Kidney Transplant

choi

Kevin Sack, 69 Lives, 30 Kidneys, All Linked; Intricate balancing act produces a record chain of transplants. New York Times, Feb 19, 2012.
http://www.nytimes.com/2012/02/1 ... lant-chain-124.html
(coordination over 4 months among 17 hospitals in 11 states)

Quote:

"While about 90,000 people are lined upfor kidneys, fewer than 17,000 receive one each year and about 4,500 die waiting, according to the United Network for Organ Sharing, which maintains the wait list for the government. Only a third of transplanted kidneys come from living donors, but they are coveted because they typically last longer than cadaver kidneys.

"The federal Medicare program, which pays most treatment costs for chronic kidney disease, saves an estimated $500,000 to $1 million each time a patient is removed from dialysis through a live donor transplant (the operations typically cost $100,000 to $200,000). Coverage for kidney disease costs the government more than $30 billion a year, about 6 percent of the Medicare budget.


Note:
(a) The "red-eye" in fly red-eye is a noun that means
"a late night or overnight flight"
(b) The gutter in "gave up his job hanging gutters" is
rain gutter
http://en.wikipedia.org/wiki/Rain_gutter

, not
street gutter
http://en.wikipedia.org/wiki/Street_gutter
(c) The newspaper misspelled. Not "nephrophthisis" but "nephronophthisis" (also knwn as medullary cystic disease).

The greek noun phthisis (pronounced TIE-sis; where ph is not pronounced) means "dwindling or wasting away."
(d) Babylon, New York
http://en.wikipedia.org/wiki/Babylon_(town),_New_York
(a town in Long Island)

------------------------
My comment:
(a) A Patient's Guide to Kidney Transplant Surgery. USC Kidney Transplant Program, undated.http://www.surgery.usc.edu/divis ... entguide/index.html

(i) Pretransplant Evaluation.
http://www.surgery.usc.edu/divis ... lantevaluation.html

Quote:

"Blood typing - Every person is a blood type A, B, AB or O. The donor's blood type does not have to be the same as the recipient's blood type, but it must be "compatible" (see crossmatch testing).

"Histocompatibility Laboratory Tests
[A] Tissue Typing - This test is done on white blood cells. The white blood cells have special 'markers' that tell your 'tissue type.' You inherit tissue type from your mother and father. This test is used to match a kidney and/or pancreas to you.
[B] Panel Reactive Antibody (PRA) - This test shows how active your immune system is. It is easier for you to get a kidney if your immune system is calm or measures 0%. Blood will be drawn at your dialysis center and sent to our laboratory. Your immune system may be active from blood transfusions, pregnancy, a previous transplant or a current infection.
[C] Crossmatch Testing - This test is done when a donor kidney is available. Your blood is mixed with the donor's blood. If there is no reaction (negative crossmatch) it means you are 'compatible' with the donor. If there is a reaction (positive crossmatch), the kidney will not work for you because it is 'incompatible.'"

(ii) The Donor/Blood Type Compatibility
("BLOOD TYPE COMPATIBILITY CHART")

(b) USC Kidney Transplant Program.http://www.surgery.usc.edu/divisions/kidney/index.html
(a) Live-Donor Laparoscopic Transplant
http://www.surgery.usc.edu/divis ... opictransplant.html
("Laparoscopic Kidney Removal ")
(b) Conventional Kidney Transplant
http://www.surgery.usc.edu/divis ... dneytransplant.html
("Regular donor nephrectomy requires a long incision with removal of a rib, to allow the surgeon access to the kidney, blood vessels and ureter. Hospitalization of about 5 days is necessary. Nonetheless, this operation has been performed thousands of times, providing a safe, reliable way of removing the donated kidney./ The new kidney is placed low in the right or left groin area. Diseased kidneys are not removed unless necessary.")

