Paired kidney exchange attracts VA

Growing practice may be allowed at four hospitals that do transplants

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Sometime in the next month, more than 600 veterans waiting for kidney transplants at VA hospital transplant centers in Pittsburgh and three other locations across the country could have a new option for finding an organ match.

William Gunnar, national director of surgery for the Veterans Health Administration, said he is reviewing the idea of letting the four VA hospitals that do kidney transplants -- in Pittsburgh, Nashville, Iowa City and Portland -- join the still novel but growing practice known as paired kidney exchange.

He said he has asked his staff for ethical and legal reviews of the concept before deciding how the VA will proceed, and he expects to have the review completed this month.

"My hope is that I'd be able to provide clarity to the transplant centers on these issues," said Dr. Gunnar.

In a paired kidney exchange, a person who has a friend or relative who wants to donate, but who is not a match, either because of blood type or antibody incompatibility, can donate to someone else. Then that person's friend or relative donates to a pool of recipients, which hopefully creates a chain of new kidney transplants.

Last month, Allegheny General Hospital took part in one of the largest paired kidney exchange chains ever, with two of its patients getting new kidneys as part of an exchange in which a total of 12 people got new kidneys.

Kidney transplant administrators at all four VA hospitals said they would like to take part in paired kidney exchanges after discussing it for four years, and are hoping for a favorable review from the central office.

"It's a no-brainer," said Mohan Ramkumar, kidney transplant program medical director at VA Pittsburgh Healthcare, which has 194 people on its waiting list and does about 40 transplants annually. "The more transplants you can do, the more money you save from dialysis, and the more people you help."

"I don't know if it will do a tremendous amount to cut down on our waiting list, but it could help. It would be one more option," said Dr. Ramkumar.

Last year, of the roughly 17,000 kidney transplants done nationally, 304 of them were the result of paired exchanges. But that's up from just 74 in 2006, according to The United Network for Organ Sharing, an organization that oversees the nation's organ and transplant network. Experts expect those figures to continue to grow rapidly as the concept takes hold.

In addition, UNOS is about to start a pilot program for a possible national paired kidney exchange program, which would join all of the nation's 241 kidney transplant centers together, greatly expanding the pool for paired exchanges. Some experts believe 3,000 or more kidney transplants could be done if a national paired exchange program were created.

The VA used to have 20 hospitals that did kidney transplants. But when Medicare in 1973 started paying for all kidney transplants, veterans chose private hospitals for transplants, and the VA closed its programs.

When Medicare started charging co-pays for its services in the 1990s, veterans asked the VA to do kidney transplants. In 2001, the VA chose three hospitals to restart their programs, with Pittsburgh joining them a year later.

All four kidney programs have seen a rapid increase in their waiting lists in recent years, which is why Dr. Gunnar is looking to get two more VA hospitals to start kidney transplant programs.

"The word took awhile to get out that we were serious about restoring our kidney programs," said Christie Thomas, transplant services director of the Iowa City VA, which has about 100 people on its waiting list and does about 30 transplants a year.

Though most of the nation's kidney transplant centers already are members of at least one of the various paired kidney exchange consortium -- which orchestrate exchanges between different hospitals -- the VA has moved more cautiously.

"There have been some accusations over the years that this ethically and legally borders on potentially selling organs," said Dr. Gunnar.

A 2007 federal law specifically said that paired kidney exchanges was not selling organs, which would be a violation of the National Organ Transplant Act, but Dr. Gunnar said a legal opinion was still needed to move forward.

Ethically, a big issue for paired kidney exchanges is dealing with altruistic donors not tied to a specific transplant recipient, said Judy Kazmar, kidney transplant coordinator for the Portland VA hospital, which has 152 people on its waiting list and does about 30 transplants a year there.

"We're pretty conservative here. And with donors, we need to know, what's their motive for donating?" Ms. Kazmar said. "I think paired donations is a good idea, but it has a lot of logistics to it to work out."

If the VA does decide to go ahead with paired exchanges, one idea would be to start with its own pilot program of sorts.

"I think a consortium among ourselves would be best to start with, and then look at joining a larger consortium or national program," said Anthony Langone, kidney transplant medical director for the Nashville VA hospital, which has about 200 people on its waiting list and does about 30 kidney transplants a year.

The VA also is debating how to pay the thousands of dollars to pre-screen potential donors -- some of whom might not donate -- and how to assign long-term, post-surgical care to donors who aren't veterans, said Dr. Thomas.

"We as a nation have done badly dealing with long-term care for living donors," he said. "We want to make sure we get it right."


Sean D. Hamill: shamill@post-gazette.com or 412-263-2579.


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