In Search of the Perfect Transplant: Packard Strives for Flawless Kidney Transplants in Kids

"The goal is not only to restore the child's health, but also to optimize the quality of life for every transplant patient." - Oscar Salvatierra Jr., M.D.

SPRING 2002 - At 10:30 p.m., Oscar Salvatierra finally looks up and smiles. The surgeon has just spent 14 hours in the operating room removing a mother's kidney and fitting it into her 9- month-old son's abdomen, while simultaneously reconstructing the baby's urinary tract.

If Salvatierra's tired, it doesn't show. He watches with satisfaction as the mom's adult kidney begins filtering blood in the baby's tiny body. "I get excited about each and every one of these," he says. "Each case is different. Each is another child made better."

About one in every 500 children is born with a urinary tract defect. Either their kidneys do not develop properly in the womb, or a blockage forces urine back into the kidney causing chronic damage to the organ. As a result, some youngsters need a new kidney even before they can walk.

Salvatierra, who directs the Pediatric Kidney Transplantation Program at Packard, wants to provide these children with a "perfect transplant." To him, perfection means not only a successful transplant, but also a normal way of life for the child.

"The goal is not only to restore the child's health, but also to optimize the quality of life for every transplant patient," says Salvatierra. He has performed more than 650 kidney transplants in infants and children.

Although kidney transplantation has evolved from near miracle to almost routine procedure in adults, pediatric cases remain challenging, particularly since transplants into children often involve adult-sized kidneys and correction of congenital urinary tract problems. Children's immune systems also are more likely to respond strongly to the foreign organ, necessitating constant monitoring to prevent rejection. "On average, transplants are three times more complicated in children than adults, and five times more complex in infants," explains Salvatierra.

Packard's Pediatric Kidney Transplantation Program has tackled some of the trickiest transplants in the world with unparalleled success, thanks to Salvatierra's surgical skill, the group's well-orchestrated teamwork, and the Program's commitment to research innovations.

Making Kidneys Comfortable

Packard has one of the three largest pediatric kidney transplant programs in the country. Last year, the team performed 25 pediatric kidney transplants, including five on children under the age of 2.Many of the transplants were difficult cases referred from other hospitals throughout the United States and around the world.

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Yet more children survive kidney transplantation at Packard than at any other center in the world. The kidneys last longer as well -- more than 20 percent longer than the national average.

Steve Alexander,M.D., the medical director of the Children's Dialysis and Renal Transplant Program, credits Salvatierra's surgical expertise for this success. Before coming to Packard four years ago, Alexander thought he had seen transplant surgery pretty well perfected.

"Now I'm seeing what perfection really is," says Alexander. "When Oscar puts in the organ, he needs it to look and be comfortable in the abdomen. He has to move it around until he's happy with it. It's the main reason we've eliminated surgical causes of graft failure."

Teamwork

But Salvatierra refuses to take all the credit for the program's accomplishments. "I'm a big believer in teams," he says. "We need a close integration of surgery and pediatrics if we're to achieve the goal of a perfect transplant."

According to Alexander, "The system works because we're all involved in what the other guy does.We have different people with different strengths and interests.We complement each other and work well as a unit."

Four full-time nephrologists work with surgeons Salvatierra and Maria Millan, M.D. In addition to Alexander, nephrologists Kevin Lemley,M.D., Ph.D., Minnie Sarwal,M.D., Ph.D., and Peter Yorgin, M.D., work together to individualize the detailed, day-today care of transplant patients.

A patient care manager, three transplant coordinators, two dialysis nurse clinicians, dieticians, and social workers are all integral in managing every aspect of a patient's care -- both before and after the surgery.

The perfect transplant begins with perfect preparation for transplantation, says Alexander. "Our goal is to send a child to Oscar who is in optimum condition."

Seventy percent of all children receiving transplants require dialysis beforehand. As the transplant program has grown, so too has the need for dialysis. Plans for a new dialysis unit are in the works. Five new state-of-the-art dialysis machines will be bought with money raised by the San Francisco Auxiliary's 2001 Jewel Ball fundraiser.

Research Innovations

The Packard team also has made major advances in research related to pediatric kidney failure and transplantation.

One of its greatest contributions has been to improve the success of adult-sized kidneys transplanted into children, thereby promoting the donation of organs from parent to child. The researchers discovered that an adult kidney sometimes failed in an infant because it received less blood from the child than it was accustomed to in the adult. By thoroughly hydrating infant transplant recipients, the researchers boosted blood flow to the oversized kidney, dramatically improving the rate of adultsized kidney survival in infants. Moreover, after one year, adult-sized kidneys in infants transplanted at Packard performed better than even the best adult transplants -- those between identical twins.

In other work, the group seeks ways to promote consistent use of prescribed immunosuppressive drugs, particularly in teenagers who are often responsible for maintaining their own drug regimens. Lemley and Yorgin also research how to prevent kidney failure so that, someday, transplants will not be needed. And Sarwal explores possible genetic causes for rejection of transplanted kidneys.

Eventually, new kidneys and bladders might be manufactured from a patient's own cells, using tissue engineering. Salvatierra has begun to collaborate with Michael Longaker,M.D., director of Packard's new Children's Surgical Research Program, and others working in this promising new field. But until that dream becomes a reality, the Packard team will continue seeking perfection in the transplantation of kidneys from one person to another.