In December 2024, a 53-year-old woman from Alabama who had endured kidney failure for eight years became the recipient of a gene-edited pig kidney at NYU Langone Health. Her journey began with an act of altruism in 1999, when she donated a kidney to her mother. However, complications from a subsequent pregnancy led to hypertension and eventual kidney failure. Despite being listed for a transplant in 2017, finding a compatible donor proved elusive due to her immune system’s abnormal development of antibodies. Under the FDA’s compassionate use program, her historic transplant was performed by Dr. Robert Montgomery and Dr. Jayme Locke. Her case marks a milestone as the first genetically modified pig kidney transplant in an otherwise healthy patient. The procedure highlights the potential of xenotransplantation (transplanting organs across species) as a viable solution to the organ shortage crisis. Pigs present an ideal donor species due to their rapid growth and large litters. While the recipient is recovering well, with plans to return home in three months, the long-term success of xenotransplantation will require extensive clinical trials.
But this is only part of the story.
The surgeon, Dr. Robert Montgomery, is a pioneering transplant surgeon who became a pioneering transplant patient. Dr. Montgomery suffered from familial dilated cardiomyopathy, a rare, progressive disease of the heart muscle that weakens its pumping ability and causes dangerous arrhythmias. In 1989, Dr. Montgomery became the first practicing surgeon in the world to receive an implantable cardiac defibrillator. In those days, the procedure required open-heart surgery. A generator the size of a soda can was placed in his abdomen, powering a pair of large capacitors attached to the outside of his heart. The apparatus made it painful to wear a belt—but worse, it threatened to dash Dr. Montgomery’s dreams of becoming a transplant surgeon. He managed to become a renowned kidney transplant surgeon, nonetheless, keeping his illness at bay with medications, electronic implants, and sheer willpower. During his surgical fellowship, he helped develop the first laparoscopic kidney procurement technique. The innovation made recovery easier for donors, facilitating donations of live-donor kidneys. Live donor kidneys last much longer than those from cadavers. He pioneered several advances in transplantation. Dr. Montgomery was among the first transplant surgeons to promote the idea of using HCV-positive organs, after the new generation of antivirals proved capable of quickly clearing the virus.
By 2003, he became director of the transplant program at Johns Hopkins, where he gained a reputation as a trailblazer because of his efforts to get more organs to people who needed them. One of his innovations was the “domino” kidney transplant, which occurs when several people who need a kidney transplant have friends or relatives who are willing to donate but are not compatible. A chain of surgeries is arranged in which each would-be donor is matched with a compatible recipient. These altruistic donors, who are willing to donate a kidney for a friend or family member, donate a kidney to a compatible recipient and their friend or family member then receives a kidney from a compatible donor. An eight-way swap in 2010 landed Dr. Montgomery in the Guinness Book of World Records. He also helped develop a protocol combining kidney and bone marrow transplants to prevent rejection of donor organs in immune-incompatible patients and eliminate the need for immunosuppressive therapy. In addition, Dr. Montgomery became the leading transplant surgeon and director of the NYU Langone Transplant Institute. He launched several initiatives to identify potential donors more swiftly and to ensure that potentially viable organs often rejected for transplantation did not go to waste. This included donors who were HCV or HIV positive. Within two years of his arrival, NYU Langone had increased the number of organ transplants from fewer than 50 to more than 280. NYU Langone’s heart transplant rate, or the number of heart transplants each year divided by the number of patients on the waiting list, was five times the average for the New York region. NYU Langone’s transplant waiting times for all organs was the shortest across the metropolitan area. An example is that the average waiting time for a heart transplant was 36.3 days versus 66.1 days across the metropolitan area.
Dr. Montgomery’s condition continued to worsen, and in 2018, his life-threatening symptoms qualified him for priority status on the heart transplant waiting list. Dr. Montgomery knew how difficult it could be to get a heart transplant. His physicians were skeptical of whether he would survive long enough to benefit from his own breakthroughs. The hoped-for “call” came at 4:00 a.m. on September 20, 2018, just five days after he was admitted to NYU Langone. His transplant surgeon said, “We have a donor. Heroin overdose, in their twenties, HCV positive.” Dr. Montgomery did not pause. “Let’s go,” he said. At 2:46 p.m., Dr. Montgomery received a new heart—healthy and strong, despite the donor being HCV positive. At 6:09 p.m., nearly seven hours after the surgery began, the surgery was completed. His new heart had some rhythm problems at first that were resolved with medication. Dr. Montgomery went home 10 days later. By then, he had tested positive for HCV, as expected. A course of medication cleared the virus.
Dr. Montogomery is grateful for the gift of a new heart, provided by a grieving family. He is thankful for the chance to prove that the risk he took in accepting an HCV positive organ can benefit many people other than himself. Everyone who receives an HCV positive organ at NYU Langone (about half of all heart recipients) does so as part of a clinical trial. So far clinical trials have shown striking results. No transplant recipient has failed to respond to the HCV therapy they were given.
Dr. Montgomery’s life exemplifies resilience and innovation. His contribution to the field of transplantation has impacted many lives, including his own.
SUMMARY
Today, more than 100,000 individuals are on the United States transplant waiting list, with the majority requiring kidneys. Thousands die each year due to a lack of available organs, and many more never qualify for transplantation. The innovative use of gene-edited pig organs and HCV-positive donations provides a glimpse into a future where organ shortage could be alleviated or greatly reduced. As clinicians refine advances in transplantation, the courage of patients like the Alabama woman and the visionary leadership of practitioners like Dr. Montgomery illuminate a path forward, bridging gaps between need and availability in transplantation.
REFERENCES
NYU Langone Health. (2024). Gene-edited pig kidney transplant milestone.
Montgomery, R. et al. (2024). Innovations in organ transplantation.
United Network for Organ Sharing (UNOS). (2024). Transplant statistics and the organ shortage crisis.
Centers for Disease Control and Prevention (CDC). (2024). Hepatitis C in organ donation.
, MSN, MS, RN, CCM, FCM, President of the Case Management Society of America
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