Blood group and HLA antibody incompatible transplants
Authored by Dr Rommel Ravanan
Previous transplants, pregnancies or blood transfusions can result in sensitisation i.e. the person’s immune system becomes programmed to fight donated organs. The higher the degree of sensitisation the more difficult it is to match a kidney transplant (either from the national waiting list or from a family or a friend). This is due to antibodies in the blood that are programmed to destroy the donated kidney very quickly after transplant. Similar antibodies when blood groups do not match can also cause similar problems.
Until recently presence of such antibodies were considered an absolute contra-indication for proceeding with the transplant. New drugs and technology is opening the possibility of overcoming such antibody barriers. A drug called Rituximab is now available that can temporarily switch off the cells in the body that make such antibodies. A treatment called plasma exchange helps clean the patient’s blood to remove the antibodies already in the system. Plasma exchange treatment is similar to haemodialysis in the sense the patient is connected to a machine that pumps blood out of the patient and passes through a special filter that removes the harmful antibodies.
Each plasma exchange treatment takes about 3 hours, has to be done on alternate days and most patients will need between 3 to 12 treatments, with the exact number depending on individual differences in antibody load. The plasma exchange makes no difference to the kidney toxins and the patient will need to continue with their normal dialysis regime (PD or HD).
A combination of Rituximab and Plasma Exchange treatment to remove harmful antibodies is often referred to as de-sensisisation. The antibody levels are regularly monitored during the de-sensisisation treatment and once sufficient antibody has been removed, the kidney transplant can proceed. Due to the planning required for de-sensisisation, this treatment can only work when there is a healthy living kidney donor available to donate a kidney.
Following the transplant, most patients do not need additional plasma exchange treatments but require to take standard anti-rejection medication (usually 3 different types on anti-rejection tablets) as long as the transplant is working.
The de-sensisisation treatment is associated with increased risk of infections (as the patient’s immune system is suppressed more than the normal transplant patient) and bleeding about the time of the operation. The medical team in conjunction with the patient will have to carefully balance the risks of de-sensisisation with the benefits of a working kidney transplant. Like most medical treatments, de-sensisisation is not suitable for every kidney patient and in some instances, the antibody intensity can be too high to make de-sensisisation impractical or unsafe.
A day in the life of the Live Kidney Donor Team
Authored by Kay Hamilton
The work of the Living Kidney Donor Transplant Coordinator can be very interesting, diverse, expansive & can necessitate a wide variety of skills. There is no such thing as a typical day, as you can pick up the phone and all your plans for the day can be blown!
After arriving at work, my colleague Tracey & I sit & go through our list of potential kidney donors & their transplant recipients. We start with the couples that are soonest planned to have their operation. The list is posted on the wall of our office in a very elaborate fashion!! (We would love to get an interactive whiteboard very soon). On our daily updates we aim to monitor every couples progress & any problems that may crop up.
Our living kidney donors are very precious to us , as they are offering to undergo a huge operation to benefit the health of another- (usually a loved one / family member / friend). The team in the renal unit’s aim is to ensure that we assess these people very carefully to detect any current or future health problems, either physically or psychologically. Their assessment is stopped if it is felt that they would be at risk in any way.
We run two nurse led clinics each week where we meet the potential recipient / donor couples on a regular basis.
There is usually at least one living kidney transplant a week and so our day may start by going to theatre first thing in the morning with the living kidney donor. (As we have three other referring units, we may be the only nurses that the donor has had any contact with). We also attend theatre to perfuse the kidney once it is removed. Once the donor is safely anaesthetised, we will visit the recipient as they frequently need reassurance and comfort at this stage. This may necessitate going to the Bristol Children’s Hospital, as some of our children have their kidney transplants from their parents who have their kidney donation at Southmead hospital.
The surgeons usually have at least one clinic a week where they are seeing patients (who have completed their medical donor assessment), to check their surgical suitability to be able to proceed as a donor or recipient. Our presence at these clinic is required also!
Regular Medical Directorate meetings every week also take place to monitor the entire renal units work, including the Live Kidney Donor programme.