GRAND FORKS, N.D. – Although he wanted to, Paul Voth could not donate a kidney to his girlfriend, Tanya Knodle, whose health has been failing in recent years. Their blood types are not compatible.

But they found another way that Knodle, who was diagnosed with Type 1 diabetes at age 10, could receive the kidney she needed due to the diabetes-caused kidney disease she had.

The Grand Forks couple agreed to be part of a "paired exchange" program. Voth would donate his kidney to a stranger, whose donor would give a kidney to Knodle.

In mid-May, she and Voth completed tests to clear them medically for the exchange, she said.

"On July 2, we got a call that the surgery had been set for July 28. I was very shocked."

Instead of a paired exchange, though, Knodle, 38, and Voth, 34, were part of a "triple exchange" which involved three donors and three recipients who had surgeries in Fargo, N.D., Minneapolis and Sioux Falls, S.D., on the same day.

Voth and Knodle were operated on at Sanford Health in Fargo. Voth's kidney went to Sioux Falls; the kidney from that recipient's donor went to Minneapolis, and the Minneapolis donor's kidney came to Knodle in Fargo--a kind of "round robin" of organ donation.

It's a way for a patient to receive a kidney even though his or her donor is not compatible, said Knodle.

For Voth, the decision to donate was a no-brainer.

"I didn't really think about it," he said. "This was someone I cared about and loved, and she needed a kidney, so why not?"


Up until the surgery took place, Knodle was worried that something might happen to derail the multi-party transplant, she said a few days before the operation. Every phone call from Sanford made her flinch.

"If one of the six (of us) gets sick or says, 'I don't want to do this,' the whole thing shuts down," she said. "It's risky, and very nerve-wracking."

Receiving a kidney meant that Knodle would no longer be tethered to a peritoneal dialysis machine for 10 hours every night. (People with end-stage kidney disease need to have waste removed from their blood by dialysis or a kidney transplant to stay alive.)

"It will be nice to be free," she said. "You don't realize how confining it is. If we travel somewhere for a day or two, I look like I'm packing for a week because of the machine, the boxes (of dialysis supplies) and bags of extra solution."

Now, with the transplant surgery behind her, Knodle said, "The doctor said, for this to work, the stars really have to be aligned.

"How it all worked out was very surprising to me, actually. ... Apparently, the stars were aligned in our case."

'Relatively new concept'

A triple exchange, involving three living donors and their designated recipients, is an unusual and relatively new concept, said Dr. Bhargav Mistry, transplant surgeon at Sanford Health in Fargo. "I would say the concept has been more active for the past five years or so ... In hindsight, we wondered why we didn't think of this 20 or 30 years ago."

Since joining Sanford in 2000, Mistry has performed more than 500 kidney and pancreas transplants, most were kidney transplants. Four years ago, he was part of a five-way kidney exchange.

The practice has expanded to larger circles of donation, he said. "You hear of nine-way or even ten-way exchanges," he said.

For such transplants to be successful, donors and their designated recipients must be compatible in blood type and other factors, and be healthy enough to go through the surgery.

Before the idea of swapping kidneys was accepted by the medical community, patients would have to wait for a compatible donor or for a kidney from a deceased donor, Mistry said.

"It's pretty sad in a way because the person has a donor and is otherwise healthy and can go through the surgery, but their donor isn't a match."

Sometimes these patients died waiting or from complications of kidney disease, or became too sick to undergo a transplant, he said.

"When we talk with families about this option, almost everyone has been willing to do this," he said.

"(The exchange program) takes a load off the transplant waiting list, which is huge. There are 120,000 patients waiting for an organ transplant. One in five dies waiting for a kidney transplant."

The wait for a kidney from a deceased donor is usually a few years, according to

About 17,000 kidney transplants were conducted in 2014 in the United States, said Knodle. In about two-thirds of the cases, the kidneys were from deceased donors.

"Three thousand people are added each month to the kidney transplant list," she said.

Living donor

Kidney transplants from a living donor, rather than a deceased donor, have a better chance of being successful, Mistry said.

He expects that the kidney Knodle received "will function well for at least 15 years," he said. "The average functionality of a cadaver kidney is about eight years--although there are variations."

Advances in specific medications and close monitoring of their effects have reduced the likelihood of rejection in the transplant patient.

Transplant is also preferable to staying on dialysis, he said.

"It is always better than dialysis, because dialysis is not a natural process.--it clears the waste (from the blood) but it doesn't give that energy."

When functioning properly, kidneys work around the clock to regulate and maintain the levels of certain chemicals in the body, he said.

"Dialysis does not provide that perfect 24-hour control. It's nowhere near close to nature."

The greatest benefit of a successful kidney transplant is improvement in quality of life, the freedom patients receive along with the fully functioning kidney, he said. "They can have a full-time job, travel outside the city, and take care of their family."

They no longer need to spend four hours a day, three times a week, in dialysis at a health care facility.

"In the long run, transplantation means less cost to the patient and to society, because there's more (worker) productivity," he said.

Knodle knows only that the person who donated a kidney to her was about 27 years old. Voth knows nothing about the person who received his kidney.

They have expressed an interest in meeting her donor, Knodle said. "The donor decides if they want to connect with the recipient."

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'New beginning'

In recovery, Knodle is staying temporarily in Fargo since she has ongoing lab tests and other medical appointments. She drinks lot of water, and meets often with a pharmacist and other health professionals who are monitoring her progress and helping her adjust after surgery.

"The education is very thorough," she said. "It can be kind of a daunting experience."

But she is up to the challenge, she said.

"I'm going to give this kidney the best chance I can to make it work."

In a month or so, if all goes well, Knodle's name will likely be placed on a waiting list to receive a pancreas to reduce complications from diabetes in the future, Mistry said. "She will probably get one in under a year."

For Knodle and Voth, who got engaged shortly before the transplant, it means that they can move forward with their lives.

"I'm hoping it's a new beginning," Knodle said. "I don't even remember what it's like, going to the bathroom like crazy."

During the first night with her new kidney, she had to make frequent bathroom visits.

"Normally that would be bothersome but, for me, that's exciting. It means the kidney is working."

She is looking forward "to start to have energy again to do stuff," she said.

"We can start planning our wedding and planning our life--and not planning around the hospital."