Transplantation in Ukraine

Any discussion of transplantation in Ukraine must begin with the remarkable career of Dr Yuri Voronoy.1 On April 3, 1933, he performed the world’s first kidney allotransplant in the city of Kherson. The kidney was removed 6-h postmortem from a donor who died from a head injury and transplanted onto the thigh of a 26-y-old woman. She had ingested mercuric chloride in an attempted suicide and died 2 d posttransplantation. The donor kidney reperfused adequately but did not produce urine, which was not surprising as it was ABO incompatible (B to O), had prolonged warm ischemia, and was exposed to mercury in the recipient’s blood. Dr Voronoy attempted 5 other DCD kidney transplants from 1933 to 1950, the most successful of which was used to bridge a patient with acute kidney injury.2 The modern era of solid organ transplantation in Ukraine is often associated with the historic heart transplant performed by Dr Borys Todurov at the Shalimov National Institute in March 2001. His team conducted 3 additional transplants at the Heart Institute in Kyiv with 2 long-term survivors. Although there was ongoing living-related kidney transplantation activity, a national policy for donation after brain death organ retrieval, organ sharing, and transplant recipient listing was only established in 2019. The progress made in developing a contemporary transplant system between 2019 and 2022 is remarkable. During the initial months of the war with Russia, the Ukrainian healthcare system faced multiple simultaneous crises. These included the massive relocation of the population toward the west, the redeployment of medical practitioners and support staff into the military with a focus on trauma and critical care services, the wide spread destruction of hospitals and healthcare facilities from Russian missiles and shelling, and the disruption of the medical supply chain. I remember being awestruck when I crossed into Ukraine in May 2022, realizing that COVID-19 was treated like a minor annoyance amid much larger events. My journey to Ukraine started in my living room on February 24, 2022. The images I was watching were so unimaginable. In my lifetime, excepting 9/11, I had never witnessed the beginnings of a conflict where the distinction between right and wrong was so apparent. I had no personal connection to Ukraine but felt an immediate moral imperative to become directly involved. I contacted my longtime friend, Dr Marek Myslak, a Polish transplant nephrologist, and offered my services to help with caring for the millions of Ukrainian refugees who were crossing into Poland. He was inspired by my desire to help but had a different vision for it. He tried on several occasions to organize a recurring virtual meeting with transplant leaders in Ukraine which failed miserably before the deployment of Starlink. Dr Igor Gumennyi, the chief of Transplantology at the Lviv Emergency Clinical Hospital, contacted Marek and said, “I know this is probably impossible but what would really help us is if you and Dr Montgomery would come here and actually help us.” The transplant center in Lviv was functioning, and despite the outbreak of war, kidney transplantation was still cost effective.3 Other life-saving transplants were being performed by Dr Gumennyi and his team, including the first of several lung transplants performed in Ukraine.4 In May 2022, I traveled to Ukraine, keeping my plans confidential because of security risks. I took this very seriously and only informed my wife a few hours before I left. I met Dr Myslek in Krakow, Poland, and we traveled by train to the border town of Przemysl. Despite a chaotic border scene, we managed to cross, driving past the curfew and reaching Lviv late at night (Figure 1). Dr Gumennyi installed an air raid siren app on our phones which produced a piercing sound when there was a missile launch. I arrived at a hotel after midnight and was shown the bomb shelter before retiring and sleeping in my clothes.FIGURE 1.: Meeting the Lviv transplant team at the Ukrainian—Polish Border (left-to-right): Drs Igor Gumennyi, Robert Montgomery, Marek Myslek, and Maksym Ovechko.The next morning, we met the rest of the Lviv transplant team and prepared for several live donor kidney procedures. We met the donors and recipients and reviewed all of the studies and data. The donor nephrectomies were performed open because of equipment and disposable shortages. The equipment and instruments were distressed, and I broke several poor-quality sutures, no doubt donated by well-meaning aid organizations from expired or inadequately stored stocks. Dr Myslek scrubbed in and translated. The western area of Ukraine was part of Poland before the end of World War 2 and most people understand Polish. The procedures went very well, and I was impressed by the resilience and professionalism of the staff. No one complained about anything. The hospital, led by Dr Oleg Samchuk, a visionary urologist, had transformed a massive, old brutalist-style building into a highly effective facility caring for thousands of soldiers and civilian casualties, and has become the largest transplant unit in Ukraine during the war. The threat of missile attacks is constant and the attacks on utility infrastructure has resulted in intermittent loss of electricity and water (Figure 2). Most of the doctors and staff lived alone, having sent their families to safer locations. Despite these incredible sacrifices, they were optimistic and tireless in their dedication to keeping hospital services running and caring for the large numbers of injured and refugees from eastern Ukraine. They rarely left the hospital. During my 3 subsequent trips, I have found that this optimism has waned and the cumulative fatigue and uncertainty has become patent.FIGURE 2.: Russian missile attack photographed from the operating room window.Upon returning to Poland, I made contact with my family and notified my Dean at NYU Langone about my activities. I was not at all sure what his reaction would be as I was aware that as a Chair my trip into a war zone could be perceived as reckless. I was not prepared for how supportive he would be. When I returned, with Dean Grossman’s help, I was able to raise $300 000 from the Greater New York Hospital Association. LiveOnNY OPO Foundation and NYU Langone purchased operating trays, retractors, staplers, sutures, and instruments with these funds, which I carried back with me to Lviv on my subsequent trip in September 2022. A transesophageal echo machine was also shipped over. During this September trip, we performed several living donor kidney transplants and a deceased donor operation procuring 2 kidneys and a heart which we implanted. Ukraine only permits donation after brain death donation and prohibits donation from any casualties of the war. This is an unfortunate but necessary response to propaganda spread by foreign sources suggesting that organs from soldiers were being sold. My third trip was April 2023. We performed more living donor kidney transplants and visited Prof Todurov’s Heart Institute in Kyiv. Prof Todurov’s team has come up with an ingenious work-around to the limitations of not being able to travel by air to donor hospitals throughout Ukraine. They built an intensive care unit in a bus and transported the heart or liver recipient to wherever the donor was, performed the transplant at the donor hospital, and then returned the recipient to Kyiv for aftercare. We traveled to Bucha, which is the town where the Russian convoy headed for Kyiv at the beginning of the war was initially stopped by the Ukrainian military. My hosts wanted very much for me to be an eye witness to the manifestations of the atrocities that occurred there during the Russian occupation and to speak to some of the victims. They believe that in the future there will be an attempt to rewrite history, and it will be important to have Western validation of the events. This was one of the most disturbing and moving experiences of my lifetime. During my most recent tour in September 2023, a Lviv urologist performed a living donor robotic operation (a first in the hospital) and we implanted the kidney. We also carried out a rehearsal in Kyiv for an arm transplant. The resourcefulness and innovation of the Ukrainian surgeons is stunning and a constant source of inspiration. NYU Langone has hosted several visits by Ukrainian surgeons and physicians for training in rehabilitation medicine and prosthetics, hospital administration, psychiatry, and transplantation. I am enormously proud of how responsive my colleagues in transplantation have been about offering assistance. On September 21, 2023, I was summoned to the National Archives in Washington, DC, and in an unexpected honor, President Zelenskyy presented me with the Order of Merit, making me a Chevalier of Ukraine (Figure 3).FIGURE 3.: Order of merit presented by President Zelenskyy, September 21, 2023, at the National Archives.