(c) Living Donor Online.
(i) Bone Marrow Donation (web page 4 of 6).
http://www.livingdonorsonline.org/marrow/marrow4.htm

Quote:

"Tissue Type. The second test run on the blood sample identifies your human leukocyte antigens (HLA). There are many different kinds of antigens, but there are three categories assessed for marrow donation, designated HLA-A, HLA-B, and HLA-DRB1. You inherit one set of these three antigens from each parent giving you a total of six HLAs.

"A similar test is run on a blood sample from the recipient, and the antigens are compared. You might hear of a 'six-of-six' match (all donor and recipient antigens match), or a 'half match' (three of the six antigens are the same), or a 'zero match' (none of the antigens matches). In the case of bone marrow donation, tissue typing is critical, so a perfect 'six-of-six' match is required.

(ii) Living Kidney Donation (web page 4 of 6).
http://www.livingdonorsonline.org/kidney/kidney4.htm

Quote:

"If you and your potential recipient are not of the same [compatible] blood type, there are two things you can consider. One option is called 'paired exchange.' * * * The other option is called 'plasmapheresis.' Plasmapheresis involves the transplant recipient undergoing a special medical process that removes the blood's incompatible antigens. * * * Note that plasmapheresis is still an experimental procedure

"Tissue Type. * * * HLA-A, HLA-B, and HLA-DR * * * There was a time when this type of tissue compatibility was important. However, the development of more effective anti-rejection drugs has reduced the importance of the HLA match. In fact, some transplant teams ignore tissue typing. Therefore, even if your degree of matching with the donor is relatively low, you may still be considered for donation. See this page for further discussion of HLA matching [see next].

(iii) The Issue: Does HLA Matching Matter?
http://www.livingdonorsonline.org/HLAData.htm
("The level of HLA match DOES matter to graft survival")

Please take notice this web page is dedicated entirely to kidney transplant, not other organs.


(d) Now is a good time for me to give you a summary, about ABO or HLA compatibility.
(i) ABO
(A) ABO blood group appears only on the surface of red blood cell, not on other blood cells or tissues of a person.
(B) A person with, say, type A somehow develops an antibody against type B in the first year of his or her life. Similarly, a person with type O has both anti-A and anti-B antibodies, whereas a person with AB has neither. Why? Nobody knows.
(C) ABO incompatibility in organ transplant can be fatal. On Feb 7, 2003 a 17-year-old Mexican girl named Jessica underwent a heart-lung transplantation, despite ABO mismatch due to negklect of the Duke University team.
(D) The (c)(ii) above is wrong to the extent it says plasmaphoresis is to remove "antigens" from a recipient's blood. In truth the procedure (plasmaphoresis) is to remove ANTIBODY: For example, removing anti-B antibody in a person with type A.
(E) Why ABO blood group is important in transplanting a kidney when the latter does not carry ABO antigen on kidney cells? I suspect vessels of an organ to be transplanted contain numerous red blood cells which can not be flushed out (such as those in capillaries).
(F) Plasmaphoresis removes the offending antibody temporarily. The recipient will make the antibody in due course. But by that time, donor's red blood cells have long disintegrated.  
(G) ABO mismatch is a disaster only if it is unforseen. With countermeasures before transplantation (like plasmaphoresis), some studies have showed graft survival rate is similar.

Shin MJ and Kim S-J, ABO Incompatible Kidney Transplantation--Current Status and uncertainties. Journal of Transplantation, _: _ (review; online publication Dec 17, 2011; not yet published in print)
http://www.hindawi.com/journals/jtran/2011/970421/
(Japan pioneered the trend "because of the near absence of deceased donors"; "Tydén et al. [18] found that graft survival was 97% for the ABOi KT [ABO-incompatibile Kidney Transplantation] compared with 95% for the ABO-compatible KT in their three-center experience at their five-year followup. Patient survivals were 98% in both KT groups")

(ii) HLA  
(A) Human Leukocyte Antigens (HLA) were discovered on the surface of human white blood cells. Later they were found to be on the surface of all human cells, hence the new name Major Histocompatibility Complex (MHC)--there are minor ones which may also affect transplantation but do not stand out prominently, especially immunosuppressive drugs make them (minor) unimportant (however, this explains quotation 1 in (f) below).
(B) HLA includes A, B, C and D which was later discovered to divide into subgroups (DP, DM, DOA, DOB, DQ, and DR).

human leukocyte antigen
http://en.wikipedia.org/wiki/Human_leukocyte_antigen
(locations on human chromosome 6)
(C) HLA
http://en.wikipedia.org/wiki/HLA-DR
(table: the protein HLA DR is--like all other HLA-D proteins--made of alpha and beta (1, 2, 3 and 4) units, which are coded by HLA-DRA and HLA-DRB1, 2, 3 and 4 genes, respectively.)   


