Commitment to Widening Kidney Transplant Access Inspires Innovation

The ethos of The George Washington University Hospital Transplant Institute’s kidney transplant program is to make transplantation available to as many patients as possible, including those from disadvantaged socioeconomic backgrounds. That commitment has spurred innovation in areas that include desensitization therapy for living donor transplants to transplantation using kidneys from deceased, hepatitis C-positive donors to the use of kidney pumps to improve outcomes from deceased donor transplants.

Combining Medical Therapy and Plasma Exchange for Sensitized Patients

GW Hospital has become one of the nation’s leading centers for living donor kidney transplants in sensitized patients. The process begins by performing a titer test for every patient upon presentation to determine their antibody levels against different blood types, a rare step at other centers, according to Keith Melancon, MD, FACS, transplant surgeon and director of the GW Transplant Institute.

“To perform desensitization, we use plasmapheresis to cull antibodies that would prove problematic for sensitized patients, and we combine that with different medications that are available for other diseases but that we use as desensitizing agents, such as the multiple myeloma medication bortezomib,” Dr. Melancon says. “This eliminates plasma cells that produce antibodies that would cause patients to reject kidneys from donors with different cell surface markers.”

GW Hospital is a high-volume center for sensitized patients, who comprise approximately 60% of its kidney transplant patients, according to Dr. Melancon.

A Novel Approach to Hepatitis C-Positive Kidney Transplantation 

The advent of highly effective direct-acting antiviral agents to treat hepatitis C allowed GW Hospital and other centers to expand access to kidney transplantation and reduce wait times by accepting donor kidneys from deceased, hepatitis C-positive individuals. The standard is to administer these medications to transplant recipients once they test positive for hepatitis C following transplantation. GW Hospital worked with DC Health and DC Medicaid to secure Medicaid coverage for the prophylactic administration of direct-acting antivirals to transplant patients. Private insurance companies later followed this precedent to provide coverage.

“Our innovation is that we do not want patients ever to test positive for hepatitis C because we think it is safer,” Dr. Melancon says. “It was a significant request of the insurance companies to cover these medications prophylactically, but they did it, and now we are transplanting patients much faster.”
Prophylactic use of direct-acting antivirals prevents several potential risks that may develop in patients who receive standard care, including:

• The possibility of receiving a high viral load from the donor kidney and developing severe illness
• The potential of hepatitis C to cause scarring in and rejection of the kidney
• The potential to develop hepatitis C later when follow up is less frequent, which could delay detection

To date, GW Hospital has performed more than 20 transplants with kidneys from hepatitis C-positive donors, with great success. 

Extending the Viability of Deceased Donor Kidneys

Many centers’ kidney transplant numbers have declined during the COVID-19 pandemic, but GW Hospital’s have remained steady, thanks, in part, to the acquisition of two kidney pumps in 2020. These pumps allow the hospital to accept donor kidneys from across the country because they can preserve viability longer — an especially valuable capability in the wake of new federal kidney allocation policies that went into effect in early 2021, increasing the movement of donor organs throughout the country.

“The longer a kidney sits on ice not receiving blood flow, the worse the patient outcome,” Dr. Melancon says. “I’ve found that every hour that passes after an organ is removed costs long-term survival significantly, especially after 10 to 12 hours. We have known for some time that this can be mitigated somewhat by placing the kidney on a perfusion pump that pumps preservation fluid in a pulsatile fashion.”

At GW Hospital, the kidney pumps have significantly lengthened the acceptable timeframe from kidney removal to transplantation. 

“Recently, I performed a transplant in which the kidney had been outside of the donor’s body for almost 48 hours,” Dr. Melancon says. “That would have been unheard of before we had the kidney pumps, but I was able to put the kidney on a pump and ascertain that it was pumping well and had acceptable pressure. That told me it was a good kidney, despite having been outside the donor’s body so long. I transplanted it, and the kidney worked immediately with an excellent outcome.”