Advances in Care

The Matchmaker: Creating New Pathways for Kidney Transplantation

The Matchmaker: Creating New Pathways for Kidney Transplantation
The Matchmaker: Creating New Pathways for Kidney Transplantation

Dr. Sandip Kapur, Chief of Transplant Surgery and Director of the Kidney and Pancreas Transplant Programs at NewYork-Presbyterian, tells the story of how Weill Cornell Medicine became one of the top kidney transplantation programs in the nation. With their creative, multidisciplinary approach, Dr. Kapur and the transplantation team are able to perform surgeries involving complex, high-risk cases that other centers can’t, so they can get more kidneys to the people who need them.

In the United States today, there are over 110,000 people waiting for an organ transplant. And, Dr. Sandip Kapur says, 92% of those patients are waiting for a kidney. In this episode, Dr. Kapur describes a simple philosophy that helped guide Weill Cornell Medicine into one of the top kidney transplantation centers in the nation: offer the maximum amount of opportunities to transplantation that could exist. That means working with multidisciplinary teams to innovate every step of the kidney transplantation process– from making donor surgeries minimally invasive, to matching donors and recipients in new ways through the National Kidney Registry, and even pioneering research into immunotherapy, to improve success rates and patients’ quality of life post-surgery.

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Dr. Sandip Kapur: You know, when I came to medical school, I was pretty much of an open book. I wasn't, I wasn't sure exactly which pathway I would take.

Catherine Price: This is Dr. Sandip Kapur. Today he's a world renowned kidney transplant surgeon, but back in med school in the late 1980s, he was still finding his way in the medical field.

Dr. Sandip Kapur: My father was a psychiatrist and I had, and I had minored in psychology in college and honestly, I thought that I may end up pursuing psychiatry, um, just as he did.

Catherine Price: But that all changed when he discovered something new: surgery.

Dr. Sandip Kapur: What I fell in love with was the immediacy with it and the ability to really be in control of how you took care of someone, and just that sense that when you operate on someone, you have a sense that you can fix them.

Catherine Price: Dr. Kapur was a little nervous to tell his dad about his choice to pursue surgery,

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afraid he'd be disappointed. But when he finally worked up the nerve to tell him…

Dr. Sandip Kapur: I remember him telling me that he wasn't surprised and I said, ‘Really?’ And I said, ‘They're so different.’ And he goes, ‘No, they're not.’ He said, ‘They're very similar if you think about it. Surgery and psychiatry are really two of the most invasive fields, just just in different ways.’

Catherine Price: So having made the decision to become a surgeon– and with his dad's incisive comment ringing in his mind– Dr. Kapur narrowed in even further. He decided to pursue a specialty that had the potential to save lives on a grand scale: organ transplantation.

Dr. Sandip Kapur: I was trained as a multi-organ surgeon with kidney, liver, pancreas, even small bowel.

Catherine Price: Of all the different types of transplants he performed, Dr. Kapur found that kidney transplantation stood out. Those surgeries were almost always successful, so they made an immediate, positive impact on lots of patients' lives. 

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Dr. Sandip Kapur: They feel invigorated, energized. When they get transplanted they often will say a fog has been lifted, ‘I didn't realize it, but a fog has been lifted from my brain,’ and they find themselves instantly more clear, and it is such an uplifting experience for them.

Catherine Price: Performing a kidney transplant was gratifying for Dr. Kapur– it reminded him of what made him fall in love with surgery in the first place: the feeling that he could fix people. Dr. Kapur wanted to give as many people as he could the chance to continue living full, rich lives post-transplant. And so his path was clear: He would focus his work on kidney transplantation.

Dr. Sandip Kapur: Every time I go to do a kidney transplant, I know the outcomes are gonna be 98, 99% successful, and that's just a really good feeling for me.

Catherine Price: But the journey to that successful outcome can be long and uncertain because in the United States today, there are almost 110,000 people 

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waiting for an organ transplant.

Dr. Sandip Kapur: 92% of those is for a kidney. 

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Last year there was less than 44,000 transplants performed. You know, literally double the number of people are waiting, and every day there's like 8 to 10 people that die on the waiting list because of the unavailability of the organ.

