OS ANGELES — Like many transplant surgeons, Dr. Jeffrey Veale got frustrated seeing so many of his patients die while waiting for a donor kidney. So he decided to do something about it: recycle.
Since last year, the UCLA surgeon has transplanted three “regifted” kidneys from previous transplant recipients who died with their donated kidneys still healthy — breaking an unspoken taboo against using kidneys for a third time. Veale said some 25 percent of people who receive kidney transplants die with organs that are perfectly acceptable for transplant into another recipient, and he is pushing hard for other transplant centers around the nation to do the same to help ease the crushing shortage of donor kidneys.
Such transplants have been done before, but infrequently. Veale is the first surgeon focused on making the re-use of transplanted kidneys routine.
“This breaks all policies and procedures,” said Veale, director of the UCLA Kidney Transplantation Exchange Program at Ronald Reagan UCLA Medical Center. “But we shouldn’t be discarding these young, healthy kidneys.”
There have been a handful of case reports of kidneys being reused after the first recipient dies or rejects the donor kidney, generally just days after the original surgery and often while the recipient and organ are still at a transplant center, said Tom Mone, CEO of OneLegacy, a nonprofit organ procurement organization based in southern California. “There’s no history or practice of re-transplanting,” he said. “Among transplant surgeons, there’s a mistrust it will not work out.”
Kidneys that have been transplanted once are rarely used again, Veale said, because they are seen as damaged goods after going through not one, but two “death events” and because transplant surgery can be rough on organs — they get flushed with solution, put on ice, and are sometimes injured by the reperfusion of blood, he said. Immune-suppressing drugs can also be toxic to kidneys.
But he said each kidney should be evaluated on its own merits. “It’s not like two death events are always worse than one,” he said. “It’s a case by case basis.”
Vertis Boyce of Las Vegas is thrilled with the “pre-owned” kidney she received in July, which allowed her to stop the dialysis treatments she’d been on for nine years and start traveling again. She recently attended a nephew’s wedding in North Carolina.
“I feel free again,” she said. “I can do all those normal things you take for granted.”
“This breaks all policies and procedures. But we shouldn’t be discarding these young, healthy kidneys.”
Dr. Jeffrey Veale, director of the UCLA Kidney Transplantation Exchange Program
The kidney she received originally belonged to a 17-year-old girl who’d been killed in a car crash and was transplanted in 2015 into Heriberto “Beto” Maldonado, a Long Beach, Calif., resident in his 20s. He had suffered serious kidney problems since childhood due to an inherited disorder called Alport syndrome. Maldonado was off dialysis and doing well after his transplant, but died in a car accident in July.
Maldonado was known for his generosity. Even after he stopped dialysis, he kept going back to spend time with patients and bring them food. He was so grateful for his new kidney, he wanted to give something back, said his sister Linda Maldonado: “He wanted to be a donor, he talked about it all the time.”
The family arranged for Maldonado’s liver to be donated but when OneLegacy noticed Maldonado was a recent kidney recipient, they contacted Veale, who had performed a transplant surgery on Maldonado. “They called and said, ‘Would you consider re-transplanting his kidney?’” Veale said. “I said, ‘Yes, I would.’”
Veale then phoned Boyce, who’d been waiting for a kidney for nearly nine years. “He said I was a match but there was a back story. I said, ‘Hmm, I’m going to be the third owner?’ But I said yes. I was 69 years old, what were the chances of getting another one?”
Now she laughs about having a pre-owned kidney. “It’s already broken in,” she said.
The scar tissue around Maldonado’s kidney was so thick Veale couldn’t even see the organ. But lab tests showed it was working perfectly. So Veale took it out, scar tissue and all. He then transplanted the organ, along with the scar tissue and some blood vessels, into Boyce’s body. It’s so far worked wonderfully for Boyce.
It turns out to be quite difficult to remove a transplanted kidney embedded in scar tissue. “It takes almost a heroic effort. It’s technically extremely challenging,” said Dr. Sandip Kapur, chief of kidney and pancreas transplant surgery at NewYork-Presbyterian/Weill Cornell Medical Center. “I think that’s why historically people have shied away from doing it.”
But many transplant surgeons are taking hard looks at a variety of kidneys once deemed unsuitable for transplant. Dr. Anthony Watkins, an abdominal transplant surgeon did his first transplant of a kidney from an HIV-positive patient into an HIV-infected recipient earlier this month at the same New York hospital. It’s a technique that was pioneered by South African transplant surgeon Elmi Muller in 2007 and is now done under research protocols at U.S. hospitals. Surgeons have also begun transplanting kidneys from patients with hepatitis C into patients who are free of the disease because hepatitis treatments are now so effective.
“We have to try to use as many innovative strategies as we can to increase the number of organs,” Watkins said. “There are so many people dying daily.” According to the National Kidney Foundation, nearly 5,000 people die each year in the U.S. while waiting for a kidney transplant and another 3,600 become too sick to receive a transplant.
Long-term outcomes for re-used kidneys are not known yet because so few have been done or followed, but Veale sees no reason re-used kidneys shouldn’t last five or six years — or maybe up to 12 years, as regular kidney transplants do — if the organs are relatively young and not damaged.
Veale’s three patients are all doing well in the months following surgery, he said. The first reused kidney has been in place nearly a year and half. One surgery, Veale said, involved a man who had focal segmental glomerulosclerosis (FSGS), a disease in which the body attacks its own kidneys. The man received a kidney from a donor in his 40s but started to reject it within days, so it was then transplanted into another patient and is working well. “The patient was like, ‘Doc, get it out of me and give it to someone else who can benefit,’” Veale said. “At the end of the day, this kidney did not get thrown out.”
Those in the transplant field say there will never be a huge number of kidneys available for regifting: Only 1 in 200 people die in a way that is viable for donation and only a small fraction of those people have received a kidney transplant. Veale said if a single surgeon can recycle three kidneys in one year “without even trying,” then there could be hundreds of such surgeries done each year nationwide.
Mone of OneLegacy, the Southern California organization that sparked the reuse of Maldonado’s kidney, said he thought the practice would spread if outcomes remain positive. “Large centers ought to be paying attention,” he said. “There’s no reason not to do this, and every organ is one more patient that might not get transplanted otherwise.”
While living-kidney donations and altruistic donation chains for kidneys developed in the past decade have increased the donor pool and the waitlist has shrunk because of the high number of opioid deaths in recent years, surgeons are bracing for a huge uptick in the need for kidney donors that will trail America’s aging and highly diabetic population.
Kapur said Veale’s efforts to reuse organs is admirable, but more importantly, it highlights the need for more donations — nearly 100,000 people are currently waiting for kidneys. Kapur said he’d like to see more people volunteer to donate organs through simple, traditional means such as signaling approval on their driver’s licenses. “It would,” he said, “make doing these extraordinary things unnecessary.”
Donor families and recipients rarely meet, but Boyce recently came to LA to meet Linda Maldonado and her mother. All were nervous, but the women immediately hugged. Eva Maldonado placed her hand on Boyce’s abdomen and said “mi hijo” — my son. Everyone was crying.
“It’s like we have a little piece of my brother still alive,” Linda Maldonado said. “He took such good care of that kidney, he did everything right. Maybe it’s him still trying to help people.”