| The Nasty Side of Organ Transplanting Second Edition Norm Barber Copyright Chapter 15 Getting A Transplant Most transplant hopefuls won�t admit it but they feel a peculiar tenseness on public holidays like Easter and Christmas. The sound of ambulance sirens on these days send bursts of hopeful energy through their body. Their success depends on a young man, usually a man, suffering catastrophic brain injury that doesn�t kill him and leaves the body relatively unscathed. Who Reaches The Waiting List? Achieving the waiting list requires a fine balancing act between dire illness and strong health. The patient must have one or two failing vital organs but still healthy enough to survive until an organ is available then surgery and immune-suppressant illnesses. For instance, a patient may need a heart transplant but also having a bad liver throws doubts on getting the heart. This is because the main anti-rejection drug, cyclosporin, damages the liver and to withstand cyclosporin one needs a strong, clean liver to begin with. Infections and Fat are Bad Those with infectious illnesses or controlled cancers are excluded because most pre-transplant illnesses will run rampant when anti-rejection drugs suppress the immune system. Being fat is another exclusion factor as the drugs cause huge increases in weight that the transplanted organs may be unable to maintain. Surgeons prefer transplanting into naturally thin or medium build people who often become fat after the surgery. Organ Recipients Can�t Have Psychotic or Depressive Tendencies Mental stability is crucial because transplant recipients often become psychotic, bi-polar or depressive. The shock of surgery, the drugs, chronic wound pain and faulty transplant organ are enough to send patients insane so a predisposition to mental illness may exclude the patient from getting a transplant. A common response to liver transplants is a period of psychosis. The ability to quickly recover mental equilibrium is crucial to survival since life with a transplant is a deadly walk between organ rejection and immune-suppression illness. Social Stability, Friends and Money are Crucial Television current affairs programs present smiling transplant recipients who are going �back to work� as if they have recovered. Waiting list doctors hold a different view. They know the recipient will never be cured and will need a dedicated network of helpers therefore social stability is crucial. A transplant hopeful shouldn�t be chased by the police, neighbours, criminals, drug dealers, lawyers, television camera crews, welfare officers or have constant financial or legal threats to their well-being. A �good� home with friends and relatives is crucial as vital organ recipients are usually on the verge of serious illness. Money is important as surroundings should be conducive to keeping the life-long patient safe and secure. All this excludes large sections of the underclass. Courage and obedience are needed to face the horrors of surgery, biopsies and drugs. Drug compliance is necessary because a recipient needs to maintain intake of anti-rejection drugs while observing them create new diseases like cancer tumours, diabetes and organ failures. The patient must not stop using the drugs that are causing harm because the immune system will then begin rejecting the transplanted organ long before the patient senses it. Mental and physical stamina are required to undergo painful and dangerous check-ups that are a regular feature for vital organ recipients. This form of obedient courage removes another range of personalities from receiving an organ. Lacking the above qualities or positive circumstances will hinder the patient�s chances of simply getting on the waiting list. The time on the list may be a few months or a few years. The patient might die on it or be taken off because other illnesses develop that lessen the ability to survive surgery. A positive reason for leaving the waiting list is when the patient recovers enough health and proceeds to less drastic and more successful treatments. Tissue Matching Upon the patient reaching the waiting list doctors begin compatibility ratings that indicate how well the body will accept foreign organs. Human Leukocyte Antigen (HLA) or tissue match testing involves mixing blood serum from the recipient hopeful with equal amounts of cells from sixty different people. The serum is classed as a 100% match if it doesn't react with any of the sixty samples. This means the recipient, with luck, will minimally reject organs from most other humans. A patient with less than a 20% match, indicating a strong, antagonistic reaction to alien cells and organs, may be removed from the waiting list. The immunological hypersensitivity test also measures reactivity acquired from previous transplanted material and pregnancies. When a patient is seeking a second organ the first transplant organ must be considered because the recipient's immune system is fired up and full of hate for organs or body material from donors with similar HLA matches and blood groups as the first transplant. Therefore, the second transplant must come from a donor with a different Human Leukocyte Antigen (HLA) type otherwise the immune system reaction may be too savage. Even a simple blood transfusion may have sensitised a potential recipient against people with similar tissue types as the blood donor. Therefore the recipient should not receive an organ from a donor with a similar blood or HLA type as any of the people from whom blood has been received. It is