Catherine Price: That seemed like a huge disconnect to Dr. Kapur. Kidney transplants were pretty much guaranteed to make renal failure patients better. But despite how successful the surgery was, not everyone who needed a transplant could get one. Dr. Kapur wanted to figure out how to close that gap–to boost the number of people who can have a successful kidney transplant– and a better quality of life because of it. 

So, he decided to create new ways to match kidney donors and recipients, and even perform transplants more efficiently, to increase the number of kidneys available for patients who need them.

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Dr. Sandip Kapur: Literally, we find ourselves today in what I think is a crossroads of changing, really the fabric of how donation has been practiced in the United States. We're now kind of coming into a period of time where we're expanding our opportunities in transplant beyond what had existed previously.

Catherine Price: I'm Catherine Price, and this is Advances In Care.

In this episode, we're joined by Dr. Sandip Kapur, Chief of Transplant Surgery and Director of the Kidney and Pancreas Transplant Programs at NewYork-Presbyterian, Weill Cornell Medicine. Over his decades-long career, Dr. Kapur has built Weill Cornell Medicine into one of the top kidney transplantation centers in the country. 

His patient-centered philosophy has led him to pioneer donation strategies and introduce medical advances in kidney transplantation

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that have allowed thousands of successful surgeries to be performed that were not previously possible. Dr. Kapur's journey has been both thrilling and challenging, and he says it's been worth every minute.

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Dr. Sandip Kapur: When I first came here in 1998, I think it would be fair to say that we were kind of a middle of the road program with not large volumes, but respectable.

Catherine Price: What the transplantation program at New York Presbyterian did have when Dr. Kapur arrived was a respected history. In 1963, they were the first hospital to perform a kidney transplant in New York State.

Dr. Sandip Kapur: We had people that had been involved in kidney transplantation since its beginning and had been major contributors to the development of kidney transplantation, and we had a physician core 

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that was second to none, you know, both on the nephrology side and on the surgery side. So in some ways it was easy when I came to kind of build upon that.

Catherine Price: Dr. Kapur trained at the University of Pittsburgh before coming to Weill Cornell Medicine.

Dr. Sandip Kapur: Which in those days was, you know, probably the leading center in transplantation in the United States.

Catherine Price: So he was tasked with using his expertise to build Weill Cornell Medicine's Kidney Transplantation program. He took the program's strong history and built on it with a simple philosophy.

Dr. Sandip Kapur: I wanted our program to offer the maximum amount of opportunities to transplantation that could exist. We expanded beyond just standard kidney transplants. We started offering opportunities to people that had other issues that may have prevented them from moving forward with transplant such as underlying extensive heart disease or older individuals. 

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We started utilizing, uh, deceased organs that wouldn't have been traditionally used in the past. So we just adapted every single avenue that exists in transplantation and made that available to any patient coming here. 

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Catherine Price: By 2007, Dr. Kapur had transformed the department from a middle of the road program into the program that performs the highest volume of kidney transplants in the nation. His team's creative, multidisciplinary approach to transplantation means that they are able to perform transplants that other hospitals can’t, particularly when it comes to dealing with complex or high risk cases.

Dr. Sandip Kapur: When you start working with older patients, sicker patients, patients that are immunologically challenged, you need a supporting staff that can help get them through an operation and get them to a place where they're healthy again. So having fantastic 

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cardiology that we've developed really strong relationships with has been invaluable. Having a radiology group so that we can get advanced imaging in the way that we need it without having to fight with anyone has been invaluable. Having anesthesia that can take care of really sick patients in the operating room has been invaluable. And it's really the sum of all these efforts that really speaks to what we're able to do and all of these things in concert are not available everywhere else.

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Catherine Price: Dr. Kapur's team has used their resources to tackle some of the enduring challenges with kidney donation. For example, living kidney donation– where a kidney from a living donor is transplanted into a patient via same-day surgery– is the gold standard of kidney transplantation. It’s the quickest way for a patient to get a transplant that lasts rather than waiting years and years

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for a deceased donor kidney… 

Dr. Sandip Kapur: And maybe not even surviving before they get an adequate organ offer, so there's the immediacy to it. But to me, more importantly, is that when you look at how long transplanted kidneys last, if you take all comers, all comers in the United States irrespective of age, underlying medical conditions, and so forth,  the average half life of a kidney from a deceased donor is about 8 to 10 years. You compare that to the average half-life of a living donor kidney, whether that's from someone that's related to you or totally unrelated to you is 18, 22, 26 plus years. There's almost a two and a half time survival advantage.

