It was April 1, 2022, and Molly Gray was excited. From her room in the Hospital of the University of Pennsylvania’s Pavilion, she’d gazed at the Philadelphia skyline long enough, and decided to get out of bed and walk.
Three doors down, she popped into the room of her friend Dan Napoleon. He was glad to see her, and together they took selfies and live chatted with their kids’ soccer team, away at a tournament in Virginia. They wished each other well, and marveled once again at the unlikely miracle that had brought them both to the hospital’s transplant floor.
Two days prior, Gray had been wheeled to an operating room, went under anesthesia, and gave away something priceless — one of her kidneys. The next day, Napoleon had received a brand-new kidney. It wasn’t from Gray, but it was a direct result of her altruism. And it was from a living rather than a deceased donor, making Napoleon a rarity among Black kidney recipients.
Welcome to the world of paired donations and donation chains — which are expanding the supply of livers and kidneys from living donors. However, there are equity issues when it comes to this trend, as recipients from Black and other minority communities do not seem to have the same level of access to this second chance as their white counterparts often do. For example, in 2014, the cumulative incidence of live donor kidney transplantation among white patients was 11.4% as compared to 2.9% among black patients, according to research published in the Journal of the American Medical Association.
Hidden Health Problem
Napoleon, 51, lives with his wife and children where he grew up, in Trenton, New Jersey. He serves as Mercer County’s director of Environmental Programs.
Gray, also 51, lives across the Delaware River in Yardley, Pennsylvania. She’s a counselor at Pennwood Middle School (also in Yardley) and a single mom of three.
Their paths crossed for the first time when Napoleon’s son Brandon and Gray’s son Cooper joined the same travel soccer team. For more than five years, the boys have played together, traveling to tournaments near and far, with their families cheering them on from the sidelines. But what Gray and the rest of the team parents didn’t know was that Napoleon’s health was failing.
After battling hypertension and type 2 diabetes for years, he was referred to Penn Medicine. In 2018 Napoleon received a diagnosis of end-stage renal disease. His doctor told Napoleon he had kidney failure, which came as a shock. He signed up for the transplant list, waiting for a deceased donor whose kidney was just the right match, and in the meantime had to endure four-hour dialysis sessions several days a week. There were days he couldn’t make his son’s soccer games or accompany the team to a tournament; often it was hard just to get out of bed, go to work, and function normally.
In 2021, Napoleon made the biggest ask of his life; he posted an appeal on social media, looking for a living donor to give him a new kidney. Between his family, his fraternity network from college, and his church community, Napoleon’s request inspired dozens of offers to help.
Paired Kidney Donation – A Silver Lining
The news reached the soccer parents too, and shocked Gray, who hadn’t realized Napoleon was sick at all. She immediately thought, “I think I could probably give him a kidney. I don’t see any reason for not giving him a kidney.”
Some of the folks who wanted to donate their kidneys to Napoleon learned through the testing process that they, too, had kidney issues. A few leads seemed promising, but ended up being false starts. “It was kind of a blow to me,” Napoleon admits.
Meanwhile, after consulting with her family and getting their unanimous support, Gray moved forward with the evaluation, but kept it a secret from Napoleon until she knew for sure she could donate. First she got good news: Her overall health and kidney condition made her an excellent candidate for donation. Then, the not-so-great news: Gray and Napoleon had different blood types, so she couldn’t donate directly to him.
However, the opportunity to participate in a “paired donation” emerged as a silver lining. Gray could donate to another patient that the National Kidney Registry (NKR) identified as compatible with her, while Napoleon could then receive his kidney from another living donor matched with him by the NKR.
“It doesn’t matter how old are you or your blood type, just that you are a healthy person and want to donate a kidney, the rest we will take care of,” remarks transplant surgeon Samir Abu-Gazala, MD, Gray’s donor surgeon. He spent many years practicing in Israel, where non-directed donors (patients who donate without a specific kidney recipient in mind) are common.
By this point, more than six months had passed since Napoleon had first reached out to ask for donors. When Gray got the final thumbs up from Penn Medicine Transplant Coordinator Donna Collins, MSN, RN, CCTC, she placed a single kidney bean into a small jewelry box and handed it to Napoleon on the sideline of their sons’ soccer game, saying she was approved to donate for him. “He’s looking at me like I had nine heads,” Gray laughs.
“Very rarely am I speechless,” notes Napoleon. “Then I’m like, ‘Wait a minute, this is happening!’ It was such a selfless act.”