a very complex situation. The Mother�s Immune System Tries To Kill the Growing Child A woman�s immune system initially experiences the growing embryo as a malignant tumor. It attacks the unborn child with intent to kill, but the embryo (or foetus) disables this attack and the mother�s body begins accepting the child as part of herself, but not before it has permanently recorded the baby's HLA and blood type as an enemy to be attacked in the future. Therefore transplant technicians need to identify the blood and HLA types of all previous pregnancies of female organ recipients. The above shows how crucial it is to identify all previous transplanted material, pregnancies and blood transfusions. Transplanting an organ or body material type that the recipient's immune system has already experienced could trigger an instant and deadly antibody attack on the new organ of a ferocity usually reserved for xeno or animal tissue transplants. The next matching process is blood compatibility. Transplants often require huge amounts of transfused blood. Those lucky enough to have AB blood can accept all blood groups. A person with A blood can only receive from A and O blood groups. A person with B blood from B and O and someone with O blood can only get blood from a donor with that blood type. So if you're AB this increases your compatibility for both blood and transplanted material. This means a patient with AB blood will find it easier to get on the waiting list and a transplant. Your Waiting Ticket Doctors will examine your Human Leukocyte Antigen (HLA) and immunological hypersensitivity test results and assign a Percent Reactive Antibody number. A lower reaction to other humans' body materials indicates an ability to accept a wider range of donated material. This means that when someone is declared brain dead you may jump the queue over those who have higher reactions. Other Factors Helping the Patient Move up the Waiting List Being Young Is an Advantage The younger patients move quicker up the list. They get priority because they are more likely to survive surgery and the drugs and will live longer if they do. Surgeons see less point in sewing scarce organs into some old dear who is approaching death. This is the cruel truth. Being Close To the Harvest Hospital Is an Advantage When three patients have equal seniority the one closest to the harvest hospital will win. Distance between donor and receiver is crucial. Hearts last about six hours between bodies so even a three-hour flight between cities plus courier times may be too long. Heart transplant failure rates increase 6% for every hour a cold and paralysed heart sits in that cold picnic container. The recipient-hopeful in the same city as the dying donor has an almost insurmountable lead over a similarly matched person in another state. Avoiding Debtor Hospitals A patient waiting for an organ in a creditor hospital gets priority to a patient in a debtor hospital. A debtor hospital has taken more organs from elsewhere than it has given and must start paying back. If your hospital or state has been sending its donor organs interstate then eventually this factor comes into play. This means that if you and an interstate person have equal priority and compatibility then you will win because the debtor must begin paying the debt. Of course, it also works the other way around. Time on the list is also a determinant. The longer you've been there the better your chances unless you�ve lost strength while waiting. In that case doctors will kick you off the list. Suddenly Deteriorating Health May Be An Advantage Another factor is deteriorating health. The patient may be next in line for the heart of someone who just had a car smash, but if another patient further down the list suddenly begins dying then that person may jump in and get your heart. On the positive a patient ahead may become too ill to undergo surgery, or simply die, or get a cold that precludes surgery for two weeks. Then you jump in laughing, though not too loudly, and get that heart. The Waiting List May Be Harder Than the Transplant Getting to the top of the waiting list may take years of stress and chance.It may wreck what is left of your life and you might not even make it to surgery. Dr J.A. Roberts, of the Royal Hampshire County Hospital in United Kingdom, said that patients� lives can be destroyed by the emotional turmoil of waiting for a transplant, not knowing whether it will ever happen. This isn�t a joke because even someone dying over a period of years can have positive inner and outer experiences. Undergoing the horror of getting onto the waiting list and then the stressful wait can destroy that stability. Then the transplant may fail and the patient dies. One might then ask if the process was worth it. The Big Day The Big Day arrives. The hospital phones and says you are third in line. Your donor has terminal brain injury and is about to be declared brain dead. There are two recipients ahead of you. The ambulance has taken the first to the hospital for theatre preparation. This is mind-breaking tension and you may find yourself hoping the two people ahead of you will suddenly die or that they have colds or minor infections that temporarily preclude them from a transplant. During the pre-transplant immune suppressant treatment or after the graft, a tiny cold or minor infection can become a deadly illness and kill the patient. A further problem may arise if a famous television celebrity or a favoured doctor or Bill Gates wants that same organ. Then the good