When Vertis Boyce first meets Eva Maldonado and Maldonado’s daughter Linda, the three of them barely speak. They exchange hugs and Eva reaches out and holds her hand over Boyce’s abdomen. It lingers there, and tears flow from Eva’s eyes.
“Mi hijo” — my son — Eva Maldonado says softly in Spanish.
Her hand presses over the spot where a kidney from her son Beto, who was in his 20s when he died in 2017, now rests in Boyce. “He lives on. He lives on,” Boyce says. “I’ll take good care of myself so I can take good care of this.”
It wasn’t the kidney with which Beto was born. He had suffered from kidney disease and received two transplants during his short life, the final one in 2015 from a deceased teenage girl. Two years later, however, the young man died in an automobile accident. Rather than discard the still viable organ, the man’s family agreed to donate it to someone who might not otherwise have received a kidney.
“Kidneys don’t go with you to heaven,” says Linda Maldonado. “Why not give somebody else a second opportunity?”
Her brother’s transplanted kidney went to Boyce, age 70. “I’m just so grateful to this family,” she says. “It’s just like a blessing. That’s the best way I can explain it.”
Boyce had been on dialysis for nearly 10 years when Jeffrey Veale, MD (FEL ’06), director of the UCLA Kidney Exchange Program, called her at home in Las Vegas, Nevada, last July to inform her that there was a kidney for her and to tell her about its unusual history. Up until then, Boyce didn’t believe she ever would receive a transplant. “I thought, I’m 69 years old — when could I get a second chance?” she says. Now, “I feel freer, and I know I’m on the road to a more fulfilled life,” she marvels. “I have a 6-year-old grandbaby who I thought I wouldn’t live to see grow up. I think I will be there now.”
Boyce benefited from “re-gifting,” an approach to organ donation with an untapped potential for saving lives by re-transplanting a previously donated kidney. According to a study published in October 2017 in the American Journal of Transplantation, 38 kidneys had been re-transplanted between 1988 and 2014 in the United States. Boyce’s re-transplant was the second that Dr. Veale had performed; he has since performed a third.
Re-gifting may extend to other organs, as well. The American Journal of Transplantation noted that 26 livers and three hearts had been re-transplanted during the time frame studied. UCLA performed two liver re-transplants during that period, and UC San Diego, in 2015, re-transplanted a heart. “This clearly offers a viable option for liver and some other organ transplantation — dictated by a variety of clinical factors that will vary from case to case,” says Ronald W. Busuttil, MD (RES ’77), PhD, executive chair of the UCLA Department of Surgery, William P. Longmire, Jr. Chair in Surgery and founding chief of the Division of Liver and Pancreas Transplantation. “I have learned that in the field of transplantation, anything is possible. Practices that seemed wildly impossible 30 or 40 years ago have evolved into today’s standard of care.”
RE-GIFTING IS NOT A MAGIC BULLET THAT WOULD DRAMATICALLY REDUCE the chronic shortage of donor organs, but its potential could have a lifesaving impact for some select patients, Dr. Veale says. “Twenty-to-25 percent of those who receive a donated kidney die while their transplanted kidney is still functional. Re-gifting that viable organ to another patient on the waiting list gives new hope to patients who otherwise may not be considered for a transplant,” he says.
Currently, less than 20 percent of the some 100,000 patients on the kidney transplant list in the U.S. receive a kidney each year, while 13 people on the waiting list die each day. Broadening the potential pool with re-gifted organs would not mean a sudden flood of available donor kidneys, however. Like any organ that is being considered as a donation, not all previously donated kidneys are suitable for transplantation. A kidney recipient who, for example, dies from cancer would not be able to pass on his or her organ. On the other hand, a recipient who dies from a heart attack or stroke or accident still might be a viable re-donor.