Catherine Price: But despite the clear advantages, fewer transplantation centers are equipped to perform living organ transplants. The procedure requires a more comprehensive approach than deceased organ transplantation because there are two

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living people you have to operate on pretty much simultaneously. Plus, the lengthy recovery time after surgery could deter some people from considering living donation in the first place. So to make the process smoother and more appealing to potential kidney donors, Dr. Kapur’s team improved the donor operation procedure so that it's minimally invasive and requires only a few weeks of downtime post-surgery.

Dr. Sandip Kapur: At our place, we uniquely have probably the largest experience in the world through Joe Del Pizzo, one of our urologists who does the donor operations in utilizing a technique called single port extraction of the kidney. And what that involves is making a small incision through the belly button and placing a port into that space through which we can introduce instruments, and then doing the operation up on the television screen. And then after the kidney is removed, we take the kidney through the belly button,

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which allows us to envelope the scar end cosmetically into the belly button. So one small single incision cosmetically placed in the belly button. People are up and about the same day. We keep 'em in the hospital one extra day just for safety, but home the next morning. And if they have a non-manual labor job, the overwhelming majority of them are ready to go back to work within three weeks.

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Catherine Price: But even with all of New York Presbyterian's multidisciplinary expertise, Dr. Kapur still came up against a persistent essential problem. There aren't enough organs available in this country to save every life that could be saved by kidney transplant.

Dr. Sandip Kapur: There's been, as far back as I can remember, many, many more people that need a transplant than there are organs available to transplant in this country. And unfortunately, that metric really hasn't changed for almost two decades now.

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Catherine Price: And on top of the fact that there just aren’t enough kidneys to go around in this country, there's another hurdle to overcome here. Usually when someone chooses to make a kidney donation, they want to donate to someone they know.

Dr. Sandip Kapur: Either it's someone within the family or a longtime personal friend. There's a longtime connection. It's been based very much on this emotional attachment.

Catherine Price: The problem is, no matter how much someone might want to donate their kidney to a loved one, they often can't, because they aren't the right match.

Dr. Sandip Kapur: When patients come to us, even if they come to us with a donor, 30% of the time, that donor would not be able to donate to the person that they came in with. Either blood type incompatibility, or if they have a positive crossmatch, uh, preventing them from donating safely to their loved one.

Catherine Price: Previously, Dr. Kapur says, if a patient found themself in that situation, they'd be left with very few options.

Dr. Sandip Kapur: The only resource those people would have

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would be either to find another donor, which in itself is very difficult to begin with, or if the opportunity existed to consider what's known as a ABO incompatible transplant to transplant across the normal blood groupings, which would put 'em at higher risk for rejection activity and also necessitating a lot more immunotherapy on board to allow that transplant to survive. In certain instances doable, but definitely with a higher degree of risk.

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Catherine Price: So when you have a patient with a willing donor, but one who isn't a match, how do you still help that patient and secure that donated organ for another person whose life could be saved? Dr. Kapur found the answer in Paired Exchange.

Dr. Sandip Kapur: Paired exchange is that when you have a recipient who has a donor, but that donor cannot donate

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to that recipient for these various reasons of ABO incompatibility and so forth, then you have another pair in a very similar situation, but that other pair's donor actually matches the recipient of the first pair, and the donor of the first pair matches the recipient of the second pair, but you do an exchange. So you exchange the donors and that ends up being a paired exchange. 

Catherine Price: But for a long time, there wasn’t a coordinated way to connect these potential matches to one another. That is until 2007, when Dr. Kapur encountered a transplant case that shined a spotlight on that problem.

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Dr. Sandip Kapur: A little 12 year old girl came to me with her parents and that little girl's father wanted to donate, but we found that he couldn't donate to her directly, and that took this gentleman on a journey

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to find a living donor transplant for his daughter.

