Transplant plan eases wait with imperfect organs

When Gloria Daise signed up last year to receive a new kidney at Brigham and Women's Hospital, she was stunned to learn that the wait for a transplant averaged five to six years. But in April, a surgeon made her an offer: The 65-year-old Dorchester woman could reduce her waiting time if she put her name on an alternative list for patients willing to accept less desirable organs.

Such organs are taken from donors who were older than 60 when they died or who were over 50 and had risk factors that might have damaged their kidneys. Ideal donors are young and healthy. Because there are fewer patients on the Brigham's alternative list -- 33, compared with 259 on the standard list -- the waiting time for a transplant can be reduced by an average of eight months.

Daise said that as Dr. Stefan Tullius, the Brigham's chief of transplant surgery, explained the speedier option to her, she wondered: ''How good are their organs? They're older. But then I thought: 'Gloria, look at you. You're 65. How good are yours?' " She suffers from diabetes, high blood pressure, and kidney failure.

Transplant centers in New England and Michigan, where the shortage of kidneys is pronounced, have been establishing alternative lists, signing up dozens of volunteer recipients, and participating in a three-year study to increase use of the kidneys and to document how well the transplanted organs function. Some surgeons believe that too many of these kidneys, which generally don't last as long as those donated from younger, healthier donors, are going to waste.

They said that the organs, called extended-criteria kidneys, can be suitable for older patients who are at greater risk of dying while on dialysis, whose expected lifespans are shorter, and whose numbers on waiting lists are growing. Surgeons are also offering them to patients who do not respond well to dialysis. The new lists reduce patients' waiting times from six months to two years, depending on their blood type, how many other patients are on the hospital's alternative list, and other factors, surgeons said.

Such organs ''don't last as long as regular kidneys, but they do last a significant amount of time," said Dr. George Lipkowitz, director of transplantation at Baystate Medical Center in Springfield.

Twenty centers are participating in the study, which is funded by the US Department of Health and Human Services, and which will be completed in February.

Preliminary results have found that New England transplant centers have reduced the percentage of extended-criteria kidneys that they discard from 40 percent to 33 percent over two years, said Dr. Francis Delmonico, medical director of the New England Organ Bank, which coordinates regional donations, and president-elect of the United Network for Organ Sharing, a nonprofit organization based in Virginia that sets policy and runs the nation's organ transplant system.

Even though the network adopted a policy 2 1/2 years ago requiring transplant centers to offer certain patients the extended-criteria kidneys, implementation is spotty, and the national rate for discarding kidneys remains at 40 percent, Delmonico said.

Results from smaller studies have found that 80 percent of regular kidneys last at least three years after the transplant, compared with 50 to 70 percent of extended-criteria kidneys. In the New England and Michigan study, 88 percent of 228 extended-criteria kidneys transplanted were still working three months after surgery.

Tullius said his discussions with patients have been ''very interesting."

''They were expecting to get the best thing that came around," he said. ''Now you're telling them they should get a used car."

When Daise left Tullius's office, she was undecided about whether to go on the alternative list. Patients who do are also allowed to keep their spot on the regular list.

But she started thinking about the activities she could engage in again if she was no longer tied to dialysis and had more energy. She spends five hours a day on at-home dialysis, which removes impurities from her blood, a function her kidneys no longer can manage. Daise has been eager to travel and return to work. For four years she was a supervisor at the Mattapan Community Health Center, but her illness forced her to quit a year ago. A month after her visit with Tullius, she told him to sign her up.

The lists are one way that surgeons are trying to address the nation's serious shortage of organs. Thousands of people die every year while waiting for a kidney transplant.

The demand far outstrips supply, even as more living donors have donated one of their kidneys to relatives or friends. Last year, 21,626 kidney patients were taken off waiting lists, including about 15,000 who received transplants. Another 3,767 patients died while waiting, according to the Organ Procurement and Transplantation Network, which is overseen by the United Network for Organ Sharing. But 27,299 new patients enrolled, a net gain of 5,673 in 2004 alone.

Some surgeons are experimenting with other types of marginal organs. In April, UCLA released results of its alternative heart transplant program, finding that 60 percent of patients who received less-than-perfect hearts were alive five years after their transplant, compared with 76 percent of patients who received regular organs.

In the past, some surgeons have used extended-criteria or marginal kidneys, but they did not always tell their patients, and they made subjective decisions about which types of organs to use.

The Michigan and New England transplant centers have adopted tests to determine the quality of the kidneys before they're transplanted. One goal is to provide information to surgeons nationwide about which extended-criteria kidneys produce the best results.

There is another reason for the alternative lists: They are a way to designate younger organs for younger patients, who surgeons say need organs durable enough to keep them from undergoing two or three transplants over the course of their lives.

''I got frustrated taking very good young kidneys and putting them in 70-year-old patients," Lipkowitz said.

Delmonico predicts that the organ-sharing network eventually will adopt a new way to distribute kidneys that takes into account a recipient's age and health, among other factors, so that the youngest kidneys go to patients who will benefit most.

The policy change could be controversial. Currently, kidneys are distributed based on blood type matches and the time the patient has spent on a waiting list, among other factors.

''There are limits on the number of donors we're going to get; that is clear now," Delmonico said. ''So we must rethink how we're distributing organs. We not only have to think about fairness, we have to think about fair use of the resources."

Not all patients will welcome the changes. Massachusetts transplant surgeons said 15 to 20 percent of the kidney patients they ask to sign up for the alternative lists refuse to do so.

Kathie Tessier, 64, told Lipkowitz not to put her name on Baystate Medical Center's alternative list, even though she was an ideal candidate.

''I have some other health issues, and I didn't want to take a chance on something that's not perfect," she said.

Dr. William Harmon, director of nephrology at Children's Hospital, said that unless transplant surgeons more actively ''winnow out" potential recipients, the shortage will remain severe.

''The question is: Does it make sense to transplant someone whose lifespan is five years?" he said. ''It's like putting a 50-year warranty motor in a 1934 Studebaker. The car is going to fall apart before the engine does."

Until the larger questions are answered, surgeons said they will continue to suggest alternative lists for older patients like J. Lawrence Kamara of Mattapan.

Kamara, 70, a retired sociology professor who suffers from high blood pressure, went on the standard waiting list at the Brigham 2 1/2 years ago.

Last year, surgeons told him about the alternative list. Kamara, whose three weekly dialysis sessions were so exhausting that he had to give up teaching a class at the University of Massachusetts at Boston, agreed to submit his name.

On May 12, a coordinator from the New England Organ Bank called Tullius, the Brigham transplant chief, to say it had an extended-criteria kidney. Kamara balked when he heard that the kidney was from a 74-year-old, but an hour later he called back to say he wanted to proceed.

Tullius was optimistic. The donor had died of a brain hemorrhage induced by medication, not a stroke, which is a risk factor for kidney damage, and the organ's functions tested normal. Doctors examined a small slice of tissue to look for blockages in the arteries and nephrons, tiny blood vessels and urine-collecting tubes through which waste moves out of the body.

Less than 10 percent of the vessels were blocked, another good sign. The surgery later that day went smoothly.

Almost a month later, Kamara knows his decision was the right one.

''Everyone said the kidney worked immediately," he said. ''I feel good. It's a relief."

Liz Kowalczyk can be reached at kowalczyk@globe.com.