Transplant Trauma

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A patient undergoing dialysis
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While transplantation of human organs has given a new lease of life to many, those between unmatched donors is risky and expensive and patients would be well advised to tread carefully before plunging into it  

By Shobha John

Three years ago, Anjali Khullar’s* life turned topsy-turvy. Her husband, Sanjay* was diagnosed with degenerative chronic kidney disease. This was a natural corollary of diabetes and high blood pressure which he had. Sanjay’s life became restricted as he was put on a renal diet to weed out excess potassium which could damage his kidneys. That meant eating leached green vegetables, limited dairy products, deskinned apples and no soup.  

Anjali said: “Whatever was considered healthy was unhealthy for him. As a wife, I would feel depressed.” And in April 2016, Sanjay reached end-stage renal failure as his creatinine levels went up. Doctors asked them to decide whether to go in for a kidney transplant or dialysis. While dialysis in their choice of hospital along with medicines would cost them around Rs 50,000 a month, a transplant from someone in the same blood group as Sanjay (who was O), would cost around Rs 6.5 lakh. But if the transplant was from an incompatible donor, called ABOIs, the costs would go up manifold.

Illustration-Anthony Lawrence
Illustration: Anthony Lawrence

And this is what happened. As they couldn’t find a donor with the same blood group within the family with the blood group O, Anjali decided to donate her kidney to her husband despite some doctors warning them against it. “We were desperate and it was too late to pull out,” she explained. Numerous tests were done to increase the compatibility and in September 2016, Anjali’s kidney was transplanted into Sanjay’s. But luck was not on their side—the kidney had what is called hyperacute rejection barely an hour after the operation and had to be removed. What this meant was that even with all the preparation and extra pre-operative costs, Anjali’s kidney from another blood group did not match and was immediately rejected by Sanjay’s body. As the trauma hit the family hard emotionally, Sanjay was immediately put back on dialysis. He now waits for someone to donate a kidney.

HIGH RISKS

This mind-numbing case is an apt example of why transplant surgery, though touted as the last cure for those suffering from debilitating kidney, liver and pancreas problems, is still fraught with risks, especially for ABOIs. According to experts who didn’t want to be named, transplants among ABOIs have a 10 percent risk factor. One of them said: “A 10 percent risk factor is quite high and I wouldn’t do an operation like this. The normal risk factor in any operation should be less than 2-3 percent, unless it is a dying emergency.”

While ABOI transplants are best avoided, they are done chiefly due to the difficulty in finding donors from the same blood group. It is especially so with blood group O as this is the universal donor, and so a swap that is usually possible with other blood groups, is a remote possibility with those requiring O group transplants. Sadly, many patients are often not aware or not told about the risk factor, the monetary burden and emotional toil it can take. 

In the case of Sanjay, the phenomenal costs of various tests and the actual operation set him back by Rs 20 lakh. This includes the cost of plasmapheresis, a method whereby antibodies are removed from the recipient’s body before the transplant. Each session cost the family Rs 80,000 and they went through eight of them. “We were under the impression that only one was needed but as the antibodies kept building up, we had to have eight sessions. Our finances went for a toss,” said Anjali. The antibodies going up was perhaps a warning of future rejection but this may have been ignored in the enthusiasm to go ahead. 

THREE CONDITIONS

For any successful transplant to take place, three things must perfectly match—blood type matching, tissue type matching and cross-matching. However, a perfect match does not occur all the time and with improved modern medication against rejection, tissue typing seems to play a less important role. However cross-match and blood typing is important. Doing transplants across blood groups is offered selectively by some hospitals due to advancement in medical science. Even then, the body will always reject a foreign object inside.

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Prof Mohamed Rela, Director and Head, Institute of Liver Disease and Transplan-tation, Global Hospital Group, told India Legal that the term “matching” in transplantation has varied interpretations. “Scientifically, matching varies from organ to organ. In liver and heart transplantation, we essentially look for a blood group match whereas in kidney transplantation, we also have to make sure that the ‘cross match’ is negative.” In cadavers, only a blood match is needed.

In blood type matching, persons with the wrong blood group cannot donate to those of other groups as this can be fatal due to the presence of antibodies. For example, those with Type A blood have antibodies to Type B and therefore, should not donate to them. Type AB group are universal recipients, while Type O is the universal donor.

