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The Nasty Side of Organ Transplanting.

Chapter 19

Getting a Transplant

Many transplant hopefuls won’t admit it but they feel a peculiar tenseness on public holidays like Easter and Christmas. The screams of ambulance sirens on these days send bursts of hopeful energy through their sick bodies. Their success depends on a young man, usually a man, suffering catastrophic brain injury that leaves his 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 requires a failing vital organ but must retain enough strength to survive the waiting list, surgery and immunosuppression illnesses. For example, a patient may need a heart transplant but if he or she also has a bad liver this throws doubts on getting either. This is because the main anti-rejection drug, Cyclosporin, damages the liver and to withstand it a heart recipient needs initially a strong liver.

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. Fat is another exclusion factor as the drugs cause huge weight gains 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 Shouldn't Have Psychotic or Depressive Tendencies

Mental stability is crucial because organ recipients often become psychotic, bi-polar or depressive after a transplant. The shock of surgery, the drugs, chronic wound pain and faulty transplant organs are enough to send patients insane anyway so a predisposition to mental illness may exclude one 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 know the truth. 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 chronically 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 recipients need to maintain intake of anti-rejection drugs while observing them create new diseases like cancer tumours, diabetes and organ failures. Any disobedience to doctors' orders may allow the immune system to begin destroying the transplanted organ long before the patient senses it. Mental and physical stamina are required to undergo unpleasant 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 waiting or be taken off because other illnesses develop that lessen the ability to survive surgery. However, all is not doom or gloom. Some heart patients leave the waiting list when their health recovers or they undertake less drastic and more successful treatments.^[113]

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 previously transplanted material and pregnancies. When a patient is seeking a second organ the first transplant 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 donor. Therefore, the second transplant must come from a donor with a different Human Leukocyte Antigen (HLA) type to minimize the savagery of the immune system reaction.

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. This can prove a severe impediment to a successful transplant if the hospital is unable to track down details of previous blood transfusions especially if the patient has received dozens of them.

The Mother’s Immune System Tries To Kill the Growing Child

A woman’s immune system tries to kill her unborn child because it experiences the embryo as a malignant tumor. The embryo (or foetus) disables this attack and the mother’s body accepts the child as part of herself, but not before her immune system permanently records the baby’s HLA and blood type as an enemy to be attacked in the future. Transplant technicians therefore need to identify the blood and HLA types of all previous pregnancies of female organ recipients.

This shows the importance of identifying previously transplanted material, pregnancies and blood transfusions. Transplanting body material familiar to the recipient’s immune system could trigger an instant and deadly antibody attack of a ferocity usually reserved for xeno or animal tissue transplants.

The next matching process is blood compatibility. Transplanting may require huge amounts of transfused blood. Those lucky enough to have AB blood can accept all blood groups. A person with A blood can receive from A and O blood groups only. A person with B blood can receive from B and O donors while someone with O blood can get blood from an O donor only. 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.

Your Waiting Ticket

Doctors assign a Percent Reactive Antibody number and those with a lower reaction to other humans' body materials will better accept a wider range of donated material. These people may jump the queue though many other factors come into play.

Moving up the Waiting List

Younger patients get priority because they're more able to survive surgery. They'll also live longer if their body accepts the organ. Why sew scarce organs into some old dear who is approaching death, anyway. This is the cruel truth.

Being Close To the Donor’s Hospital Is an Advantage

When three patients have equal seniority the one closest to the organ donor’s hospital will win, as distance between donor and recipient is crucial. Chilled hearts last about six hours out of the body so even a three-hour flight between cities, plus courier times to and from the airport, may be too long. Heart transplant failure rates increase 6% for every hour a cold and paralysed heart sits in the picnic container. A patient in the same hospital as the dying donor has an almost insurmountable lead over similarly matched people in other states.

Avoid Debtor Hospitals

A debtor hospital has received more organs than it has given and must repay the debt. If your hospital or state has been sending its organs interstate then eventually the reverse comes into play. This means that if you and a patient in a debtor hospital have equal priority then you win, and vice versa.

Time on the list is a determinant. The longer you've been there the better your chances unless you’ve lost strength while waiting. In that case you're booted off the list.

Suddenly Deteriorating Health May Be Advantageous

The patient next in line may miss out if another patient begins dying quickly and is given higher category priority. That person grabs your donor’s heart and you're waiting for the next car smash. But if a patient ahead of you becomes too ill to undergo surgery, or simply dies, or gets a cold that precludes surgery for two weeks then you jump in laughing, though not too loudly. 

The Waiting List May Be Harsher Than the Transplant

Getting to the top of the waiting list may involve years of having one’s hopes crushed repeatedly. It may wreck what is left of your life and you might fail to make it to surgery, anyway. Dr J.A. Roberts, of the Royal Hampshire County Hospital in the United Kingdom, said that patients’ lives could be destroyed by the emotional turmoil of waiting for a transplant, not knowing whether it will happen.

This isn’t a joke because even someone dying over a period of years can have positive inner and outer experiences. Undergoing waiting list anxiety can destroy that stability and then the transplant may fail and the patient die, anyway. Was the process worth it?