word arrives. For unspecified reasons the other two have dropped out. You are number one and in the ambulance heading for transplant surgery. There is now a fourth patient behind you hoping you will fail and he or she gets the heart that is still beating in the prospective donor. Last Disease and Deformity Check While the donor is declared brain dead and moved to the harvest table last minute medical and social history checks continue. Personal history checks are required to ensure donors haven't recently worked as prostitutes and that men have not had active homosexual activity since 1976. Donors must not have HIV-AIDS, evidence of prion diseases or other infectious agents. An exception to this strict regime of disease control is the new policy in the United States approving some donors with localised cancer for organ harvesting. They are desperate to beat the shortage of donors though, even in the USA, cancer generally precludes organ donating. Ex-Organ or Human Growth Hormone Recipients Can�t Be Donors Previous transplant recipients cannot donate organs because the attendant immune suppression they experienced has filled their bodies with powerful and diabolical diseases. Those receiving Human Growth Hormone injections from pituitary glands taken from human corpses preclude them from donating due to fear of latent Creutzfeldt-Jakob disease. Donors can't have lived in Great Britain for more than six months between 1988 and 1996 (unless they live permanently in that country), this again from the fear of vCJD, a human form of Mad Cow Disease. Prion diseases have incubation periods of up to fifty years. Size Does Count The donor's organs must be a similar size to the recipients. Transplants have been cancelled due to the shocking discovery that the donor's heart was too big. During harvesting the organs are checked for abnormalities. Smallish tumours are cut off the liver but if too large or extensive it is rejected and the transplant cancelled. New surprise illnesses or infections may be discovered during harvest. The car smash or injury, which broke blood vessels in the donor�s brain, may also have damaged the transplantable organs. Fatal auto smashes are violently traumatic and frequently ruin the vital organs. Or the bullet that killed a gunshot victim may have pierced the organ. The medical literature also contains references to surgeons ruining organs during the complicated process of excision. All the above obstacles must be surmounted to obtain a scarce vital organ that may cost $300,000 to transplant. Preparing For Theatre Heart, liver and lung failure patients reaching theatre for a transplant are in the minority. The majority fail to make the waiting list and up to 9% on the waiting list for hearts are removed because their health has improved. Then comes the preparation at the hospital. The skin on the area to be cut open will be shaved and disinfected. A paralysing drug and anaesthetic are administered similar to those given the donor and, hopefully, the roles won't be confused. The harvested body, after vital organ removal, may be sent to the skin and bone harvesters or directly to the morgue awaiting collection then taken to a funeral home. The transplant surgeons will not remove the failing organ from the recipient until they see and confirm the health of the harvest organ. They take this precaution because the plane or car carrying the organ may crash or it may arrive spoiled or defective. An exception is when the patient is about to die anyway and harvesting is happening in the same hospital. Kidney transplants are easier. Unless the recipient's natural kidneys have cancer, or are previous transplants being rejected, they may be left in the body and the transplanted organ plonked into the patient's abdomen then connected from there to the renal system. Inserting a third kidney in the abdomen is such a smooth operation that recipients are often discharged from hospital before the living kidney donors (the walking around types) get out. Removing the donor's kidney involves cutting muscle tissue and even sawing off a rib, far different than a relatively gentle insertion of the harvested kidney into the abdomen of the recipient. Living liver section donors have it worse than living kidney donors and can expect to lose eight kilograms and return for repeat surgical repairs. A healthy person donating a liver section undergoes risky surgery with full anaesthetic that may damage the brain. Some living donors even die. When the donated organ has been cut from the dead or almost dead patient it is paralysed or stabilised, chilled and washed of blood and delivered in an ice-packed picnic cooler to the recipient's operating room which may be across the hall or across the country. Bloodless Liver Surgery? Liver transplants are the most difficult and expensive and very bloody. Four major arteries are cut and blood flow re-routed through the body. One transplant can use ninety litres of blood. During the 1980's a city's blood supply could be used on one liver transplant.53 Nurses have reported being metaphorically �up to their knees in blood.