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Saturday, January 8, 2011

Answering Two of the What Ifs--Rejection & Rejection

There are obviously a lot of "What Ifs" in this process that either friends have asked me, I have asked myself or I've had to answer to medical professionals within the screening process. Two of the more common "What Ifs" deal with rejection. Rejection is such a great word isn't it?

What if I am rejected from the program? This one was asked pretty consistently through the process, although more by the social workers and doctors I've seen along the way.  How would I feel if I was told I am not able to donate?  This one is actually a pretty easy answer. The screening process is there for a reason and it is 100% to protect me.  Other than a couple of extra vials of blood that will help with potential initial matching with recipients, all of the tests I have gone through are to make sure I am okay to go ahead with this. I was told at the beginning that there are perfectly healthy people who don't make it through because they aren't quiet healthy enough in a couple of categories (for example their kidneys work fine for them but the doctors aren't sure that one wold be enough if left on its own). So if I am told that I can't, I can't. Sure, it would be disappointing after all the preparation, testing, and thought that goes into a decision like this but in the long run I am safer if they need to say no.

The other big rejection "What If" relates to what I would feel if the recipient's body rejected my organ? At my very first appointment with the Living Donor program folks, it was put very bluntly. "Picture us taking out your kidney then throwing it out because that is essentially what could happen". Of course they don't want that to happen, but the reality is that it can. With kidneys, the rejection rate is under 10% but if you are one of those 10% the statistics don't matter all that much. Living organ donation does however have a lower rejection rate than transplants received from cadavers.

There are a few kinds of rejection. The first type, Hyperacute, occurs within minutes after the transplant and must be immediately removed to prevent severe harm to the patient. The good news is that with crossmatching tests, they are now able to better predict if rejection will occur. How does this work? Basically my blood and the recipients blood is mixed in a tube - if the white cells in one attack the other, it's not going to work out between us.

The second type is chronic rejection and it is much more common in transplants involving lungs and/or heart where there is significant rejection that causes irreversible damage and reduces function of the organ (say to 50%) but then stabilizes for an unknown period of time (could be months, could be years) after which another damage cycle occurs. The term chronic rejection is most commonly reserved for cases of transplant rejection where the rejection is due to a poorly understood chronic inflammatory and immune response against the transplanted tissue.

The third type is known most commonly as acute rejection. This can happen a week, months or years after the transplant. From what I have read, if you receive an organ from someone, you will face acute rejection in some form at some point (fun fact: this is less likely if you are an identical twin who received your organ from your twin). The trick is for it to be caught in time. In the past they had to rely on patient symptoms such as fatigue, pain, fever, significant weight gain each day to give them a hint there was acute rejection occurring. A biopsy (a chunk of the organ is taken out to be analyzed) is then done to confirm diagnosis and anti rejection drugs are altered to attempt to curb the rejection. Often by the time they got to this point the organ is already damaged. It has been a mix of science, guess work and hoping for the best because each patient can react differently to the drugs.  Not enough of the drugs leads to continued rejection and potential damage to the organ, a dosage too high also leads to potential organ failure. 

The good news is that in late 2010, scientists have developed a simple blood test that tests for proteins in the blood that are present even if there is the slightest bit of rejection beginning to occur.  They believe the test could be used to adjust the levels of immuno-suppressant drugs administered – increasing them only if rejection is imminent – thus minimizing side-effects. It could also potentially prompt doctors to conduct a biopsy only if necessary rather than doing a biopsy straight away, which would be much less invasive and not risk further damage to the organ. More research will show whether these test can predict an acute episode of rejection before any change in organ function. Pretty promising stuff.

I can cross all my fingers and toes and hope that if I donate, my recipient's body welcomes my kidney with open arms.  But the reality is there is nothing outside of the cross matching tests that I or the recipient can do to predict how the union will go. Because of this and being fully aware this is beyond my control, I am okay with whatever the outcome may be. Just like the first rejection "What If" , there would be disappointment. However the odds are in favour of it being a success and I have to hang on to that.

“For us, there is only the trying. The rest is not our business.” T.S. Eliot

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