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”. Two recipients are ahead of you. The first is undergoing theatre preparation at the hospital.

This is mind-breaking tension and you may find yourself hoping those ahead of you die suddenly or develop minor infections that temporarily preclude them from surgery. During pre-transplant immunosuppression, or after the graft, a minor infection can become a deadly illness and kill the patient.

A further problem may arise if a famous television celebrity or Bill Gates wants that same organ.

Finally, the good word arrives. The other two have dropped out for unspecified reasons. You're in the ambulance heading for the hospital. A fourth patient comes on line who hopes you'll be precluded from surgery.

Final Donor Organ Disease Checks

The donor is declared brain dead and moved to the surgery table but even now last minute disease checks continue. Did the donor recently work as a prostitute; if male has he had any homosexual activity since 1976? Donors can't have HIV-AIDS, evidence of prion diseases or other infectious agents. An exception is some nations approving donors with certain cancers and hepatitis conditions. The Americans are especially desperate to obtain organs though cancer usually precludes organ donating.

Ex-Organ or Human Growth Hormone Recipients Can’t Be Donors

Previous transplant recipients cannot donate organs because the immunosuppression they've experienced has filled their bodies with powerful and diabolical diseases. Those having received Human Growth Hormone injections from pituitary glands taken from corpses preclude them from donating due to Creutzfeldt-Jakob (CJD) prion infection fears. Potential donors having lived in Great Britain for more than six months between 1988 and 1996 may be excluded in some jurisdictions due to Mad Cow Disease. Mad Cow prion diseases have incubation periods extending to fifty years.

Size Does Count

Transplants have been cancelled due to the shocking discovery that the donor’s heart was too big. Donor organ size must be compatible with the recipient’s organ size. Harvest organs are checked for abnormalities such as tumours. Small ones are cut off livers but if large or extensive the organ is rejected. Other harvest table nightmares include discovering the car smash that injured the donor’s brain has also damaged the organs. Or the bullets that killed the donor have also pierced an organ. Surgeons might also ruin organs during 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 the minority. The majority fail to make the waiting list though on the positive side up to 9% are removed from the heart list because their health improves.

Preparation at the hospital involves paralysing and anaesthetising the patient similarly to the donor and hopefully the roles won't be confused. Surgeons won't remove the recipient’s failing organ until they see and confirm the health of the harvest organ. They take this precaution in case the plane or car carrying the organ crashes or it may arrive spoiled or defective. An exception is when the patient is about to die anyway and the donor is in the same hospital.

Kidney transplants are easier. The recipient’s failing kidneys are usually left in the body unless cancerous because removing even a failing kidney can cause heaps of new surgical problems. The new kidney is placed into the abdomen then connected from there to the renal system.

Inserting a third kidney into the abdomen is such a smooth operation that a recipient may be discharged from hospital before a living donor is released. Surgeons cut through muscle tissue and even saw off part of a rib to remove a living donor’s kidney, far different than a relatively gentle insertion of the donor kidney into the recipient’s abdomen. The living donor may suffer a collapsed lung and have a drain pipe inserted to help with re-expansion. Donating a kidney is no simple matter and the donor is left with a permanent body defect.^{[114], [115]} Laparoscopic or keyhole surgery avoids savage cutting and sawing and the kidney is squeezed out through a little hole. This apparently gentler method has dangers of kidney damage during removal and damage to the donor’s ureter. The technique is far from perfected and very few surgeons perform this procedure well.

Living liver section donors suffer far more 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 liver section donors even die.

When the organ or part thereof has been excised it is then 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 difficult, 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.Nurses have reported being metaphorically “up to their knees in blood.”

Blood is now conserved by catching it in a trough, cleaning it and pumping it back into 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.^[116]

Denton Cooley ranks along with Christiaan Barnard and Norman Shumway as one of the world’s greatest transplant surgeons. He has performed numerous transplants without blood transfusion and is, predicably, a favourite 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 slips into a coma, suffers brain damage then dies. Even surviving can feel like losing. Mark Dowie has described the process 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.”^[117]

Politics and surgery

British transplant survival rates are higher than American rates because they 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 received another blow. After two years of psychological agony while waiting for the transplant a doctor then told her she was too sick for a transplant and that putting 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 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.”^[118]

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. These animal livers 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 flesh rots 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° Fahrenheit, which slows the metabolism, reduces its need for oxygen and slows the onset of brain damage. An anaesthetised and chilled body has a slowed metabolism which helps prevent both rotting and reacting to the knife. The anaesthetist is the theatre “stage-master” poisoning the patient to the edge of death but still alive.

Surgical procedures have improved since Washkansky’s 1967 transplant but surgeons still can't avoid the fundamentals of transplanting. 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. An excised 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 when running a pump dry.

A transplanted heart requires a jolt of Direct Current electricity to get it beating, just like Frankenstein’s monster. The present day process is more reliable than during Washkansky’s time because heart harvesting now begins while the organ is still beating inside the donor. Previously, hearts removed after the donor had died wouldn't always restart or would not beat properly because of damage sustained during the lengthy dying process.

