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A Performance for a Lifetime

When people reach the pinnacle of their profession, we sometimes call them rock stars. They are showered with adulation, and we say they’ve turned their talents into performance art. For surgeons, tasked with bridging science and art, intellect and dexterity, the allusion is more fact than flourish.

By Steve Goldstein; Photographs by Barbara McGowan and Michael Leong, Biomedical Communications

Take J. Keith Melancon, M.D., professor of surgery and chief of the Division of Transplant Surgery at GW’s School of Medicine and Health Sciences (SMHS) and director of the new GW Transplant Institute at George Washington University Hospital (GW Hospital). Describing the charismatic and dapper Louisiana native as a transplant surgeon is a little bit like saying Mick Jagger has some stage presence. Which, in a way, explains why Melancon got into the business of swapping organs in the first place.

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Keith Melancon, M.D., professor of surgery and chief of the Division of Transplant Surgery at GW SMHS and director of the GW Transplant Institute at George Washington University Hospital.

Melancon’s medical baptism first came from the hindquarters of a cow — more on this later — but he always envisioned himself as a surgeon. As a boy in Lafayette, Melancon idolized Hawkeye Pierce, the wisecracking protagonist-M.D. of the 1970s television show “M.A.S.H.” Through his mother, a surgical nurse at Charity Hospital, he got a firsthand view of the dominion doctors held in the hospital world.

That impression — surgeons as saviors — became permanently stitched on his psyche. Years later, Melancon, a third-year medical student researching a project on transplantation, witnessed a daily miracle in the OR. “The surgeon took the kidney out of the ice bucket, prepared the patient, and connected the vessels and the kidney, which was white, pale, and cadaveric,” he recalls. “Suddenly, it came to life.
“The surgeons were like rock stars,” Melancon exclaims. “I wanted to be a rock star!”

Now a transplant surgeon, the 46-year-old father of four boys has earned that status, with more “firsts” on his resume than a van full of valedictorians. In 2009, Melancon, leading the charge in making transplantation more widely available to the Washington, D.C. community, headed a team that performed a 26-person paired kidney exchange — 13 recipients and 13 donors. A year later, he helped set a record with a 32-person kidney swap. The key in both these massive exchanges, says Melancon, is the altruistic donor — someone willing to donate one of his or her two kidneys, which can set off a “daisy chain,” in Melancon’s words, of matches between donors and patients.

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At GW Hospital in late June 2015, to the tune of classic rock playing softly in the background, Melancon and Thomas Jarrett, M.D., professor and chair of  the Department of Urology at SMHS, led such a daisy chain: a successful three-way paired kidney exchange. The procedures were the first ever at GW Hospital, and tricky ones at that. “The unique nature of the exchange was the fact that all of these recipients had received kidney transplants many years ago and were in need of new transplants, but [the kidneys of] their loved ones did not match,” he explains. “The patients were ‘sensitized,’ meaning it’s even harder to find a match.”

The transplant program Melancon and colleagues are building at GW, however, is dedicated to utilizing all means of performing live donor transplants. “We were able to help these patients find other transplant patients in the same predicament of needing a better-matched donor than their loved one,” he says. “We always aggressively push for local paired kidney exchange, because it is the quickest, most convenient, most cost-effective, and most reliable means of transplanting the most patients.”

“It’s not just one person,” adds Muralidharan Jagadeesan, M.B.B.S., associate professor of medicine and chair of transplant medicine at SMHS, and medical director of the renal transplant program at GW Hospital, about the transplant team being created at GW. “ It’s not just a surgeon, it’s not just me; it’s the coordinator, the social worker, the pharmacist, the dietician, it’s everybody on the GW transplant team who’s going to work together to provide the service for you, so that you can participate on this very successful voyage of kidney transplant with us.”

With the increased incidence of precipitating illnesses such as hypertension and diabetes, and the fact that donations from deceased donors are, by necessity, limited, the GW transplant team has sought to bolster live donations through paired exchanges using altruistic donors.

