23 doctors, 10 hours, 6 ORs, 5 lives: The logistics of an innovative kidney exchange

Johns Hopkins surgeons completed the nation's first five-way kidney swap. Here's how they linked living donors with unrelated recipients.

By Damon Adams — Posted Jan. 1, 2007

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Hours after making history at Johns Hopkins Hospital, surgeon Robert Montgomery, MD, PhD, retreated to the solitude of his office. He sat mostly in darkness at 10 p.m. and stared at a poster diagram of the organ donors and recipients operated on that day.

There was no champagne celebration. Just quiet reflection, and the realization that he and his colleagues had accomplished the first five-way kidney transplant.

"The day had been kind of surreal. Then later I thought, 'Wow, look what we did,' " said Dr. Montgomery, who headed the transplant team. "It was one of those great moments in one's life, and I just felt so privileged to be part of it."

In one day, Dr. Montgomery and his fellow transplant surgeons simultaneously removed five kidneys from living donors, then placed the organs in five recipients. Start to finish, the quintuple transplant took 10 hours and required six operating rooms.

Johns Hopkins had done triple swaps before, but it broke new medical ground with the five-way exchange. Boldly going there took great skill, precision, cooperation and coordination. The massive undertaking required the planning and work of nearly 100 medical professionals, including critical care doctors, nephrologists, operating room nurses, technicians and pharmacists.

"It's like an orchestra. You have a conductor and you have all the instruments, and each instrument knows what it's supposed to be doing," Dr. Montgomery said. "You keep it straight by having people responsible for different pieces of it, and they understand their piece very well."

How did it come to be?

Four ill patients, ages 40 to 77 and from Maine to California, separately came to Johns Hopkins in Baltimore in search of a kidney. Each had a family member willing to donate, but the relatives were incompatible by blood and/or tissue type.

The hospital added the donor and recipient information to its donor matching system, and it produced the five-way swap by using an altruistic donor and a fifth patient waiting for a kidney. Each donor would give a kidney to an unrelated recipient.

"It's a domino effect," said Janet Hiller, RN, who helped coordinate the transplant logistics.

About three weeks before surgery, coordinators worked on scheduling operating rooms and lining up physicians and staff. Surgeons met to review the donors' anatomies and other details, and meetings were held with everyone involved. Doing the transplants at the same time would prevent any patients from backing out.

With everything in place, on Nov. 14, 2006, the five donor surgeries started at 7:15 a.m. In separate operating rooms, five transplant surgeons and their teams each removed a donor's kidney.

"The level of energy was higher than it usually is. Here we had the entire transplant division working on the same day for the same goal," said surgeon Dorry Segev, MD, who operated on a donor and recipient. "You know each of your colleagues is doing something cool next to you."

Along with doing his own surgeries, Dr. Montgomery checked on the other transplants. "I was running around like a madman to every room to make sure everything was OK," he said.

Pizza and planning

The donor operations finished by noon. Four kidneys stayed on ice in their operating rooms; extra coolers had been bought for the occasion. One kidney went to a sixth OR so the surgeon could start the recipient surgery before handling another procedure, Hiller said.

About 20 pizzas were delivered for lunch, and the surgeons touched base during the break.

The hospital used its checks-and-balances system to ensure patients were paired with the right kidneys.

After the operating rooms were cleaned, surgery began on the recipients around 1 p.m. Four of the surgeons returned to their operating rooms and implanted the waiting kidneys. A fifth surgeon had started work in the sixth OR a little earlier.

"It made for a big, long day," said surgeon Warren R. Maley, MD, who operated on a kidney recipient. "The great thing is how it benefited people who otherwise wouldn't have had transplants."

Throughout the day, 12 surgeons, 11 anesthesiologists and 18 nurses worked inside the six ORs.

By 5:15 p.m., the five implants were done without any major problems.

"It was very exciting. I would definitely do it again," said surgeon J. Keith Melancon, MD, who operated on a donor and recipient.

The patients are recovering well. Johns Hopkins is working on other cases. And the surgeons involved say the five-way swap showed how paired donations might help other patients waiting for kidneys.

Like his colleagues, Dr. Melancon will remember his part in the historic transplant, and the grateful reactions of the patients and families whose lives were touched that day.

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How it worked

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Twelve surgeons and 10 patients took part in the 5-way kidney transplant at Johns Hopkins Hospital in Baltimore on Nov. 14, 2006. Five living donors gave organs to unrelated recipients.

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