New transplant
method coaxes
living donors

A specialist presents his
kidney-transplant
plan to isle doctors

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By Helen Altonn
haltonn@starbulletin.com

The nation's diabetes epidemic has triggered a crisis: people with kidney failure waiting for transplants.

"The need for kidneys for people on dialysis is rising rapidly in the United States, by about 10 to 13 percent per year," said Dr. Stephen T. Bartlett, transplant surgery director at the University of Maryland Medical Center.

One of the complications of diabetes is kidney failure. Also, "people are living to an older age in general, long enough to develop kidney failure," Bartlett pointed out. Hawaii has the highest growth rate of people over age 65 in the United States.

Bartlett was in Honolulu recently, talking to doctors and the National Kidney Foundation of Hawaii about his program of living-donor kidney transplantations.

The foundation invited him here to describe new laparoscopic technology, which makes it easier for people to be living kidney donors, said Julie Schweitzer, associate executive director.

She said the foundation hopes through education to increase living donors, which would reduce the demand for limited cadaver kidney donations.

The Maryland transplant center leads the world in kidney transplants and is No. 2 nationally in pancreas transplants. It performed 437 kidney transplants last year and 69 pancreas transplants. It has a waiting list of 1,200 for kidneys.

Bartlett, in an interview, said the laparoscopic nephrectomy technique has resulted in increased living kidney donors because it is less invasive and recovery is faster.

The procedure involves use of a laparoscopic camera and a small slit through the belly button to remove a kidney instead of an 8- to 9-inch incision in the flank.

Donors are out of the hospital in two days, and those with desk jobs are back to work within a week instead of six to eight weeks with other surgery, Bartlett said.

"I think as word gets out to the public that they can both ask the family comfortably (for a kidney) and they can donate more comfortably, there is a much greater chance people will have a kidney transplant through this method."

Another good thing about increasing living donors is that it leaves more cadaver kidneys for people without family, he said.

"They (Maryland doctors) are very aggressive about identifying living related or unrelated donors because of the cadaver organ shortage," said Dr. Whitney Limm, medical director of the kidney transplant program at St. Francis Medical Center. He began using laparoscopy here in 1999.

Dr. Richard Perez, University of Hawaii medical school graduate and transplant head at the University of California-Davis, came here to help with the first cases, Limm said.

"Since then, especially this year, we've seen an increase in people who express an interest in (living) donations and have gone through with the donation," he said.

He said he has performed about 25 kidney transplants this year, and one-fourth involved live donors, compared with 10 to 15 percent in the past. He said 220 people are waiting for a kidney transplant.

Limm said he learned from Bartlett that there is greater potential to identify living kidney donors, but it is a sensitive topic. "What we have done is make an increased effort to educate the public and respective families."

Living organ donors have had various relationships with recipients, he said. Some are blood-related and others emotionally related, such as husbands and wives.

"The matching requirement has been lessened with the stronger medications that we have, with less side effects," Limm said.

Bartlett's program also switched to a new technique four years ago for pancreas transplants for Type 1 juvenile diabetics on insulin.

Investigations by his center and others have shown putting in a pancreas through the old technique probably led to a weight gain and a syndrome resembling Type 2 diabetes, Bartlett said.

People can gain weight from Predisone, a drug used in the old method to prevent rejection of the organ, he said. "Our worry is that it's going to convert them from one diabetic to another," he said, stressing the need to limit or even eliminate Predisone.

Lower insulin levels occur in the blood with the new technique, and there is a lower rejection rate, Bartlett said, explaining his center "is trying to re-create the situation as it exists in nature. We're coming pretty darn close."

His center also does simultaneous kidney-pancreas transplants, using kidneys from a live donor if one is available and a cadaver pancreas.

Combining the two procedures is difficult logistically, Dr. Alan Cheung said, "if you imagine having a living donor, not knowing when a cadaver pancreas will be available, on alert, waiting for a call to donate a kidney.

"One of our problems locally," he said, "is we have a limited number of cadaver donors. We never know when the next cadaver pancreas is available, and shipping it to Hawaii from the mainland is difficult."

Cheung said he has performed 10 kidney-pancreas operations with cadaver organs since 1993 "with very good results."

Seven people are on the waiting list for combination transplants, he said. Only patients with Type 1 diabetes are eligible, he said, explaining that Type 2 diabetes does not respond appropriately.