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The kidney swap program

The kidney swap program is a significant medical advance for Canada and involved months of logistical planning by Canadian Blood Services and several surgeons, doctors, co-ordinators and nurses across the country. The CBS database for incompatible donor-recipient pairs took months to fine-tune. First, the agency had to ensure that the standards of testing for donors and recipients were consistent at all hospitals involved in the pilot program in Ontario, British Columbia and Alberta.

"Lab work is so important because it tells us in advance which donor will work for which recipient, in terms of blood compatibility as well as tissue," said Patricia Campbell, a nephrologist at University of Alberta Hospital in Edmonton.

"The domino transplant was a huge accomplishment and represents the hope that this program will continue to grow and become a national system," Dr. Campbell said.

Kidney swaps have been done in Europe and the United States, with one group swap portrayed on a recent episode of Grey's Anatomy . In June and July, a team at Johns Hopkins University led the first 16-patient domino kidney swap in which eight people received new kidneys through transplants co-ordinated between four different hospitals.

"We've largely benefited with altruistic donors coming forward. It really does expand the number of transplants we can do," said John Gill, a transplant nephrologist at St. Paul's Hospital in Vancouver.

Dr. Gill stressed that even if this pilot project - which took place in Toronto, Edmonton and Vancouver hospitals - expands to other regions of Canada, the need for kidneys will not be met by living donations alone. He said people who want to donate their kidneys after death should sign their organ donor cards and speak with family members about the deceased organ donation program.

Sworn to secrecy

In Canada, the non-directed altruistic living kidney donor program is anonymous. The identities of incompatible donor-recipient pairs who register for kidney swaps are also kept secret. When a swap goes ahead, the recipient doesn't know whose kidney he or she receives or who receives his or her partner's kidney.

Medical experts say that the relationship between recipients and donors can be fraught with tension and dashed expectations. Will the recipient be burdened by a sense of gratitude? Will the donor feel let down by the recipient if she or he doesn't want to carry on a friendship with the person? There is also the possibility that a donor may approach the recipient for money.

An anonymous program guards against these complex psychosocial dynamics and protects both the patient and the recipient. However, if a year after surgery both sides decide they'd like to meet one another, the hospital will facilitate such an encounter and has done so in the past with no negative repercussions.

But such encounters are extremely rare, said transplant nephrologist John Gill from St. Paul's Hospital in Vancouver.

"The fact is that we haven't had a situation where both parties have independently requested a meeting," he said. "Usually, people move on with their lives."

In cases of deceased donors, many transplant programs allow recipients to send in thank-you cards, which are forwarded to the donor's family.

Steps to donation

1. To be an altruistic donor, you must have healthy kidneys and be in good general health. People of any age can become donors but because there is a correlation between age and a decline in health, older patients may not be approved, says Joseph Kim, transplant nephrologist at the Toronto General Hospital.

2. Potential donors are initially tested for their blood and tissue type. In general, family members are better candidates but still match in only one in four cases, Dr. Kim said.

3. The potential donor is then introduced to the transplant team including a social worker, a nurse leader, a surgeon, a medical doctor, a psychiatrist and a donor advocate, who makes sure the volunteer fully understands the process.

4. The psychiatrist screens the potential donor for his or her psychological health. An individual in a vulnerable position, who is depressed or under stress, would not be considered a suitable candidate.

"We assess the motivations of why a person wants to do it to make sure that it's generally altruistic," said John Gill, a transplant nephrologist at St. Paul's Hospital in Vancouver. That means ensuring someone isn't participating in the program to alleviate guilt or absolve himself or herself of a previous wrong committed.

5. The psychiatrist and social worker also make sure the potential donor has a strong support network to get through the process and weeks of recovery.

6. If the transplant team agrees that the individual is suitable, they move forward with a CT scan and a renogram to evaluate the size, shape and function of the kidneys.

7. At St. Paul's, the next step is a mandatory "cooling off" period before surgery.

"Some people think this is a romantic idea and until someone has a doctor looking at them saying, 'Yeah, we're ready to go,' it doesn't sink in," Dr. Gill said. "People need time to digest information."

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