� To reduce blood use during the transplant it is caught in a trough, cleansed and pumped back inside the body. Ironically, some liver transplants are done without using blood transfusions. In May 1999, Belgium surgeons transplanted a liver, without transfusing blood, into a Jehovah's Witness.53 Denton Cooley ranks along with Christiaan Barnard and Norman Shumway as one of the world's greatest transplant surgeons. He has done numerous transplants without blood transfusion and is, predicably, a hero of the Jehovah Witness religion. Just surviving liver surgery itself, which can take twelve hours, is an accomplishment. The added hurdle is that unlike heart and kidney transplanting there isn't an effective liver replacement machine so if the transplanted liver doesn't quickly begin working the patient usually goes into a coma and suffers brain damage then death. Even surviving can be bad. Mark Dowie has described it in his book We Have A Donor, �The post operative course can be so much worse than the end-stage disease itself that the families have been known to pray for a merciful death for their loved ones � lying semiconscious, half-crazed by chemical imbalances in the brain, racked with pain and fever, and deeply depressed. Nurses and health workers often wish that liver transplantation had never been started in their hospitals.�54 Jennifer Rickman in The United Kingdom British transplant survival rates are higher than American rates because they too avoid transplanting into the sickest patients who, ironically, could extend their lives with a transplant. Jennifer Rickman of Winchester, Hampshire, in the United Kingdom, had bronchiectasis since childhood and in 1997 at age 54 was put on the waiting list for a double lung transplant. She felt uneasy knowing she was waiting for someone to die. One day the hospital called and she was taken by ambulance for surgery, but the donor lungs proved unsuitable for transplant. Jennifer then received another blow. After two years of psychological agony while waiting for the transplant a doctor told her she was too sick and that transplanting lungs into her was �little better than throwing the organs in the dustbin�. Jennifer was devastated and didn't understand how she could be kept seriously waiting for lungs then suddenly reclassified as too sick. Next day she heard a news report that hospitals were now required to publish death lists and that surgeons would be reducing risky surgery to keep their death figures down. Inga Clendinnen in Australia The redoubtable Inga Clendinnen describes her liver transplant thus, �Laying still for twelve hours or more can lead to the blood pooling, which is dangerous. So from time to time they pick us up by the feet and shoulders and shake us.� Another unusual procedure for a human with liver failure, who may or may not be awaiting a transplant, is to have pig or baboon livers connected to their blood stream. The animal livers then cleanse the blood similarly to a human liver. Baboon livers last up to 24 hours while pigs� last less than nine hours. Baboon livers cleanse best but pigs are preferred because baboons cost too much and look like us while people tend to dislike pigs. The liver transplant recipient may go temporarily insane after a liver transplant due to the build-up of toxins in the blood stream that cloud the mind. Transplanted livers are notoriously slow to regain full function. Heart Transplant Dead bodies rot quickly in a hot jungle, yet if you die on a glacier your body could still be there in ten thousand years. Surgeons use this principle when performing heart transplants. The recipient's body is chilled to 77 degrees Fahrenheit slowing the metabolism and the need for oxygen. This reduces the risk of brain damage and brain rot. An anaesthetised and chilled body has a slower metabolism because it is slowed down to the edge of death. The anaesthetist is the �stage-master� poisoning the patient to the edge of death but still alive. This helps prevent the body from rotting and reacting to the knife. Surgical procedures have improved since Washkansky's 1967 transplant but surgeons still, somewhat savagely, cut the patient open. Christiaan Barnard described it thus, �...massive trauma of open heart surgery. His chest had been split open by knife, cleaver and saw - cutting through tissue, muscle, nerve and bone. Its ragged gap had been pulled still further apart by steel retractors.� The donor heart is paralysed then removed from the previously heart-beating donor for its journey to the recipient. A removed heart has a natural pacemaker and if kept in a nutrient solution could arrive for the recipient still beating, but this would cause damage like running a pump dry. When transplanted the harvested heart starts beating on its own or may require a jolt of Direct Current electricity just like Frankenstein�s monster. The present day process is more reliable than during Washkansky�s time because the harvesting of hearts begins while they are still beating inside the donor. Previously hearts wouldn't always begin beating or would not beat properly because they had been damaged during the lengthy dying process. Patients with Two Hearts In the early days surgeons averted the risk of patient death, due to the transplant heart not performing, by leaving the old one in. These heterotopic transplants meant the old heart remained and a second heart was squashed in beside it. Patients then had two beating hearts which was quite good insurance. Mr Goss of South Africa was one such patient. Christiaan Barnard recounts in his book, Second Life, that when Mr Goss felt his natural heart stop he calmly got into his car and drove to the hospital with his transplanted heart still beating. Barnard also said that, as of 1993, one man had lived 17 years with two hearts. What If The New Organ Doesn�t Work? The reader might be wondering why a patient on the operating table, whose transplanted lung, heart or liver has failed to