Consider Living Donation

Preemptive transplantation refers to kidney transplantation before a patient needs to start dialysis therapy (either peritoneal dialysis or hemodialysis). Patients who get a preemptive transplant receive their kidney when their health is generally good, which can improve new kidney function and enhance overall health and life expectancy. Published medical data has shown that the kidney will work much longer in patients transplanted before dialysis is started. However, no matter how long someone has been on dialysis, a transplant from a live donor should still be considered.

Spending a long time on dialysis does not ruin your chances of having a kidney transplant. But getting a transplant sooner rather than later is generally the best approach. Preemptive transplant is especially beneficial for patients with type 1 diabetes who need both a kidney transplant and a subsequent deceased donor pancreas transplant.

For more information about preemptive transplantation, please review to the medical article and brochure below:

• Meier-Kriesche, Herwig-Ulf, "Waiting Time on Dialysis as the Strongest Modifiable Risk Factor for Renal Transplant Outcomes," Transplantation 2002 Nov 27; Vol. 74, 1337-1381, No. 10.
• "Kidney Transplantation BEFORE Starting Dialysis: Frequently Asked Questions," a brochure prepared by the BIDMC Transplant Center

There are many different types of living donors. They can be a husband or wife, adult child, parent, sibling, other relative, friend, co-worker and Good Samaritan (a compassionate stranger). A living donor does not have to be a blood relative to you. Any healthy person over age 18 with a similar blood type may be considered as a possible donor. However, individuals with certain medical conditions such as diabetes and heart disease may not be able to donate. Members of the transplant team (who are not involved in your care) will evaluate possible donors for you.

Expanding the Donor Pool

Your living donor may be healthy enough to donate, but not be a good match for you, because of his or her blood type or because you might have proteins in your blood (antibodies) that would attack the donor kidney (crossmatch incompatibility). However, you may still be able to benefit from living donation. The Transplant Center at Beth Israel Deaconess offers:

• Desensitizing protocols for highly sensitized patients who, because of the presence of antibodies, would otherwise not qualify for a living donor transplant
• Kidney transplants across blood groups (called ABO incompatible)
• Paired exchange, a New England Program for Kidney Exchange (NEPKE) organ donation initiative
• List exchange or donation on your behalf to the top of the transplant list

These are explained in more detail below, and there are also links to sources with even more detailed information.

A sensitized patient has antibodies (proteins) in his or her blood, which attack the donor kidney. This is tested before any transplant can be performed by mixing the blood of the possible recipient, which contains these antibodies, with white cells from the potential donor. This is called a "crossmatch" test. If there are antibodies in the recipient specifically directed against the potential donor, they will kill the donor white cells and the crossmatch is "positive." This means the transplant cannot be performed. If the transplant were to be performed under these circumstances, the kidney would be destroyed immediately after blood was restored to the new kidney in the operating room. So a highly sensitized patient (one with many different antibodies) is likely to have a positive crossmatch, limiting the pool of potential donors. However, there is hope for these patients, through procedures called desensitization, which removes and neutralizes these antibodies. Patients can be desensitized using a combination of plasmapheresis, a procedure to remove antibodies, and a variety of specialized drugs.

This desensitization treatment has good success rates in allowing transplantation with a donor, despite a positive crossmatch, but there are some extra steps involved.

Plasmapheresis is similar to dialysis, only it removes antibodies that are stored in blood plasma. This process is complex and is tailored to fit each individual situation. Generally, an IV infusion of immune globulin is given after each plasmapheresis treatment (to help fight infection and neutralize the antibodies). In addition, you will need to start transplant medications before the surgery. Patients may need several rounds of plasmapheresis. The amount of treatment depends on the level of antibodies against the donor's blood type. When patient antibodies are low enough to result in a "negative" crossmatch so that the recipient will accept the transplanted organ, the surgery can occur.

ABO (Blood Type) Incompatible

Sometimes it is possible to transplant kidneys even when donors and recipients have different and incompatible blood types. The protocols used are similar to those used to desensitize patients with a positive crossmatch, and include plasmapheresis and immunosuppression before the time of transplant.

There are other good ways to have a transplant even if your living donor and you are ABO incompatible or have a positive crossmatch. The Transplant Center participates in two unique initiatives to expand living donation in this situation through the New England Program for Kidney Exchange (NEPKE), a program of New England Organ Bank (NEOB), the organ procurement organization for BIDMC. The initiatives are:

Kidney Swap

Donation to List

A living donor donates to the list of patients waiting for a kidney, and the organ is allocated as if it were from a deceased donor. In return, the patient who was not able to receive his or her living donor's kidney now moves to the top of the wait list, and receives a kidney more quickly from the deceased donor pool.

A living donor transplant is preferable to a deceased donor for a number of reasons:

• Transplanted sooner 
  By eliminating the waiting time for an organ, the patient spends much less time on dialysis. This improves both the quality of life and the life expectancy.
• Lasts longer 
  A living donor kidney typically functions for between 12 to 20 years, compared to 8 to 12 years for a deceased donor transplant. What accounts for the higher success rate? Closer genetic matches between donors and recipients, lower chances of donor organs being damaged during preservation and transport, and the fact that kidneys are taken from healthy individuals all play a role.
• Works immediately 
  Compared to a kidney from a deceased donor, which can take as long as three weeks to "wake up," a live donor kidney works immediately almost all of the time.
• Works better 
  The kidney function from a living donor is usually better than from a deceased donor.
• More convenient 
  Living donation can be scheduled at the convenience of both donor and recipient, and is performed at a pre-determined time, rather than as an urgent operation when a deceased donor kidney becomes available.
• Quicker recovery 
  Patients who receive a kidney from a living donor usually spend less recovery time in the hospital following the surgery, compared to those who receive a deceased organ. Patients are generally in better health when they receive a living kidney, compared to patients who may suffer some additional health complications as they wait for a deceased organ.
• Transplant before dialysis 
  If a living donor is available, it may be possible for the patient with kidney failure to undergo a preemptive transplant before he or she ever needs dialysis. Studies show that a transplanted kidney from a living donor functions longer, and the recipient lives longer, compared to those patients who have had dialysis prior to transplant.
• Better match 
  Family donors may offer recipients a better HLA tissue match.

Believe it or not, patients are the primary barriers to doing more living donor kidney transplants. Most patients who need a donated organ do not want to burden family and friends, or put loved ones at risk. Many are reluctant to ask, even though there are people within their social network who are very willing to consider donating a kidney. Our behavioral health team can help patients and families explore their own feelings and concerns about living donation. Together we can develop a plan to talk to your family and friends about this option.

Our expertise in this area is especially helpful in supporting minority patients who need organ transplants and would benefit greatly from living donors. The Transplant Center has started novel programs to reduce racial disparity in organ transplantation. For instance, to make it as convenient as possible for patients and their loved ones, our transplant health educators will make "house calls" to provide information about living donation and kidney transplantation.

Some people who are waiting for a kidney transplant decide to use social media sites such as Facebook, Twitter, Instagram and others to post about their kidney disease and to look for a living kidney donor. Using social media lets you share your story quickly and simply, and lets you reach a large number of people who might consider live kidney donation for you.

Please think about the pros and cons of using social media to find a living donor before posting online. We ask that you consider the information in the handout linked below to help you decide if it is right for you.

• Using Social Media to Find a Living Donor