Robert A. Montgomery, MD, DPhil, Director of the Transplant Institute, Discusses Tissue Rejection & Making Organ Donations Less Invasive
Robert A. Montgomery, MD, DPhil, one of the nation’s foremost kidney transplant surgeons, joined NYU Langone in March as director of its new Transplant Institute. His charge is to broaden the Medical Center’s existing expertise in transplantation and advance surgical approaches that address the needs of a growing and increasingly diverse patient population. Most recently, Dr. Montgomery professor of surgery, served as chief of the Division of Transplantation and director of the Comprehensive Transplant Center at Johns Hopkins Hospital. A relentless innovator, he has helped pioneer minimally invasive surgery to remove donor kidneys, novel techniques to reduce the risk of organ rejection, and “domino” kidney transplants, which involve multiple pairs of donors and recipients. In 2010, Dr. Montgomery led a 10-way domino transplant, earning a citation in the Guinness Book of World Records for the most kidney transplants performed in a day.
What brought you to NYU Langone?
I wrote a white paper about the future of transplantation and what it would take to realize that vision here at the Medical Center. When the leadership read my proposal, which called for a unification and expansion of the various transplant programs, they said, “Okay, let’s do it.” I was floored by the offer to lead this effort.
What is the value of unifying these different programs?
NYU Langone has some key strengths in transplantation, such as the liver transplant program—one of the first in the nation to implement a living-donor program—and the pioneering face transplant program. But to move to the next level, we must shift from traditional, siloed services to a single institute. By working together, we can reduce fragmentation and inefficiencies, manage costs, expand services, and collaborate on research and training.
“If I have a talent, it’s that when I see something, I can tell right away whether it’s going to be important. That’s what I felt when I saw my colleagues remove a diseased kidney laparoscopically.”—Robert Montgomery, MD
Do you plan to perform any new types of transplants?
We plan to begin heart, lung, and pancreas transplants, as well as bone marrow transplants, which are increasingly being used alongside other tissue transplants to reduce rejection.
Each year, just 20 percent of patients on the transplant waiting list get a donor kidney. What can be done to improve the odds?
It’s depressing. People are waiting on average four to six years, with a mortality rate around 30 percent. Deceased donations are flat, despite significant public outreach. One possible solution is xenotransplantation—transplanting organs from genetically modified animals. People are always saying it’s just around the corner. But with transgenic pigs, it just might be.
Another factor driving the shortage is the need for retransplants, which account for one in five kidney transplants. Are there ways to reduce this percentage?
Retransplants occur for a number of reasons: clots, infection, recurrence of the disease that caused the patient’s own kidney to fail, and most often, rejection of donor tissue. We are beginning to reduce rejection with “allogenic” cell and organ transplants, in which a related donor gives their bone marrow along with a kidney. Since the bone marrow determines the immune system, this reduces both rejection and the need for immunosuppression. This is critical for young transplant recipients, who might need three or four transplants over a lifetime.
One of your innovations—desensitization therapy—has helped increase access to kidney transplants. Can you elaborate?
One of the big challenges was that up to 30 percent of patients were essentially untransplantable because they had become sensitized, that is, they developed antibodies to other people’s tissues, usually because of a previous transplant, a pregnancy, or a blood transfusion. In 2001, we developed a treatment protocol in which we remove the problematic antibodies from the patient’s blood prior to the transplantion. Our research shows it reduces the risk of rejection and doubles life expectancy, compared to those who remained on dialysis.
Do you ever feel conflicted about operating on perfectly healthy people who’ve chosen to donate an organ?
Kidney transplants actually started with donations between relatives in the 1950s, not with cadaver kidneys. Medical ethicists long ago agreed that it’s ethical for an individual to undergo an operation that will only benefit someone else. Altruistic donations in which the donor does not even know the recipient are just an expansion of that concept. People can be connected in very powerful ways that don’t involve blood ties. In a way, altruistic donation is purer. There’s no possibility of family coercion.
What was your role in the development of laparoscopic live-kidney donation?
If I have a talent, it’s that when I see something, I can tell right away whether it’s going to be important. That’s what I felt when I saw my colleagues remove a diseased kidney laparoscopically. My colleagues at Hopkins and I spent two years figuring out how to tweak the operation so we could remove and preserve a healthy kidney for transplantation. It has changed the calculation for donors. Many more people now donate because the operation is less traumatic.
And you pushed that idea even further with nephrectomies using vaginal extraction.
One of the drawbacks of laparoscopic nephrectomy is that while most of the work is done through three tiny incisions, at the very last moment, you have to make a larger incision to remove the kidney. My colleagues and I were always thinking, How can we do this better? One day at grand rounds, I overheard two residents debating a novel approach for removing an appendix or gallbladder through natural body openings. That gave me the idea of removing a kidney through the vagina. It was a eureka moment. We did the first case in 2009, requiring only a few tiny abdominal incisions. It went amazingly well. The next step is to eliminate those external incisions entirely. I think it’s going to be increasingly common, as laparoscopic and robotics techniques get even more sophisticated.
What was your most difficult case?
A 43-year-old woman with end-stage renal disease and just about every imaginable complication that would normally preclude a transplant: loss of vascular access for dialysis, chronic thrombosis, sepsis, and near-total sensitization. Without a transplant, there was no chance she was going to survive. We were able to identify a live donor at the end of a domino chain with a good tissue match. The option for a living donor transplant gave us the flexibility to control the timing of the operation and prepare her for transplant with a novel combination of treatments and medications. She survived.
Africa loomed large in your early life. Could you describe those experiences?
When I was a little kid, I dreamed about traveling to Africa. My first actual visit came in college, when I did a health-related summer program in The Gambia with Operation Crossroads Africa—a model for the Peace Corps. I went back just before medical school under a Thomas J. Watson Fellowship, which allowed me to spend a year backpacking around Africa, studying the interface between Western and traditional medicine. Africa gets under your skin. I’ve been back many times since.
Did that experience affect you as a physician?
Yes, and it was reinforced in medical school at the University of Rochester, the vortex of psychosocial medicine, which takes into account the whole universe around the patient. That’s also what appealed to me about transplant surgery. You care for patients who are very medically complex, and you follow them, in most cases, throughout their lives.
You’ve done more than 1,000 kidney transplants. Does it ever get routine?
Never. It’s always magical when you let blood go into that organ and something so lifeless suddenly animates. I wax poetic every time I see that.