How A Kidney Transplant Works
Dr. Jon “Kai” Yamaguchi
Surgeon at The Queen’s Medical Center
Where did you receive your schooling and training?
I went to college at Stanford and did my medical education at Temple University in Philadelphia. After that, I went to University of Maryland for surgical residency and did my fellowship training in transplant and hepatobiliary surgery at Emory University in Atlanta. Following fellowship, I went to University of Vermont, where I was part of the transplant team for six years, eventually as chief of the division of transplantation. I am now the primary kidney transplant surgeon at Queen’s transplant center.
What were transplant patients doing before Queen’s transplant center opened in 2012?
The first kidney transplant in Hawaii was done in 1969 by Dr. Livingston Wong, and transplantation before 2012 was all done at Hawaii Medical Center East at St. Francis. Given the financial difficulties of St. Francis and the closure of HMC East, transplant had to find a new home. Queen’s stepped up and was willing to provide the resources and physical structure needed to open a transplant operation. That was a tough transition. I was fortunate to come after that was completed.
Despite moving to a new location in the same city, and despite the fact that it was the same team, same doctors and same coordinators, the administrative hurdles were monumental. Regulations behind transplant said that HMC East transplant center had to be closed, and Queen’s transplant center had to meet all governmental regulations and approvals, and had to start the entire evaluation process over again for all of those patients. As a testament to the transplant team and Queen’s, the transplant center transitioned and began transplanting in just three months for the liver-transplant program and six months for the kidney-transplant program.
When people are waiting for organs, what happens next?
Transplant serves as a model for multidisciplinary care.
Transplant outcomes aren’t based just on the surgery. They’re based on good surgical care and good overall medical care. Medications can be exorbitantly expensive, so we want to make sure we’re not disadvantaging any of our patients based on finances. We have people who are wonderful at their job, who make my job possible, by making sure all of our patients are able to get transplanted and all of our patients are able to get the financial resources the government has made available to pay for the medications.
The process from beginning to end can be months to even years just in the evaluation process. If we take kidneys as a model ― rather than trying to cover all of the different organs ― you are referred to the transplant center, usually by your nephrologist, your kidney medicine doctor. You are evaluated by the transplant center, and that evaluation constitutes the financial, psychosocial, medical and surgical aspects.
We do a comprehensive workup, including cardiopulmonary and any other indicated organ systems, getting specialists involved as needed. From there, patients are put on the waiting list. Our waiting times here relatively mirror the national average of two to six years. You can bypass the list with living donor transplantation.
What is living donor transplantation?
It’s when you bring your own donor to the process. We have two kidneys, and we function perfectly well with about 25 percent of one kidney. The kidney-donor medical, psychosocial and surgical workup is just as rigorous as for the kidney recipient, because we try our best to ensure we are not creating more kidney problems in the future.
With living donor transplantation, patients don’t need to wait on the list, and they get an organ that tends to work better, faster and longer. The ideal transplant is a well-matched living donor transplant. But there are plenty of patients who don’t have a living donor available. Part of the reason for that involves the need of education for the community. Part of it also has to do with kidney failure. The two most-common reasons for kidney failure are diabetes and high blood pressure, which tend to run in families. We can’t ethically remove a kidney for transplant from somebody if we think there’s a reasonable chance they might have current kidney disease or chronic kidney disease in the future.
We rush you through that evaluation process to get your place on the list. From there, you have to wait two to six years, continuing to maintain your annual evaluations. When an organ donor becomes available, which means when somebody becomes brain dead, whether from car crash, gunshot or whatever tragedy has happened, their family is approached by the organ-procurement organization. Here, that is Legacy of Life Hawaii. When the family consents to organ donation, then the process really starts in terms of finding a match. We look for which patients will be acceptable matches for the kidney based on blood type as well as more complicated immunologic matching. Using computer programs, we run a list that details all the patients who will fit that kidney match.
Once we get to a patient who is ready for transplant and will be a good match, we do a final cross match, matching the patient’s blood with blood cells from the donor to make sure there’s nothing preformed in the recipient that’s going to attack that donor organ. From there, we get the patient admitted for transplant.
So much work goes into getting everything arranged, from regulatory aspects to organizational aspects. Everybody focuses on the surgeons, nephrologists and hepatologists, but really, it takes an army. A kidney transplant surgery takes two to three hours, but the process has been started years prior and will continue for years to come.
Can the patient then live a fairly normal life?
Kidney transplant isn’t a life-saving operation per se because you can replace kidney function, at least in the short term, with dialysis. Kidney transplant is a life-lengthening operation, but quantity without quality isn’t a particularly good goal. The goal is to get the patient back to a normal life, back to the job they know and liked — allow the patient to spend more time with their families so they don’t have to be tethered down to dialysis which, depending on the type of dialysis, can be every night or three times a week for three to five hours at a time. That really controls the life and schedule of the patient. It is always a careful balance: Are they always more susceptible to infection? Do we always make them get more tests? Of course. We never cut the umbilical cord to our patients because we’re trying to keep them doing the things they love.