Chain of 30 kidney transplantations sets new US record

BMJ 2012; 344 doi: (Published 21 February 2012) Cite this as: BMJ 2012;344:e1304
  1. Nigel Hawkes
  1. 1London

A new record for chained kidney transplantations has been set in the United States. It involved 30 transplantations across the country between March and December last year, which linked living donors to recipients whom they were unlikely ever to meet.

Chained transplantations start with a single altruistic donor. If this donor’s kidney is used to help a recipient who has been denied a transplant from a relation who was willing to donate but was unable to do so because of immunological incompatibility, then the chain can continue if that relation remains willing to donate anyway. That kidney goes to the next recipient in the chain, who also has a willing but incompatible relation, prepared once more to reciprocate the gift by donating onwards. Technically such a chain need not end, but people are excluded who have no relation or partner who is willing to keep the chain going.

The 30 strong chain in the US has been anatomised by the New York Times in a meticulous reconstruction that traced and identified all but one of the 60 people involved ( The chain began with a single altruistic donor, Rick Ruzzamenti, 44, of Riverside, California, who decided one day to give a kidney to a needy kidney patient—any needy kidney patient. He attributed this spur of the moment decision to his Buddhist beliefs and to the recession, which had temporarily dried up his work as an electrical contractor and given him time to spare.

His kidney was flown across the country to Livingston, New Jersey, where it was transplanted into a 66 year old man. His niece had offered him her kidney, but it did not match, so in recognition of Mr Ruzzamenti’s gift she gave it anyway, and it was shipped to the University of Wisconsin Hospital in Madison and transplanted into Brooke Kitzman, 29. In reciprocity Ms Kitzman’s former partner, David Madosh, 46, donated one of his kidneys, in spite of the fact that he and Ms Kitzman had just had an acrimonious break up.

And so it went on, until the 30 transplant chain terminated with Donald Terry, 47, in Joliet, Illinois, who had nobody in his family willing or able to donate a kidney. Overwhelmed by his good fortune, he began to feel guilty that he would be last in the chain. “Is it going to continue?” he asked his transplant surgeon. “I don’t want to be the reason to stop anything.”

He was reassured that as one chain stops, another begins. The process is made possible by a registry of would-be donors and their intended recipients started by Garet Hil, a business executive whose daughter was saved by a kidney donated by one of his nephews. With his wife, Mr Hil set up the National Kidney Registry and created an algorithm to match pairs and create chains.

Mr Hil’s pool consists of up to 350 donor-recipient pairs, making possible a huge series of different possible chains. The programme eliminates those matches that are immunologically impossible and creates viable combinations, which are then ranked by the number of transplantations they would enable, with weight given to chains that find kidneys for patients who are hard to match or who have waited for a long time. Last year Mr Hil’s registry arranged 175 transplantations, including the 30 in the record breaking chain. “We’ve just scratched the surface,” Mr Hil told the New York Times.

Chained donations, which take place over several months, have not occurred in the United Kingdom, but “pooled” donations, which are carried out simultaneously on the same day, have. There is no legal obstacle to chained donations in the UK, and from the beginning of this year would-be altruistic donors have been able to choose to donate into a pooled scheme rather than to the next suitable patient on the national transplant waiting list.

Lisa Burnapp, lead nurse for living donation at NHS Blood and Transplant, said, “The story of the 30 long chain shows the future potential for what is possible in living donor kidney transplantation.

“In the UK we’ve just embarked on introducing altruistic donor chains into our established national living donor kidney sharing schemes. We’ve chosen to build on the strengths of our existing paired and pooled donation scheme to extend the benefits of altruistic donation, by creating the potential for a single donation to benefit more than one recipient [by starting a chain].

“We recognise the importance of considering all possible options that extend the benefits of transplantation for patients, and once we’ve established the principles of altruistic donor chains we can consider different approaches and we will look to international expertise and experience as a benchmark for future developments.”


Cite this as: BMJ 2012;344:e1304


  • Competing interest: Annabel Ferriman, news editor of the BMJ, is chairwoman of Give a Kidney—One’s Enough, a charity dedicated to raising awareness of altruistic kidney donation.