(e) Amy L Friedman MD, FACS and Thomas G Peters, MD, FACS, FASN. Make Me a Perfect Match: Understanding Transplant Compatibility. American Association of Kidney Patients, undated.
http://www.aakp.org/aakp-library ... atibility/index.cfm

Quote:

(i) "Blood Type Matching

"The four major blood types [ABO] in humans correspond to the type of glycoproteins (a combination of sugar and protein) on the surface of the blood cells. Type A cells carry type A glycoproteins and type B cells carry type B glycoproteins. Type AB cells have a mixture of both A and B glycoproteins. Type O cells have neither.

"Humans also naturally have antibodies to the glycoproteins their own cells lack. These antibodies are responsible for causing serious (and sometimes fatal) reactions when they attack their targets. Since people with type A cells have antibodies to type B glycoproteins, a donor with type B blood is not compatible with a type A recipient. Similarly, those with type B cells have antibodies to type A glycoproteins, indicating a type A donor is not compatible with a type B recipient. Individuals with type AB cells lack antibodies to these glycoproteins and are therefore compatible with any potential donors (with regard to blood type matching). Those with type O have antibodies against both type A and type B cells and therefore require type O kidney donors. Thus, the person with blood type AB is the universal kidney recipient and the person with blood type O is the universal kidney donor.

"The other factor, called the RH factor, adds a plus or minus to the blood type letter. This factor relates only to a particular cell type in the blood, is not part of the kidney and is not important in kidney matching.

(ii) "Tissue Matching[:] * * * A six-antigen match (both people have the same set of six antigens) is the best compatibility between a donor recipient pair who is not identical twins. This match occurs 25 percent of the time between siblings having the same mother and father and also occurs from time-to-time in the general population.


(f) Tissue Typing for Kidney Donation. Great Ormond Street Hospital for Children, undated.
http://www.gosh.nhs.uk/medical-c ... or-kidney-donation/

Quote:

"If the child [patient] is lucky enough to receive a full house 6-antigen matched kidney from a deceased donor, then this is the only match that does as well as a kidney from a parent, even though the parent may only have three numbers in common with their child. This is because the parent may have other things in common that we do not match for or even understand. It is also because the kidney is taken from the parent and very rapidly transferred into the child, with very little wait in between.

"Another reason why we prefer well-matched kidneys is that if your child meets with an HLA number that they do not have, they make an antibody to it. This means that if the transplant fails, they cannot be given that number again. This makes it more difficult to find a transplant for them the second time.


(g)

HLA Matching for Hematopoietic Cell Transplantation. National Marrow Donor Program (NMDP), undated.
http://marrow.org/Physicians/Unr ... tching_for_BMT.aspx

Quote:

"The patient should be tested at high resolution at HLA-A, -B, -C, and -DRB1. It may also be useful to identify DRB3, DRB4, and DRB5, although the benefit of matching at these loci has not been evaluated. [7] A 2007 study of 3,857 unrelated donor transplants found that mismatches at HLA-DQ or HLA-DP did not affect survival. [6]

"The National Marrow Donor Program recommends that when possible, patients and adult donors (marrow or PBSC ["peripheral blood stem cell"]) should be fully matched (8 of 8 loci) at high resolution for HLA-A, -B, -C, and -DRB1. Matching for cord blood units is less stringent, and the NMDP recommends fully matched (6 of 6) CBUs ["cord blood units"] at HLA-A, -B (antigen level) and -DRB1 (allele level). [8-10]