function, couldn�t continue living until another organ was located. Theoretically, this is possible but the cost of keeping patients for months or years on heart and lung machines, or filtering their blood through three pig livers a day, wouldn�t be sustained by government medical services or insurance companies. Also, animal rights activists wouldn�t tolerate herds of pigs being slaughtered for that purpose. Maintaining these patients isn�t worth the trouble so when a transplant of this sort has obviously failed theatre staff will turn off the patient�s air and quietly wait a few minutes for death. This is cheaper, more humane, less degrading and less painful for the patient, and a form of euthanasia. Post-Operative Conditions Pre-loved organs are like reconditioned car engines. They rarely work as well as the original motors. The problem with lung transplanting is that surgeons don�t have the technological skills to connect the tiny nerve endings between the new lungs and recipient�s body. This means lung recipients don�t have our natural reflex reactions to irritants. When a normal person breathes in pepper, liquid or dust the reflex action prompts a cough to expel the material. Transplanted lungs don�t have this healthy reaction and consequently these irritants build up so the patient must consciously and artificially cough and also make frequent visits to the hospital for lung drainage and cleansing. The Transplanted Heart Heart surgeons face a similar problem and can only connect the major blood vessels and nerve endings between the donor heart and recipient. The loss of these subtle nerve attachments means the transplanted heart won�t initially beat at appropriate speeds and the patient may require a pacemaker. A normal heart increases speed to meet higher energy demands but when a patient stands up the transplanted heart fails to increase speed resulting in fainting spells. This is why new recipients appear so fragile and walk in slow motion. The situation improves as the human body rewires its nerve routes between the brain and transplanted lungs and heart though this explanation is still unproven. A second theory is that new connections are hormonally mediated rather than rewired, a stronger view, perhaps, since heart recipients don�t feel the usual pain associated with angina because certain nerve connections are never re-routed. Like reconditioned engines another problem with pre-loved hearts is their rapid deterioration. Coronary arteriosclerosis appears in 90% of transplanted hearts within five years and the patient can�t get bi-pass surgery but will need another transplant (if one is available). This is called a re-transplant and the survival rates are lower than for the first transplant. 55 Long Term Recovery For neurotics or hypochondriacs a transplant is a dream come true and bringing many new, exciting and deadly illnesses. The patient will be on a constant series of antibiotics and other drugs to fight germs the suppressed immune system can no longer battle. The transplantee�s immune system may be too compromised to even share coffee cups and will need to avoid those with colds, avoid public toilets, and not eat raw eggs, uncooked dough or lightly cooked meat. Working in the garden may be too dangerous as a scratch could easily turn into the patient�s last infection on this earth. The best part will be that doctors and friends won�t deride or laugh at the new ailments since the hypochondria will be a reality. Patients can expect new illnesses like high blood pressure, organ failure, diabetes and even cancer that will pop up from nowhere. Rejection will be the biggest problem and the whole family can spend hours playing 'spot the rejection symptom' before it becomes overt and it is too late to save the organ. The recipient should also like pain, as there will be considerable physical and mental anguish. The Alligator Clip Heart recipients need to regularly visit special doctors for rejection checks. This is tested by cutting a hole in the neck artery and pushing a cord, with a tiny alligator clip attached, down the artery into the heart where it chomps out a piece of flesh. The doctor pulls the cord back up and sends the chunk to the lab for analysis. Doctors will change or increase drugs at the first sign of rejection though it may be too late. Patients ideally require monthly alligator clip tests to maintain the fine balance between rejection and immune deficiency diseases, but due to their unpleasant and dangerous nature these tests are done each six or twelve months. One problem is that the alligator clip might prompt a cardiac arrest creating a situation where it may be too dangerous to yank it out. After a vital organ transplant life is never again assured and as Inga Clendinnen puts it in her book, �Tiger�s Eye�, "We know that for us health is an artificial condition. We will remain guinea pigs, experimental animals for as long as we live or, if you prefer, angels borne on the wings of our drugs, dancing on the pin of mortality. We know that today is as contingent as tomorrow.� US$ transplant prices in 1996 and annual maintenance costs. (UNOS) Heart $253,200(surgery), $21,200 (annual maintenance); Liver $314,500 (surgery), $21,900 (annual maintenance); Kidney $116,100 (surgery), $15,900 (annual maintenance); Pancreas $125,800 (surgery), $6,900 (annual maintenance); Heart-Lung $271,400 (surgery), $25,100 (annual maintenance); Lung $265,900 (surgery), $25,100 (annual maintenance); Kidney-Pancreas $141,300 (surgery), $16,900 (annual maintenance). |