry, as currently, there are no registries at the state or national levels. Such registries are the need of the hour and have been previously discussed. However, they have yet to take shape,’ says Dr Narayanan.

Ready donors are often family members. However, transplantation is often limited due to blood group incompatibility or crossmatch positivity. With medical advances, A-B blood incompatible transplants are possible. However, such procedures are riskier and require an additional procedure such as plasmapheresis to neutralize the differences in the blood groups. To avoid this, paired exchanges are a more feasible option, and are often carried out. Since kidney transplants are often not required immediately, eventually a suitable donor can be identified. This case shows that 3-way swaps can, and should, be considered to help more patients in need of kidney transplants. 

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