Surgeons Research Changes Kidney Transplantation

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Quote:Dr. Robert A. Montgomery's wife would never have taken him for a kidney transplant surgeon the first time she saw him, not with the long hair and that outrageous mustache. Maybe a biker, she figured, and maybe she was onto something there.

When he heads for work at Johns Hopkins Hospital from his loft in Baltimore's Fells Point neighborhood or the manse he shares in Bethesda with Denyce Graves, the internationally known mezzo soprano, Montgomery roars off in his 500-horsepower Shelby Cobra, painted white with a blue stripe down the center. Chances are he's in black cowboy boots, blue jeans and a dark shirt, and you probably wouldn't peg him for a kidney transplant surgeon, either, much less one who heads a team that is breaking ground in the field.

By all accounts it's all in character for Montgomery, all slightly outside the bounds of convention. The brawny car, the loft decor he calls "industrial gothic," the boar hunting trips. The rock music in the operating room. The wedding extravaganza that included a Masai ceremony on one continent and an airplane hangar dance party on another. And, oh yes, the medical research that has helped jump barriers to kidney transplantation that 10 years ago would have seemed impassable.

The problem of finding healthy kidneys to replace ailing ones is growing as kidney failure mounts with accelerating rates of high blood pressure, diabetes and obesity. At last count, more than 89,000 people in the United States were awaiting a kidney transplant, suffering the late stages of kidney disease on dialysis treatments several times a week. Finding kidneys for these patients especially those whose blood and tissue types makes them hard to match with donors is a complex puzzle of immunology and logistics, one that Montgomery has made key strides in solving.

These patients "need someone who will step up and take some risks for them, and Bob has done that," said fellow researcher and surgeon Dr. Stanley C. Jordan of Cedars-Sinai Medical Center in Los Angeles. "You need eccentrics, people who think about things in a different way."

"I'm much less conformist" than most, said Montgomery in a gentle, measured tone that seems out of sync with the macho accessorizing. "I'm more open to other ways of thinking and looking at problems."

As a kid, according to family lore, he once came home with a report card on which his fourth-grade teacher had written: "Bobby doesn't think the rules apply to him." He's been making idiosyncrasy work.

Peers and friends get a smile in their voice when they talk about this wild hair who managed to ascend the conservative ranks at Hopkins. You can almost hear them shaking their heads over the phone. That's Bob, famous party animal — "sucking the marrow out of life," as the Hopkins surgical residents used to say at their all-day pig roasts in Fallston.

Bob's the one who shows up at the black-tie surgical fellows' dinner at the Maryland Club in his black Nehru jacket. Maybe he doesn't have to worry about tuxedo formalities or the mustache trim. Not anymore, not with six titles to his name at Hopkins, including chief of the division of transplantation, director of the Comprehensive Transplant Center and director of the Incompatible Kidney Transplant Program. Not with the international speaking engagements, the documentary videographers showing up in his operating rooms on a regular basis.

In January, this native of Buffalo who was raised in Philadelphia turned 50, which means that for all his life surgeons have been transplanting human kidneys from living donors with increasing success, though not quite with his dramatic flair. Three surgeries at once? They pulled that off as a first at Hopkins a few years ago. That made news, but Montgomery and his surgical teams were just getting warmed up. In the past few years, his teams have performed a series of firsts involving living donor kidneys transplanted into five patients, then six, then a production involving four hospitals in four states, 16 patients and new kidneys for eight people.

Last year, his surgical team removed a kidney from a female donor as if he were delivering a baby. "Isn't it wild?" he said to a reporter at the time.

It was wild, and that vaginal nephrectomy, as it could be known, was a first in the world and might have been good advertising for more living donors — look, one less scar! but it paled in comparison to the scientific complexity of the work that never gets on camera.

That would be the immunological work, where the real action in transplantation goes on. Ever since a British doctor during World War II identified the immune system as the culprit in skin graft rejection, the central battle in transplantation has been engaged in this extremely complex system of lymph nodes, bone marrow, two organs and an array of cell types. That's where Montgomery who holds a doctorate in molecular immunology from the University of Oxford to go with his University of Rochester medical degree is probably making his biggest mark.

In the lab and the clinic, doctors such as Montgomery tinker with the immune system and tell it not to do everything God intended. They might treat the patient with any number of drugs. They might treat the patient's blood to remove the plasma containing the antibodies, then pump in fresh plasma. They might do both in varying combinations, trying different drugs to stifle immune response, or "desensitize" the patient.

To be sure, Montgomery is working with tools developed by others, at Hopkins and elsewhere the drugs, the blood treatments, the laparoscopic surgical technique and the logistically complicated practice of "kidney paired donation," not performed in this country until 2000 in Massachusetts. Hopkins physicians did their first in 2001.

Simply put, kidney paired donation is a way to get around the problem that arises when a donor is not a good match for the intended recipient. What then? Then the names of donors and recipients, along with their blood and tissue types, are fed into a computer database in hopes of finding better matches. Sometimes those matches are with strangers thousands of miles away. In a simple two-way swap, for instance, the donor in pair A gives to the recipient in pair B and vice-versa. The more pairs in the database, the more possible matches.

A donation "chain" is a bit different. This would start with one donor giving a kidney to no one in particular, setting in motion a succession of donor-recipient couplings. At the end, a kidney would be left that could start another chain or go to a patient on the list for a kidney from a deceased donor.

Montgomery didn't invent any of this, but he and his research and surgery teams have combined these elements in novel ways and pushed things further. Among other things, they've built on work done at Hopkins in the 1990s and overseas to leap the blood-type barrier between donor and recipient. Montgomery's research has also refined the categories of "sensitized" patients meaning those with heightened immune responses who are difficult to match with donors arguing for specific procedures that would work best for each group.

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