5 Questions: Scandling on Stanford's top-ranked kidney transplantation program

John Scandling

Fifty-one years after the first successful kidney transplant, the operation has gone from being a medical miracle to almost routine.

Perhaps no transplant program highlights that success as well as the one at the Stanford University Medical Center. For the fourth consecutive year, the Stanford adult kidney transplant program had the best one-year survival rate—about 98 percent. That's out of a nationwide field of 246 centers evaluated in the latest report from the Scientific Registry of Transplant Recipients.

John Scandling, MD, professor of medicine (nephrology) and medical director of the Stanford kidney transplant program, spoke with Medical Center Report managing editor Jonathan Rabinovitz about the improved outcome in kidney transplants and the effort to achieve better long-term success.

1. Are there enough kidneys to go around?

Scandling: About 16,000 kidney transplants were performed last year, with about 9,400 from deceased donors and 6,600 from living donors.

Still, there are more than 60,000 patients on the waiting list for a deceased-donor kidney transplant; hence the waiting time for such an organ is measured in years. What makes the kidney shortage even more dire is that chronic kidney failure is increasing, having more than doubled over the past decade. The U.S. population is aging and changing, and, accompanying that, we see growth in the incidence of type-2 diabetes mellitus, the primary cause of chronic kidney failure.

The U.S. Medicare end-stage renal disease program had approximately 430,000 patients under care in 2002 and accounted for 6.7 percent of that year's Medicare budget.

2. Why did live-donor kidney transplants triple over the last 15 years?

Scandling: A lot of loved ones now realize that the waiting list for a deceased- donor transplant is so long that they're coming forward and offering to donate one of their own.

That goes hand-in-hand with improvements in the method for taking a kidney from a live donor. Laparoscopic or minimally invasive kidney donor surgery results in a more rapid return to daily life activities. While that was first reported about 10 years ago, it really took off in the late 1990s with technical advances in the procedure.

Now more than half of live kidney donations are obtained laparoscopically. Live-kidney donors return quickly to full, active lives without restriction on diet or physical activity. Police, fire and military personnel can all return to active duty after donation. Women may have children after donation. Life expectancy is not affected by donation.

3. How has the prognosis changed for kidney recipients?

Scandling: Kidney transplantation is quite successful in the short term nowadays, with one-year transplant kidney survival in the United States more than 90 percent. The gratifying success in short-term outcome, which has improved progressively over the last 20 years, is due to advances in tissue compatibility testing, surgical technique, immunosuppressive medications and specialized medical care by dedicated transplant nurses, physicians and surgeons.

However, there is attrition over ensuing years. The average life expectancy of a kidney from a deceased donor is only 10 years or so. The average life expectancy of a kidney from a living donor is longer, about 18 years. One of the greatest challenges in transplantation today is to improve long-term outcome.

4. How come Stanford has such a strong one-year outcome?

Scandling: All transplant programs share a basic foundation, but we are particularly committed to a multidisciplinary team approach. At Stanford, the care of the transplant candidate and of the recipient are the joint responsibility of transplant surgery and transplant nephrology. Dr. Stephan Busque, my counterpart in the Department of Surgery (transplantation), shares this philosophy. This is critical because a kidney transplant is more than just a surgery: it's a whole new way of life. The patient has to go on a regimen of immunosuppressants that require a big commitment.

What's more, Stanford has a history of embracing new advances in the field—in the laboratory, the hospital and the clinic. We have actively participated in bringing new techniques in tissue compatibility and new immunosuppressive drugs into practice. It also helps that we're one of the larger programs, so that we have nephrologists and surgeons who devote most of their time to transplants. This isn't to say that smaller centers can't do a great job, but on average the larger do better.

5. What's on the horizon that could improve the long-term outcome?

Scandling: Among our ongoing research projects, the most exciting is the clinical trial to induce tolerance in kidney transplant recipients. Tolerance is the condition in which the immune system recognizes the transplant organ as self rather than foreign. Once tolerance develops, no immunosuppressive drugs are necessary.

This project is being led by Dr. Sam Strober of immunology, in collaboration with Dr. Maria Millan of transplant surgery and our team, and only patients who have a complete-match sibling donor can participate. In this trial, the recipient receives donor blood stem cell transplantation in addition to kidney transplantation. If the patient then develops and sustains chimerism—a condition wherein the recipient's blood contains cells of donor origin—the immunosuppressive medication may be able to be reduced and then stopped completely at six months.

The first participant in this protocol recently stopped immunosuppressive medication and is enjoying excellent transplant kidney function.