Patients with Two Beating Hearts

In the early days some surgeons averted the risk of patient death by leaving the old heart inside. This was called the “piggy back” transplant procedure - where the diseased heart was left in situ, in parallel, to do what it could. Relieved of the total load, it might recover - as happens nowadays with the LV assist device idea.

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, another man had lived 17 years with two hearts.

What If The New Organ Doesn’t Work?

The reader might be wondering what happens on the operating table when a transplanted lung, heart or liver fails to function. Couldn’t the patient continue living until another organ is located?

Theoretically, this is possible but the cost of keeping patients alive for weeks or months on heart and lung machines, or by 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.

It isn’t worth the trouble so when a transplant of this sort has obviously failed theatre staff may turn off the patient’s oxygen then stand quietly without speaking for a few minutes until death. This is cheaper, less degrading and less painful for the patient, and a form of euthanasia.

However, those buying Chinese organs get a special deal: if the transplanted organ fails the Chinese offer a replacement guarantee within one week. No problem for them: they have heaps of “donors” waiting to be chopped up.

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 fluid drainage and cleansing.

The Transplanted Heart

Heart surgeons face similar problems and can re-connect the major blood vessels and nerve endings only. The loss of these subtle nerve attachments mean the transplanted heart won’t initially beat at appropriate speeds and the patient may require a pacemaker.

A normal heart increases beats to meet higher energy demands but when an organ recipient stands up the transplanted heart fails to speed up 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 from the brain to the transplanted lungs and heart though this explanation remains a theory.

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-owned hearts is their rapid deterioration. Coronary arteriosclerosis appears in 90% of transplanted hearts within five years. Those with their own original hearts receive by-pass surgery to remedy this problem but those with transplanted hearts can't get this procedure. They may even require another heart, if one is available. This is called a re-transplant and the survival rate is lower than for the first transplant.^[119]

Long Term Recovery

Neurotics and hypochondriacs may find their transplant a dream come true. Illnesses and deadly diseases will spring up like mushrooms after a warm damp night. They will require a constant series of antibiotics and other drugs to fight germs the suppressed immune system can no longer battle. The patient’s infection fighting capabilities will be too compromised to share coffee cups and it will be wise to avoid public toilets or those with colds. The organ recipient should not eat raw eggs, uncooked dough or lightly cooked meat. A scratch from working in the garden might easily turn into the patient’s last infection on this earth. But at least doctors and friends will no longer deride the patient or laugh at new ailments because they'll be real and hypochondria a survival tool keeping the person alive.

Organ recipients can expect new illnesses like high blood pressure, diabetes and even cancer that will pop up from nowhere. Rejection will be a huge worry and the whole family can spend hours playing ’spot the rejection symptom' before it becomes overt and it’s too late to save the organ. The recipient should also like pain as there will be considerable physical and mental anguish.

The Surgical Procedure for Bone Marrow Replacement

Millions of people are waiting to become living bone marrow donors. The chosen few are admitted to hospital for removal of approximately half a litre of bone marrow from their pelvic bones. Recuperation entails a week in hospital and longer if infection develops from the needle pushing outer flesh into the bone itself.

The difficulty is finding a donor with the most identical marrow to the leukaemia-suffering recipient. The donor, once found, signs a contract agreeing to donate marrow within one week. 

Doctors prepare the recipient by injecting poison drugs and irradiating bone marrow inside his or her bones. This kills the bone marrow and the patient will die in one week unless the donor fulfils the contract. The donor can theoretically murder the recipient and get away with it however the injected marrow is more often the culprit. It hates the recipient and its anti-bodies may rise up in what is called graft-versus-host disease and this kills its new host. 

Another problem is the patient’s cancerous bone marrow cells surviving the irradiation. It takes just a few surviving cells to recolonise the donor marrow and the patient is back to square one. It’s a war and transplant recipients face a day-to-day struggle where life is never again assured.

Inga Clendinnen describes it eloquently 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.”^[120]

Transplant organ prices in the United States and China

Transplant prices in the United States in US$ 1996
Organ To Be Transplanted	Cost To Transplant	Annual Maintenance Charge in United States (UNOS) 1996
Heart	253,200	21,200
Liver	314,500	21,900
Kidney	116,100	15,900
Pancreas	125,800	6,900
Heart-Lung	271,400	25,100
Lung	265,900	25,100
Kidney-Pancreas	141,300	16,900

China transplant prices using organs from criminals and dissidents 2006. [121] Prices in U.S dollars. Annual Maintenance costs are based on postoperative care in the United States.
Organ To Be Transplanted	Cost of Transplant in China (2006)	Annual Maintenance in United States (UNOS) 1996
Heart	130,000 to 160,000	21,200
Liver	98,000 to 130,000	21,900
Kidney and Pancreas	150,000	16,900
Liver and Kidney	160,000 to 180,000	N/A
Kidney	62,000	15,900
Lung	150,000 to 170,000	25,100
Cornea	30,000	N/A

Another more current source quotes, “… transplant in the United States costs between 250,000 to 800,000 dollars, depending on the type of organ).^[122]

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