Vertis Boyce got the call from her transplant surgeon last July. We have a kidney for you, Jeffrey Veale explained on the phone, but it has an unusual backstory. The kidney was first transplanted two years ago from a 17-year-old girl into a man in his early 20s, who just unexpectedly died in a car accident. Boyce would be its second recipient. Did she want it?
Boyce had by then been on dialysis for nine-and-a-half years and on the transplant list for nearly as long. “I thought, I’m 69 years old. When could I get a second chance? I really thought I wouldn’t get a kidney,” she recalls. So she said yes. Soon, she was on a plane from Las Vegas to Ronald Reagan UCLA Medical Center, where Veale performed the transplant.
Boyce took the chance because she did not want to be one of the 13 people who die waiting for a kidney transplant every day. The kidney-transplant list in the United States has 100,000 people, of whom only 17,000 will get transplants each year. In the face of this cold brutal math, doctors have tried a variety of ways to expand the pool of available organs—taking up organs from older donors as well as donors who suffered a cardiac death rather than brain death. Reusing previously transplanted organs, however, is rarely considered. “It’s just dogma,” says Veale. “It’s almost like taboo to retransplant a kidney.”
There are reasons, of course. “These kidneys have gone through multiple rounds of insults,” says Richard Formica, a nephrologist at Yale University and the secretary of the American Society of Transplantation. He ticked them off: death of the original donor, ice, reperfusion injury when the kidney is placed back in the body, immune system-suppressing drugs that can cause kidney damage, death of the second donor, ice again, reperfusion injury again. “Few kidneys would be good enough,” he says.
In this specific case, says Veale, the kidney did seem good enough. The original donor was a young, healthy teenager, and the second donor’s creatinine levels—a common measure of kidney function—were good. Once Boyce agreed to the transplant, Veale went out to recover the kidney himself.
There he ran into another challenge. When patients receive a transplant, the new kidney usually goes into the pelvis attached to the iliac blood vessels that supply the leg. (The patient’s original kidneys in the lower back usually stay put. ) Over time, scar tissue can form. To make sure he could sew the kidney into Boyce’s body, Veale took out not just the kidney but also some of the second donor’s iliac vessels. Boyce now has tissue inside her from two donors: the kidney of the 17-year-old girl as well as the iliac vessels of the young man.
It was only the second transplant reusing a kidney Veale had ever performed, and he has now done three, all at UCLA. He estimates that 30 to 40 have ever been performed in the United States. A spokesperson for United Network for Organ Sharing, the organization that matches donors to recipients in the United States, told me it does not specifically track the reuse of previously transplanted organs, so it did not have a number readily available.
A handful of case studies have documented reuse of kidney, liver and heart transplants. The published cases have been generally successful—though that may reflect a bias in what gets published. One case study followed a patient with a reused kidney who was still in “good health” 14 years later. Another case documented some complications—the second recipient became infected with an antibiotic-resistant virus from the first recipient, which ultimately went away with different drugs. “Our patient eventually had a good outcome, but it was tough,” says Pradeep Kadambi, an author of that case study. “We still think we did the right thing” in offering him a reused organ.
Case studies are not clinical trials though. “I think the thing that’s really held [reusing transplanted organs] back is it’s too infrequent and too difficult to structure a trial,” says Alejandro Lugo, who published a 10-year follow-up case study of a reused kidney in 2015. In other words, there is no good data on the outcome of these cases compared to ordinary kidney transplants. Formica, the nephrologist at Yale, put it this way: “This has never been studied to what we would hold to be scientific rigor.”
Given the small number of organ recipients compared to the general population, the number of organs that could be reused is ultimately quite small. But it illuminates larger issues that come with efforts to expand the pool of donor organs.
Transplant centers are reluctant to take organs that are imperfect for any number of reasons. The centers are tightly regulated by the federal government and can lose their status if too many of their transplants fail. “A lot of [transplant centers] are risk averse enough to not want to give it a try,” says Tom Mone, the CEO of OneLegacy, the organ procurement organization that matched the kidney to Boyce.
How to inform patients about previously transplanted organs is also not quite settled. Should they be consulted ad hoc, when an opportunity arises? Should they be asked their preference when they sign up for the list? “Doing it at the moment of the transplant, that’s not really fair. That’s my opinion,” says Formica. Patients do not have much time to decide, and the stakes of the decision can be high—even life and death. But Mone says it is not that different from decisions potential recipients already have to make—like whether to accept an organ from an older donor or wait for a younger one. “It’s a common event where people say I’d rather wait for a younger one,” he says.
For Boyce, the transplant has been life changing. She no longer needs to go to her dialysis center three times a week. She can travel, and recently, she went to her nephew’s wedding in North Carolina. “It just felt good,” she says, “I felt free.”
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