By Debra Anscombe Wood, RN
Transplant coordinators at Montefiore Medical Center recognized an opportunity to help two patients through the hospital’s first internal live kidney donor swap in March.
“It was exciting; we were able to find a suitable donor match for a swap, considering they would have to wait on the deceased donor list for five to seven years,” said Jessica Motilal, BSN, RN, transplant coordinator.
“The [transplant coordinators] worked hard to make this a success,” recipient Pauline Powell said. “I was in really good hands.” A 56-year-old mental health worker from Mount Vernon, N.Y., Powell sought a transplant before starting on dialysis. She arrived at the hospital with her daughter, Sedicah, as a candidate to donate a kidney. But Sedicah, 23, was not compatible on cross match. Montefiore enrolled them in the United Network for Organ Sharing Kidney Paired Exchange, but no match was found. Six months later, Edmonia Fulmore, a 46-year-old woman on dialysis, came to the hospital with her son, Brandon Garrett, as a potential donor, but he was not a match by blood type.
“When we looked at them, we realized this could be a swap,” said Pat McDonough, RN, CCTC, CPTC, a transplant coordinator who works with live donors. “It was almost like a match made in heaven.”
The coordinators met with the individuals to explain the swap, including the risks, so the four could give informed consents. Teams at Montefiore work with recipients and live donors to avoid any conflict of interest. The donors always have an option to change their minds. “Donors are incredible,” McDonough said. “They’re healthy people, putting their lives on the line to save someone they love. The reward is someone gets their mother back.”
Preparing for surgery
Scheduling pre-op visits at different times to ensure the parties do not meet represents one of the challenges to preparing for the surgery. The pre-op medical work-up is intense and may uncover challenges to the swap. Patients may need additional testing, which the coordinators arrange. They also help patients with job issues.
“You get to know them so well,” said Helen Stamy, BSN, RN, transplant coordinator.
Even one person catching a cold will disrupt the carefully arranged plans.
“If any one of four are sick, that’s it,” McDonough said.
Fulmore needed plasmapheresis treatment just before the surgery to clear anti-HLA antibodies and obtain a negative cross match.
“It wasn’t until 7 o’clock the night before that we knew it was a go,” Motilal said.
Stamy called it a nail biter.
On the day of surgery, coordinators make sure everyone has arrived. The donor team also ensures correct identification of the patients and the labeling and preservation of the kidney. The donor surgery takes about 2.5 hours, and the recipient surgery takes 3 to 4 hours. The donor and recipient stay in PACU until awake and a bed is available.
The coordinators complete discharge teaching. Recipients stay about five days and the donors one to two days. The Montefiore recipients and donors met after the surgery.
“The connection these four people have is heartwarming and so genuine,” Stamy said. “It’s pretty emotional.”
Recipients receive close monitoring for the first three months to regulate medications and assess for rejection, according to Stamy. After surgery, the donor must come in at two weeks, six months, one year and two years.
Powell and Fulmore both are feeling great and praised the coordinators.
“They were very helpful,” Fulmore said. “I could always call either one of the coordinators for any questions or concerns I had. It made me feel like I was the only patient they had.”
Seeing the recipients looking and feeling better at follow-up, Stamy said, makes all the efforts to make a swap happen worthwhile.
McDonough said she does not worry about donors in surgery, but for the rest of their lives they must receive regular follow-up and maintain a healthy lifestyle.
“The challenges of chasing after healthy people are many,” McDonough said. “They feel fine. You have to call 25 times or threaten to drive to Brooklyn and get them, because we want our follow-up complete.”
That holds true for the recipients, too, as they return to active lives.
The coordinators are looking forward to more internal swaps. McDonough called them easier and less complicated than distant swaps.
“We want to get the message out that you don’t have to be compatible, that paired exchanges are [possible],” McDonough said. “I’d encourage more people to move forward with this.”
Debra Anscombe Wood, RN, is a freelance writer.