Repeat transplants are on the increase

She knew the words were coming. For a few days shy of 20 years, Charlotte Wolfe had lived with her mother's kidney, transplanted when she was just 9 years old.

No matter. She still burst into tears that day in October 2000 when Dr. Edward Kraus put his hands in his lap and leaned in. "Well," he told her, "it's time. We'd better start looking." Looking, that is, for another kidney.

Like a growing number of transplant recipients, Wolfe would need a second new kidney - retransplantation, they call it. Kidney transplants have come a long way since the first was performed more than 50 years ago. Today, more than 90 percent of kidney transplant patients are alive a year after surgery and most of those kidneys last a decade or more.

As a result, the lucky recipients are now wearing out their donated kidneys - and going on to need second and sometimes third surgeries.

"When transplantation first started out, it was often not successful," said Dr. Mark Stegall, chief of transplant surgery at the Mayo Clinic in Rochester, Minn. "Now it's not uncommon for patients to go 10 to 20 years on a kidney."

In 2005 in the United States, 1,846 repeat kidney transplants were performed, up 40 percent from a decade earlier, according to a report by the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients. About 20 percent of those on the ever-growing list of more than 70,000 waiting for a kidney have been transplanted before.

With the operation all but perfected, doctors are trying to figure out why transplanted kidneys don't last longer and what can be done to increase their life span. Chances are, the kidneys would have worked for decades more in their original hosts.

But some kidneys are rejected slowly after transplantation, leading to decreased function over time. Others are damaged in small ways when doctors transplant them, chipping away at the organs' effectiveness.

"We can't get the grafts to last forever," said Dr. Alicia M. Neu, a pediatric nephrologist at Johns Hopkins Children's Center. "We've kind of hit a wall. People live with one kidney all the time. They donate one, and they're fine.

"Why is it that we transplant, and it's not fine?"

Regardless of how long a transplant lasts, without one, most patients will die. "The number of people who live 15 years on dialysis is almost zero," Stegall said.

Charlotte Wolfe, a physical therapy assistant from Frederick, knew all that when she walked into Kraus' office at Johns Hopkins Hospital in 2000. She knew her doctors weren't pleased with her blood work and had warned her that a kidney transplant is actually a temporary fix. And hers had lasted 20 years.

"In the back of my mind and in my heart, I knew what he was going to say," she recalled. Still, she said, when she heard those words, "I lost it."

Wolfe was fortunate. Her oldest brother, Craig, was willing to donate. He turned out to be an identical match, meaning his kidney might last even longer than her mother's did. Still, she wasn't sure if she could take it. What if something happened to Craig and he needed the kidney?

After some prayer, she decided to accept her brother's kidney. On Jan. 5, 2001, doctors transplanted it.

Since the match was perfect, Wolfe hoped that she would no longer need the medications she had taken all those years - the ones that caused the weight gain, the insomnia, the depression, the arthritis. Instead, she said, "I came home with 19 new prescriptions."

A kidney transplant requires constant care to keep it going. The immunosuppressants - often a handful of drugs, twice a day, every day - must be taken religiously.

The medications also are expensive. Medicare pays for only a three-year supply, and co-pays from private insurance can run hundreds of dollars a month.

"I have a credit card that will never be paid off, because all that's on it is the medicine," said Wolfe, now 36. "I don't make enough to pay for all the prescriptions I have to get."

Each drug has a side effect, which often requires yet another medication. "If it's not one thing, it's another," she said. Still, she added, "I know there's always somebody out there worse than me."

"As a little girl, I never imagined graduating high school, and I graduated with my class," she said. When friends made noises about turning 30 and "getting old," she would say, "If you walk a mile in my shoes, you will be so proud to be 30 years old."

Wolfe is unusual because she has never undergone dialysis, the exhausting, time-consuming process that forces patients with failed kidneys to have toxins flushed out of their blood three times a week for many hours a day.

Only 2.5 percent of patients get transplants before they need dialysis, said Dr. Stephen T. Bartlett, a kidney transplant specialist and chief of surgery at the University of Maryland Medical Center.

He advises his patients to look for a living donor as soon as they know they might need a new kidney in hopes of avoiding dialysis. Transplants tend to last longer, he said, when patients have never gone on dialysis.

Although many kidneys wear out before the patient does, some patients die of other causes with their transplant still working. That has led the United Network of Organ Sharing to develop a new allocation system.

The idea is to give the "right kidney to the right recipient," said Stegall, past chairman of the UNOS kidney transplant committee. Often, that means matching a young person's kidney with a young recipient and an older person's kidney with someone who has a shorter life expectancy.

Retransplant patients wind up with a slightly lower priority, Stegall said, because statistically, second and third transplants don't last as long as first ones. Meanwhile, it also can be harder to find kidneys for repeat transplants, doctors say, because some patients build up antibodies that could attack a new kidney.

Stegall also hears ethical questions: "Is it really right for somebody to get a second kidney before somebody else gets their first?"

Brenda LaPorte, 44, of Dundalk has heard all this more than once. Born with an oversized bladder and malformed ureters that pumped urine into her kidneys, and not just out of them, LaPorte was pregnant when her kidneys gave out.

LaPorte's name went on the transplant list soon after the birth of her daughter Amber, and six months later, in February 1989, she received her first new kidney at the University of Maryland hospital. It didn't go well. She was in the hospital with kidney rejection two days before her wedding that November.

Doctors were able to keep that kidney working for a few more years. But by 1995, LaPorte was back on the list. This time, she spent three years on dialysis before the call came - at 3 a.m. on Mother's Day in 1998. An older woman had died, and surgeons gave LaPorte both of her kidneys, thinking that might stave off the need for yet another transplant.

"I was hoping this would be it," she recalled.

For a few years, it seemed as if that would happen. She stayed on her regimen of medication. She tried to quit smoking. But those blood tests again told doctors that LaPorte would not live a long life on the kidneys she had.

She would need a sixth.

This time, LaPorte's survival would not depend the death of a stranger. A cousin offered one of her kidneys, and in July 2005, LaPorte got No. 6.

"From what I understand," she said, "that's it."

The transplanted kidneys are in the back of her abdomen, under the rib cage. In fact, when patients get new kidneys, doctors rarely take out the old ones; they usually shrivel up and cause no harm.

Surgeons typically place kidneys Nos. 3 and 4 in the pelvic region - but they may have to get creative if a patient needs additional kidneys.

LaPorte said she doesn't notice the extras, save for the scars on her belly.

She said she's "doing great now," spending her days caring for her granddaughters and her evenings cooking in a pizza shop. But she knows that could always change.

"You're given a second chance," she said. "You can't dwell on it - that today might be the day my kidney might fail. If this kidney fails, what do I have to look forward to? Dialysis for the rest of my life?

"You can't sit there and dwell on it every day or you won't get nothing done. But it's always going to be there in the back of my mind."

stephanie.desmon@baltsun.com

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