Almost exactly one year after posting about his need for a donor, Napoleon woke up in the post-acute care unit with a new, fully functioning kidney, given to him by a stranger. And simultaneously, Gray was recuperating from her own surgery, while her kidney had a new home in another stranger. “I felt the paired exchange is even more of a gift, because two people received kidneys — a magical mystery person in their 40s in New Jersey ultimately received mine, and Dan received a ‘golden ticket’ for a kidney from another donor,” marveled Gray.
It’s something that Mary Cate Wilhelm, PA-C, a physician assistant the Penn Transplant Institute, never tires of witnessing. “Because of Molly’s generosity, Dan is free from dialysis and will be on the sidelines of the soccer field for many more games,” she says. “Living organ donation really gets to the root of human kindness.”
Teaming Up to Tackle Disparity
Since the paired donation, this pair has spent months recovering and getting stronger. They’re both back to work, and preparing for another busy travel soccer season. And they’re both doing great; Gray’s recovery was swift, and Napoleon is getting good numbers in his follow-up tests. “It’s a new lease on life,” he says, after four long, grueling years of slogging through dialysis. “I feel like my old self.”
They are also teaming up to spread the word about living donation, and how desperately it’s needed among communities of color. Napoleon recalls the first time he walked into the dialysis clinic: “What immediately jumped out is that everyone looked like me — people of color.”
With so many Black people receiving kidneys from deceased donors — which have on average half the lifespan of those from living donors — Napoleon is grateful for his gift and adamant that he wants to raise awareness as well as recruit more donors. “A kidney’s a kidney, but living donations usually go to affluent white individuals, and deceased donors more often go to communities of color,” he observes. “We need to change that.”
Gray is on board with that effort. “I felt ignorant for not knowing there was a disparity,” she says. “We need to focus more on the Black community.”
They’ve shared their story throughout the soccer program and elsewhere in the community, and committed to seeking out opportunities to recruit other donors, especially those who are Black and members of other minority groups, such as speaking at Black churches.
It’s sorely needed, says Robert R. Redfield, III, MD, FACS, surgical director of Penn Medicine’s Living Donor Kidney Transplant Program, who performed Napoleon’s transplant. Education about the lack of living donors is only part of the issue; it’s also “finding friends and family members who are healthy enough or can take time off work to donate.”
Wealthier, white recipients may also have more resources for casting a wide net to ask for a donation, or more comprehensive health insurance coverage. As a result, Black patients often spend longer on the waiting list for a new organ (which means many more hours enduring dialysis); when they do receive a transplant, it’s more likely to come from a deceased donor than a living one.
Redfield says that the organ transplant situation in the United States as it exists today unfairly makes the best treatments available fastest to patients who already have the most resources. “We are trying to think of ways to decrease that disparity.”
“We Need to Pay It Forward”
“Our wish is to get everyone access to a living donor kidney transplant,” Redfield says. “We're far away from it. But the reality is we can solve this problem through the generosity of others.”
He states that Penn has a multifaceted strategy to “bulldoze the barriers” for donors and make the so-called #pennlivingdonor experience a positive one. Partnering with the NKR, the National Kidney Donation Organization, and other groups, Penn aims to make it as easy, convenient, and safe as possible for living donors to give up an organ.
For example, the transplant team tries to coordinate testing and other appointments to maximize the value of donors’ in-person time, as some aspects of the process can be accomplished remotely. Indeed, Gray was pleased that many of her initial consults happened via Zoom, so she didn’t have to take time off of work and drive to Philadelphia and back. To remove financial obstacles, Penn Medicine and its partners can help donors with a place to stay in the city, as well as recouping lost wages for the transplant process and recovery in addition to transportation costs.
Further, Penn is investing in ways to make the choice physically easier on donors. Abu-Gazala points out that all living donations are performed laparoscopically (minimally invasive), for quicker recovery and marginal scarring. And within the last year, the team has started incorporating robotic procedures for even greater precision.
Additionally, Penn recently hired an outreach worker to engage local Black communities, letting people know about the disparities surrounding transplants from living donors, and how donors are supported to make a difference in the lives of patients, even those they don’t know.
Napoleon is all-in on that effort. For the one-year anniversary of his and Gray’s surgeries next spring, they are planning a “party with a purpose” to raise money for kidney transplant organizations as well as to raise awareness of kidney health and the need for more living donors. “I still can’t thank her enough,” Napoleon says of Gray’s willingness to donate her kidney on his behalf. “We need to pay it forward, so that other people can benefit just like I am.”
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