Catherine Price: This little girl's dad worked day and night to find a donor, reaching out to every paired kidney exchange program in the nation. Some of the programs never returned his calls. Others wanted his family to move his daughter's care to a far away hospital just to participate in their program. And none of them were able to find a match.

Dr. Sandip Kapur: And he saw how broken the system was. There was no coordination.

Catherine Price: In the end, a distant cousin came out of the woodwork and proved to be a good match for the little girl. Dr. Kapur performed the surgery and it was successful, but the process of searching for a donor had had a profound impact on this dad.

Dr. Sandip Kapur: That process influenced him so strongly that he came back to me and he goes, ‘Sandy, how do we work on this paired exchange process? How do we make it such that people aren't in my situation and they have opportunities

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 to help the person that they wanna help, but they may not be able to do it directly.’

Catherine Price: This little girl's dad happened to be a software engineer, so he created an algorithm that could match potential donors. Dr. Kapur got to work coordinating on the donor side…

Dr. Sandip Kapur: And that was the beginnings of the development of the National Kidney Registry.

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Catherine Price: The National Kidney Registry is essentially a central pool of potential kidney donors. Say you want to donate your kidney to a family member, but you're an incompatible match. Well, your information stays in this database and then if at some point the matching algorithm finds a person who you do match with, the program is easily able to reach out and initiate a transplant. Dr. Kapur remembers the first time he performed a chain of transplants initiated through the National Kidney Registry on Valentine's Day, 2008.

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Dr. Sandip Kapur: So that day is kind of hectic. 

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That first set of transplants on Valentine's Day, 2008, started with an altruistic donor in Los Angeles that my friends at UCLA harvested the kidney and it was flown here overnight by the red eye. That initiated a set of four transplants here. We have 3 or 4 ORs all kind of functioning either in a slightly staggered way or really at the same time. My entire surgical team is involved and that kidney comes and we literally have 3 or 4 transplants happening at the same time. That, that altruistic donor literally was the key that unlocked the door to allow four other transplants to occur, including a four year old little boy who's now in college. At the end of that four person chain, that little boy's father became the bridge donor to start another chain. And it's just, you know, it's very uplifting.

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Uh, you feel like you've accomplished an incredible amount in a single day. Without a doubt, it was, uh, that was a very gratifying time.

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Catherine Price: And, Dr. Kapur says, since that first donor chain in 2008, the National Kidney Registry has only grown.

Dr. Sandip Kapur: What's developed from there is, you know, sometimes unimaginable when, when you step back and think of it, ‘cuz we started with two programs, UCLA and us. 

Catherine Price: Now there are over 160 programs all over the country that participate in the program.

Dr. Sandip Kapur: 20% of the living donor transplants performed in the United States are now through the National Kidney Registry and the Paired Exchange Program. So there's literally been thousands of transplants performed, but now we're finding that we're evolving to even a higher degree

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of practice.

Catherine Price: Now, Dr. Kapur and his team are building on the multidisciplinary approach they've established at Weill Cornell Medicine. Since they have a larger pool of donors, they can begin to innovate the next frontier: finding ways to ensure the best quality matches rather than settling for matches that are good enough in order to improve patients’ quality of life post-transplant.

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Dr. Sandip Kapur: Immunological match is based on looking at the HLA antibodies and seeing how many of the proteins line up.

Catherine Price: That protein match is rated on a scale of 0 to 6. Dr. Kapur says that if a pair is blood type compatible, but a 0 out of 6 protein match, that's still technically an acceptable transplant.

Dr. Sandip Kapur: That it's good enough, but it's not the best and it can be better. And you know, as our knowledge of the HLA matching algorithm has expanded, we're now looking at even more proteins, 

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uh, on the cell surfaces. We're trying to prioritize matches with what we call low eplet matches. The lesser number of eplet, epitopes that you have, the lower the degree of reactivity of the cells from the donor and the recipient translating into less immunological activity and damage over the lifespan of that transplanted kidney. 

Catherine Price: With a low eplet match, donor kidneys last longer and recipients can avoid having to follow an intense and potentially disruptive immunotherapy regimen after surgery. 