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The second major factor in transplants is tissue matching. Here numerous blood tests are done to see if certain proteins called antigens are similar between the donor and the recipient. For kidney transplantation, six of these are looked at and are called HLA antigens. Having a six-antigen match is the best compatibility. This happens in 25 percent of the time between siblings with the same mother and father.

The third and ultimate test for transplantation is serum crossmatching, which identifies antibodies that can damage the transplanted organ. Here, cells from the donor are incubated with the serum of the recipient. If the serum has antibodies against the donor’s cells, they will be destroyed. This is called a positive crossmatch and it means that the transplant cannot take place. This test is taken many times, including just before the transplant surgery. A negative crossmatch means the recipient has not responded and transplantation can take place. 

WATCH OUT

However, despite these serious risks, hospitals, especially private ones, advertise that incompatible donors (desensitization) too can get transplants. Rela said that some 30-35 percent patients do not have matching donors and will have to be on the waitlist for an organ from a brain dead donor. Rela said: “Desensitization is an accepted procedure but does not carry the same success rate as a matched donor.”

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Dr Sunil Shroff, senior consultant urologist and transplant surgeon and managing trustee of MOHAN Foundation, an NGO, said: “A patient should be given all possible options before a transplant is done such as swap transplants and cadaver donation. ABOI should be the last option. It is only in India that patients are in such a hurry to get a transplant. Abroad, people on dialysis can wait for 3-4 years before a transplant is done. While life on dialysis is somewhat compromised, it is best to wait for a cadaver donation if that option is available, otherwise they should explore the option of a swap transplant. The 2011 amended law allows such kidney transplants and a few hospitals have done them.”

Dr Shroff said that desensitization is rare as it is an expensive proposition. “The whole procedure can be twice as expensive as a normal kidney transplant and there is always a risk of rejection,” he said. He advised that hospitals should explore the option of swap transplant first before considering ABOIs. “They should also inform patients and relatives of the possibility of rejections.”

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He said that in Kerala, paired chain transplants have been done where one altruistic donor donates his organ to someone who does not have a compatible donor and that family donates a kidney to the next incompatible kidney recipient. This is also called domino transplant. The longest such paired chain took place in the US, where 60 operations and 30 kidneys were used in this paired kidney exchange program. 

Researchers have discovered that by tweaking a recipient’s immune system, the donor’s organ can be prevented from being rejected. The incompatibility is reduced by giving the recipient immunoglobulin, a blood product, through plasmapheresis. Here, as antibodies in the body are depleted, the crossmatch result becomes negative. But Dr Amy L Friedman at Yale University School of Medicine and Dr Thomas Peters, a transplant surgeon at Shands Jacksonville Medical Center in Florida reportedly said that this method should be done only if there is no other strategy to permit transplantation.

LIFELONG MEDICINES

In all these cases, immunesuppressants are given to stop the body from rejecting the organ which is transplanted. These could comprise inhibitors, antiproliferative agents and steroids. While they are given as early as three weeks prior to surgery in ABOIs, in other cases they are given a couple of days prior to the transplant. Andyes, they are expensive. They also have debilitating side-effects. These have to be taken life-long and with rigorous discipline as missing even a single does can lead to rejection. The tell-tale signs of this are:

  • drop in urine output
  • fever above 100 degrees
  • bloody urine
  • weight gain

Rela said the side-effects of immune suppressants place the recipient at an increased risk of infection. “To mention a few others, they can cause diabetes, increased blood pressure and renal dysfunction,” he explained.

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Though a new study by the National Institute of Diabetes and Digestive and Kidney Diseases on 1,025 patients found that “patients who received kidney transplants from HLA-incompatible live donors had a substantial survival benefit as compared with patients who did not undergo transplantation”, the fact is that there are risks and patients would do well to understand that clearly. 

In the case of liver transplants, said Rela, ABOIs have produced 80-85 percent survival in centers with experience in handling such patients. “In highly sensitized patients, the outcome following de-sensitization is variable and depends on the level of sensitization to start with,” he said. So even as desperate end-stage kidney patients search for this vital organ, it would be in their interest to weigh all the pros and cons before plunging into a risky proposition.

Names changed to protect identity 

Lead picture: A patient undergoing dialysis

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