There are many other issues that stand between a once-used donated organ and a successful second transplant, notes Richard Formica, MD, a nephrologist at Yale University and secretary of the American Society of Transplantation. Before listing the many potential hurdles, Dr. Formica is quick to add that, “in any given circumstance, when a group — and UCLA is excellent — is able to make use of an organ, it’s always a good thing.” But the list of impediments to success is lengthy. “It is not a fruit cake that can be re-gifted over and over,” he says. A kidney that is considered for retransplantation already has gone through a number of significant insults. In the case of a deceased donor, it begins with the circumstances around the death of that donor. “Maybe that person had varying degrees of comorbidity,” Dr. Formica notes. “Maybe they had hypertension or maybe they were older. So right there, the kidney already is suffering some disease while being in that person.” Then the kidney is removed and put on ice, “so there’s injury there,” he says. Then when it is transplanted into a recipient “the restored blood flow rips through that kidney again — ischemia reperfusion injury. So that kidney’s already been bashed around a bit.” Follow that with exposure to immunosuppression medication, and perhaps some episodes of rejection, Dr. Formica continues, and then a second death and the process starts all over again. “There’s already so much injury to the kidney, it’s unlikely that most would be usable in a meaningful way by a second recipient,” he concludes.
In Boyce’s case, however, Dr. Veale felt that the kidney was in excellent condition to be retransplanted. The donor’s creatinine levels, which measure kidney function, were within appropriate range, and the organ was functioning well — “The donor was making plenty of urine,” Dr. Veale notes. The kidney “had been working very well in the original 17-year-old donor and was functioning perfectly for two years inside a 25-year-old man before he died in a car crash,” Dr. Veale says. “The nephrologist and I consulted, and together we felt that there were unrealized life-years left on that kidney, so why discard a valuable organ?”
Because two years had passed between the first and second transplants, there was a good deal of scarring, which would make the procedure more complex. Dr. Veale addressed that issue by taking iliac arteries, which descend from the lower abdomen, from Beto Maldonado and transplanting them, along with the kidney from the original donor, into Boyce. “I sewed the first donor’s kidney, along with the second patient’s vessels, and they all kind of work together to help the third person get off dialysis,” Dr. Veale says.
KIDNEY DISEASE RAN IN BOYCE’S FAMILY. Both her mother and grandfather died from it. When her own kidneys failed shortly after she turned 60, she didn’t think she had much longer to live. She signed onto the deceased-donor waiting list, on which she would likely remain for years before receiving a kidney — if ever. “I had to resign myself to the fact that I probably would never receive a kidney, that I would spend the rest of my remaining days, which I was thinking wouldn’t be long, on dialysis,” she says.
Then, last year, “A miracle happened,” she says. “I received a call: There was a possibility I was in line for a kidney transplant. I just couldn’t believe it. Still, right now, it just seems so surreal.”
She met with Dr. Veale and the rest of the UCLA kidney transplant team, and Dr. Veale explained the unusual journey of the hand-me-down kidney they had for her. It also was unusual that, in this case, two years had passed between the first and what would be the second transplant for this particular organ. In most prior re-transplant cases, the interval between first and second transplant was only a matter of hours or days, not years, Dr. Veale notes.
“They gave me the decision as to whether or not I wanted to accept the kidney, and I’m thinking, how can I say no? Nothing ventured, nothing gained, so, OK!” she says.
She considers herself “living proof” that kidney re-gifting can be a viable option. “If someone can have a second chance to receive a kidney that normally would’ve just been discarded, it would make a big difference,” she says.
While Dr. Formica views re-gifting as having limited potential to address the chronic shortage of donor organs, he firmly believes that the procedure sends a significant positive message. “The value, in my mind, is in what it says to the community of people who are signed up as deceased donors, and, more important, to the community of family members of deceased donors. It says to them that the transplant profession takes its fiduciary duty very seriously, and, therefore, if there is an opportunity to make sure that a person’s organs can help someone else, we’ve got to do it.”
IT HAD NOT OCCURRED TO LINDA MALDONADO AND HER FAMILY TO DONATE her brother’s functioning organ to someone else. But when a health care worker brought up the possibility, they recognized that the gift Beto had received from the unknown teenage girl helped to extend his life and the time he had with his loved ones, and so it made sense to give his kidney to someone else who was in need. “We thought, someone gave my brother that gift, so why not us give that gift to somebody else — why not help another family if we can?” she says.
And re-gifting her brother’s kidney helps, in its way, to keep Beto Maldonado alive for his family. “A person’s never truly gone until he’s forgotten, until you don’t remember him anymore, and now that we were able to meet his recipient, it’s very rewarding for us,” Linda Maldonado says. “It’s a very good feeling to know that we have somebody that kind of still represents him now, even though we can’t see him anymore.”
Enrique Rivero has been writing about health care and other topics for more than 25 years as a newspaper reporter and senior media relations officer for UCLA Health.