Rebirth of old technique gives kidney transplant patients new lease on life
May 7, 2012
BETHESDA, Md. (May 7, 2012) -- It was midnight when retired Navy Petty Officer Second Class Joyce Brillantes received the call in Chula Vista, Calif., that a kidney was waiting for her at Walter Reed National Military Medical Center in Bethesda, Md. She had spent more than a year on the transplant list and administered peritoneal dialysis infusions to herself at home four times a day to clean her blood like her kidneys should.
Brillantes scrambled to make flight arrangements. Airline delays caused the 30-year-old to miss a connecting flight by 18 minutes and forced her to wait seven hours in a Salt Lake City, Utah airport.
"It was nerve-wracking," Brillantes said.
A phone call to Sgt. Candice Westbrook in the transplant services department at the medical center assured her it would be okay. The team that would perform the life-saving surgery was waiting for her in Bethesda, and her kidney was waiting, too -- on a kidney perfusion machine, a first for WRNMMC.
Kidney perfusion places a donor organ in a system, which preserves kidneys outside of the donor's body until they are transplanted. The perfusion process enables doctors to ensure the viability of the donor kidney, energize the kidney as it waits on the machine, and buys time for the recipient and surgeons to prepare for transplant surgery.
The kidney Brillantes received spent almost 17 hours on the perfusion machine and began working immediately after it was transplanted on Jan. 30 -- not the case for some kidneys that don't receive perfusion on the machine. Commonly kept on "ice," kidneys preserved in static cold storage must "unthaw" from this static or suspended state, and may take up to three months to begin functioning normally, requiring some kidney transplant patients to continue dialysis until the kidneys can work on their own.
Brillantes' transplanted kidney was stored outside of the donor's body for about seven hours before it was placed on the perfusion machine, also called a pump, for another 16 hours -- nearly 24 hours of organ preservation before surgery.
"When you get over about the 24-hour period of storage, you have more of problems with the kidney functioning right away," explained transplant surgeon Lt. Col. Edward Falta, chief of Transplant Services at WRNMMC. "The kidney perfusion machine was key in the success of our patient."
Clinical Research Coordinator Fred Gage and his team in the new kidney perfusion lab at WRNMMC resurrected a technique more than four decades old to give retirees, active-duty service members and their beneficiaries a new lease on life.
Gage, who has worked in the field for 30 years, began assembling resources for the kidney perfusion lab in October 2011, soon after the transplant programs at the former Walter Reed Army Medical Center and former National Naval Medical Center integrated when the hospitals joined to form WRNMMC in August. Staffers there performed the first kidney perfusion in the new lab Jan. 30, for Brilliantes' transplant, and a second Feb. 15, for another patient.
The technique, honed over the last 40 years, will enable WRNMMC, the only Department of Defense military treatment facility that performs organ transplants, to move more patients off the waiting list, allow more military families to donate organs to loved ones and further organ preservation research.
Human kidney perfusion became a reality August 1967, when Dr. Folkert O. Belzer placed a recovered kidney on a perfusion machine in his University of California, San Francisco laboratory. The organ was transplanted in a recipient 17 hours after preservation efforts were initiated and began working immediately, according to the International Society for Organ Preservation.
Some civilian hospitals chose to abandon the kidney perfusion technique beginning in the 1980s, as air transportation costs began to climb, according to Gage. He explained that the organ recovery program at WRNMMC can opt to fly commercial or hop a military flight, cutting costs.
Finding trained personnel to perform kidney perfusion is also a challenge for transplant programs. Gage began training members of the WRNMMC organ recovery team in September 2011.
"It's an older technology. It's been around, but it's fallen away for several reasons: more so economical and logistical, but we brought it back to life here at Bethesda because of our situation, our travel times that [are] involved with both our patients and our kidneys," Falta said.
DOD transplant patients travel from as far away as Landstuhl, Germany, to Bethesda, for the life-saving surgery at WRNMMC. "The furthest kidney we've brought in was [from] Hawaii," Gage said.
Using the perfusion machine, organs can be sustained up to 80 hours after recovery from the donor, remain viable, and often begin working immediately after transplant to the recipient.
Whittled down in size from Belzer's four-feet wide, eight-feet long apparatus that ran on two 12-volt car batteries in 1967, the portable kidney perfusion machine Gage and his team use to recover organs is smaller than some suitcases, about 18 inches by 24 inches and weighs about 35 pounds. Gage's kidney pump is small enough to fit in a passenger seat on an airplane.
"It's portable to the point that it has two motorcycle batteries in it so it has eight hours of travel time," said Gage, who explained extra batteries are packed for longer distances.
A trip on a plane carrying Gage and a kidney in the perfusion machine could mean a shorter flight for other passengers. "They'll give you a straight flight if the pilot will declare it a life flight," he said. "And they will even clear the runways when you're landing so that you're first to land."
BENEFITS NOW, FUTURE HOPES
Gage said the kidney perfusion machine allows his team to evaluate, potentially resuscitate the kidneys and fine tune them using an adenosine triphosphate substrate, a modified sugar module, to energize the organ's cells, so that when the kidneys are transplanted, they'll receive normal blood flow and begin functioning immediately. "You're including different additives in there. The kidney stores all that up," he explained. The process increases the chance that the transplanted kidney will work, and begin working sooner.
"It allows us the opportunity to service our military brothers and sisters more effectively," Gage added.
Surgeons at WRNMMC have performed 18 kidney transplants since the two hospitals integrated, the first within a week of moving the WRAMC department to Bethesda. All DOD transplants were performed at WRAMC prior to the move.
The WRAMC transplant service performed an average 30 kidney transplants per year, according to Transplant Coordinator Caroline Acker. She said about 100 or more of the hospital's DoD and VA patients await kidney transplants. The WRNMMC transplant service achieved a clinical score of 100 percent during a recent review by the United Network of Organ Sharing. Participation in a nationwide kidney swap chain is slated for the hospital later this year.
For service members like Brillantes, who once lived her life around the dialysis she needed 28 times per week, the advances in transplant surgery and kidney perfusion at WRNMMC offer new opportunities, too.
"I'm feeling great," she said, two months after receiving her new kidney.
Brillantes said her energy is up and she has returned to walking her 3-year-old chihuahua/beagle Luie -- up to more than two miles, recently. And her appetite has returned: before her transplant, Brillantes said she ate like a bird, with restrictions on what she could eat. On the third day after her operation, she ordered shrimp pasta in the ICU.
"Let's say I demolished it," Brillantes said.
The swimmer looks forward to laps in the pool once again, and traveling abroad to visit relatives in the Philippines and Australia. For now, she's returned to online coursework in health administration, but Brillantes hopes to one day become a nurse for a transplant team, dialysis unit or nephrology department. She thinks it would be an inspiration to her patients to see her healthy and working.
"So they can believe there is a chance and there is hope," she said.
The former Sailor said all she knows about her organ donor is that she was a 43-year-old woman, who perished.
"She was able to give me new life," said Brillantes, who elected to become an organ donor herself at age 17 when she earned her driver's license, not knowing she would need an organ nearly 15 years later after she was diagnosed with stage five Advanced Chronic Renal Disease in 2010.
"I planned to stay in the Navy for 20 years," she said, and become a "lifer" like her father, retired Chief Jesse Brillantes, a Vietnam veteran who spent 22 years in the Navy.
Brillantes said she became a donor because she knew that if there was any chance to help someone, it would be worth it. "Being a donor means that if you can do it, you want the other person to live," she said.
(Sharon Renee Taylor writes for the Journal newspaper at Walter Reed National Military Medical Center in Bethesda, Md.)