Amato had one infusion per month for four months, and in January 2009
she had a dose of an additional drug, Rituxan, which knocks out many
of the immune-system cells that produce antibodies. "Boom!
My antibodies dropped," she said. "I got my transplant two
The desensitization program, as well as improvements in minimally
invasive surgery and the promise of an experimental "tolerance
induction" protocol, have placed Stanford Hospital & Clinics
at the forefront of kidney transplant programs. It was the only one
among 240 kidney transplant centers nationwide that exceeded expected
results in both patient and graft (transplant kidney) survival at one
year and at three years after transplantation, according to data
reported by the independent Scientific Registry of Transplant
Recipients, or SRTR. The registry's data also shows that Stanford was
the top program in one-year transplant kidney survival rates for four
years running, from July 2000 to June 2004.
"It's not just a fluke," Stephan Busque,
MD, surgical director of the adult
kidney and pancreas transplant program, said about the latest
SRTR data. "Even though we're treating patients at higher risk,
we perform better than expected because we have a very good team and
our patients get very attentive, individualized care."
Busque and nephrologist John Scandling,
MD, medical director of the program, have been pursuing new tests,
treatments and technologies that will get more patients to
transplantation. That effort received a boost when they recruited
Dolly Tyan, PhD, to direct Stanford's Histocompatibility,
Immunogenetics and Disease Profiling Laboratory in 2006. Tyan had
co-developed a program at Cedars-Sinai Medical Center in Los Angeles
that addresses the plight of people who, like Rachel Amato, need
transplants but can’t qualify for them because they are "highly sensitized."
The new protocol involves giving these high-risk patients a high
dose of IVIG. The IVIG infusions, which may be repeated over several
months, lower the number of organ-rejecting antibodies in patients
awaiting transplants. "If we lower their antibodies after the
first dose, we assume by the second dose they’re going to be lowered
more," Tyan said. "So we schedule the OR time, we give the
dose and then they go to transplantation."
Tyan estimates that 30 percent of the 80,000 people on the national
waiting list are HLA sensitized, and potentially could benefit from
being desensitized by the IVIG protocol. The treatment currently is
available at only a handful of other medical centers, including
Cedars-Sinai, Johns Hopkins, the Mayo Clinic and the University of
Toronto. Tyan and her colleagues also have developed a new assay
system that "allows us to see very specifically what antibodies a
person has, and exactly which ones are going to go away."
The hot topic at this year's annual meeting of the American
Transplant Congress, Tyan said, was how to control antibodies. But she
was quick to add that the "holy grail" of transplantation
remains tolerance. "That's 'true' tolerance, which means, 'I'm
not taking any meds and my [transplanted] organ is working fine.'"
Stanford and Harvard University currently are the only two academic
medical centers in the United States that have active clinical
tolerance-induction protocols. Ten transplanted patients at Stanford
are enrolled in an NIH-funded clinical trial, directed by Samuel
Strober, MD, professor of immunology and rheumatology, to wean them
off immunosuppressant medications. "It draws a lot of interest
from patients because the appeal of having to take no drugs is
tremendous," Scandling said about the study, while noting that
the experimental therapy is a long way from becoming routine care.
In the meantime, Amato is grateful that she had the opportunity to
get a kidney. While she still takes medication to ensure against her
body's rejecting the organ, her life is almost back to normal. She had
a migraine headache after the first infusion, and one rejection
episode that hospitalized her for five days and was addressed by the
team at SHC. "They had all these game plans ready," she said.
Nowadays Amato has her antibodies tested once a month, and she said
she is doing great. "I have a rare autoimmune disease—not
hypertension induced, not diabetes related," she said.
"Stanford was my saving grace because they did not give up on me."
By Diane Rogers