J. Keith Melancon, M.D. (left), and Muralidharan Jagadeesan, M.B.B.S. (center), convene weekly transplant committee meetings to discuss the elements of each case, from a patient’s medical history to current physical and mental health status, as well as the availability and compatibility of a live organ donor.
J. Keith Melancon, M.D. (left), and Muralidharan Jagadeesan, M.B.B.S. (center), convene weekly transplant committee meetings to discuss the elements of each case, from a patient’s medical history to current physical and mental health status, as well as the availability and compatibility of a live organ donor.

All this is made feasible by the fact that humans come equipped with a spare kidney to share. The bean-shaped organ, roughly five inches long and weighing a bit more than a bar of soap, performs critical cleansing functions for the body, filtering waste materials from blood to then pass them out as urine. If the kidneys are not working properly, they can cause havoc. When that happens, patients have to go on dialysis to keep their bodies running, but sooner or later their kidneys will need to be swapped out. The good news is, although we are born with a pair, we can function just fine with only one kidney. Despite that redundancy, demand still dwarfs supply.

Numbers underline the immediacy of the crisis. Some 26 million Americans suffer from chronic kidney disease, and fewer than 400,000 of them have received kidney transplants. About 3,000 more are added to the waiting list annually, and roughly 4,500 of those on the transplant list die each year according to the National Kidney Foundation. In the United States, more than 100,000 people with renal failure are on the list for a deceased-donor kidney, typically waiting between four and five years. With nearly 2,000 patients in the queue, D.C.’s transplant waiting list is the country’s longest, says Melancon. Only one in four will receive a transplant. And although African-Americans make up only about 12 percent of the U.S. population, they represent 23 percent of patients on the waiting list, according to a report by the U.S. Department of Health and Human Services.

Organ donation, according to Melancon and Jagadeesan, offers patients the best of both worlds: low cost and better outcomes. Dialysis — which uses machines to cleanse the blood — is a big and profitable business. Melancon estimates that dialysis for one patient costs $80,000 to $100,000 annually, whereas a transplant runs about $30,000. Transplant patients also have a longer life expectancy.

“Right now, all the advancements in immunosuppression and surgical techniques have improved outcome significantly,” explains Jagadeesan. The availability of desensitization (reducing antibodies) drugs and ABO-incompatible transplants — meaning the donor and recipient have different blood types — means a broader selection of patients can be transplanted successfully.

So if transplants are better, and more patients who need a kidney can qualify, why can’t they get them? Simply, explains Jagadeesan, “it’s a demand and supply problem. The demand for organs is not met by the supply.”

Since arriving at GW in early 2014, Melancon, with supportfrom Anton Sidawy, M.D., M.P.H. ’99, Lewis B. Saltz Chair of Surgery, and professor of surgery at SMHS, has made it his mission to expand the universe of donors and thus increase transplantation. To help achieve this goal, Melancon has engineered a partnership with the Minority Organ and Tissue Transplant Education Program to inform the minority community about the facts — and fictions — of kidney donation.

“What I concentrated on was, let’s see if we can help people in the hardest-to-transplant areas,” Melancon says, “and it will translate into more transplants for everyone who is difficult to transplant. That is my strategy.”

“What I want to concentrate on is helping people in the hardest-to-transplant areas,” Melancon says, “and it will translate into more transplants for everyone who is difficult to transplant. That is my strategy.”

The prospects, he adds, for making a significant improvement in the D.C. community is palpable.

Speaking of palpable — how now to explain the cow?

Melancon’s skill as a surgeon and as an advocate for his cause seem reinforced by an uncanny perceptiveness about the challenges ahead. One of his oldest friends, Perry Franklin, a classmate at Louisiana State University, recalls their first meeting at a post-high school summer program for minority students interested in veterinary medicine or health careers.

“We became fast friends,” says Franklin, “and one day we were being taught how to palpate a cow’s ovaries prior to artificial insemination. Keith was in front of me, but somehow he slipped behind me in line, and I was next. When I reached in, the cow explosively ejected my hand and arm and painted me with [awful stuff].

“Now how did Keith know not to be next in line?” Franklin laughs.

Perhaps that timely line swap was Melancon’s first transplant.