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Dr. Kapur and his team have taken these innovations beyond the operating room, pioneering research into immunotherapy.

Dr. Sandip Kapur: If I think back to my fellowship days, we're literally using one third the amount of medication that we used then. 

Catherine Price: Their findings have drastically reduced the amount of immune suppressing drugs patients need to take after transplantation

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and that's improved patient outcomes overall.

Dr. Sandip Kapur: Some of the things that have allowed us to do that are some of the things that have been developed here.

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Catherine Price: Dr. Kapur and his team developed a non-invasive method for monitoring immune response after transplant surgery, which is usually tested by biopsy.

Dr. Sandip Kapur: Out of Dr. Suthanthiran’s laboratory, he's developed a molecular test that can look at the urine of our transplant patients and it'll provide a non-invasive way to have an index of the immunological activity that's happening within the graft. So a biopsy has always been the gold standard, but obviously in a practical way, you can't biopsy someone every week. Uh, it's an invasive procedure with its own set of potential issues, but just collecting the urine of a transplant patient and taking it to a laboratory and running a molecular assay on it is a lot more doable.

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Catherine Price: All of these advances pairing donors and improving immunological research have allowed Dr. Kapur to deliver on his goal: to get more people the best transplants possible, to improve their quality of life. He's especially passionate about providing transplantation opportunities to people who might traditionally be passed over for kidney transplant due to their age. 

Dr. Sandip Kapur: The American population is living longer and you see a fair amount of kidney disease progressing to kidney failure later on in life, and people are still pretty well preserved and they have a lot of life still left to live.

Catherine Price: Dr. Kapur says that his conviction that older people still deserve a chance at kidney transplant comes from observing his own 94 year old mother's relationship with his grown children.

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Dr. Sandip Kapur: My mother worked till she was 84 years old. She lives independently and my kids 

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have a great relationship with her. They'll go and they'll spend a weekend with her. They'll go out to dinner with her. That kind of experience has just informed me that I don't find that it's my job to tell someone that they can't continue on with their life. As long as they have a life to live that's meaningful, and a kidney transplant will allow them to live that life, and I think that we can perform it safely, then I'm gonna give 'em that opportunity.

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Catherine Price: While the advances he's made, and the robust program he's built, are pushing the field forward. Dr. Kapur's ultimate hope for the future of kidney transplantation remains simple.

Dr. Sandip Kapur: I think the number one hope that I would have is that we find a way to increase the supply of organs in this country, and then obviously the extension of that is utilizing stem cell

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therapy to even potentially inject kidneys with a stem cell therapy and rejuvenate failing kidneys. Maybe we could rehabilitate the kidneys they have, or at the very least, as I mentioned, find a way to increase the supply of organs so we don't have people dying on the waiting list for something that they shouldn't be dying for.

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I feel there's a tremendous amount of under utilization that exists from lack of education and awareness.

Catherine Price: So Dr. Kapur continues to elevate the conversation around kidney transplantation, with the public and with his patients, because like his dad said all those years ago, what he does as a transplant surgeon is about connecting with people to make their lives better.

Dr. Sandip Kapur: What I've learned over the years, uh, these are patients that most of them are chronically ill for a lot of years,

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and by the time they come to me, they've overcome a lot of hurdles in their lives. And I find that even when I relate to them and speak to them about their options and what they can look forward to, there's a lot of psychology involved in that. When recipients can meet their donors, it is a phenomenally satisfying event. And I think for some of them it sets up a lifelong friendship. That in essence is the beauty of kidney transplantation and a large part of why I really enjoy being involved in it. It's the totality of what it symbolizes and what it involves in just people doing really decent things.

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Catherine Price: Thank you so much to Dr. Sandip Kapur for speaking with us for this episode. His dedication to improving care options for renal failure patients is really inspiring. I personally have a much deeper appreciation for my own kidneys. 

I’m Catherine Price. Advances In Care is a production of New York Presbyterian Hospital. As a reminder that the views expressed on this podcast solely reflect the expertise and experience of our guests. To find more amazing stories about the pioneering physicians at New York Presbyterian, go to nyp.org/advances.

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