- Many patients have living kidney donors who are not a match to them because of blood group incompatibility or tissue incompatibility. They are otherwise able and willing donors. However, until recently, the only option for these patients in NJ was to wait 3 to 7 years for a compatible deceased donor kidney or to enter a living donor kidney exchange program.
- The Program for Incompatible Transplants offers some potential recipients the option to receive a living donor kidney from an incompatible donor. Depending on the type and degree of incompatibility, medical technology may be able to overcome those immune system responses that cause transplant rejection and possible loss of the transplant.
- Incompatible transplants are more complicated and a higher risk. A significant number of these transplants have been performed in the world with acceptable success rates.
- Potential patients must have exhausted the search for a compatible living donor and only then will an incompatible donor be considered. Recipients must understand the labor intensive nature of this type of transplant and make the commitment to extra visits, therapies, diagnostics tests and procedures required.
- Potential recipient and donors must complete all necessary medical and psychosocial evaluations and be deemed acceptable candidates.
- Insurance clearance will be required before treatment begins. Your insurance will be reviewed by the Financial Coordinator and will be discussed with you.
Types of Incompatible Transplants:
Blood Group Incompatible:
In the past, only certain blood groups could donate to each other.
||O or A
||O or B
||O or A or B or AB
Blood Group Incompatibility occurs when donor/recipient pairs have incompatible blood groups.
As part of our immune system, we have natural antibodies against different blood groups (blood group antibody). In some cases, it is now possible to decrease the blood group antibody to a safer level and proceed with the transplant procedure. If the initial level is too high, it may be impossible to reduce it to a safe level and the risk of transplant rejection and failure is too high to proceed safely. If the initial antibody level is acceptable and it is deemed possible to reduce it to a safe level for successful transplantation, you will meet with the transplant physician who will discuss the process of incompatible transplantation in detail.
Tissue Type Incompatibility:
Many times recipients and their donors are blood group compatible but the crossmatch or tissues (human leukocyte antigens – HLA) are incompatible. Crossmatching involves the mixing of the recipient and donor’s blood to see if the recipient has developed any antibodies to the donor’s tissues or HLA. If the crossmatch is positive, this means the recipient has developed antibodies against the donor’s HLA. These antibodies are formed when the patient has a previous exposure to another’s antigens: pregnancy, blood transfusion or a previous transplant. The antibody level can vary which determines if a transplant can take place. In the past a negative cross match was required for a transplant to take place. Now it is possible to remove many of the harmful antibodies prior to transplant.
How are Antibodies Removed and Prevented from Returning?
For both Blood Group Incompatible and Tissue Incompatible transplants, the therapy used to decrease the antibody levels is named plasma exchange (plasmapheresis) and a medication named intravenous immunoglobulin (IVIG). The number of treatments required is determined by the level of antibodies in the blood. Usually the treatments are done before and after the transplant. The antibody levels are monitored at certain intervals to make sure the treatment is working. If the initial antibody levels are very high, the risk of transplant rejection is too high and the transplant cannot be performed safely.
In both types of the incompatible transplants, there is a risk of the harmful antibodies returning. Plasmapheresis and IVIG will continue for several days after the transplant procedure to prevent this. The antibody levels in the blood will be monitored frequently and kidney biopsies will be routinely scheduled.
Several other immunosuppressive drugs will be given during and after the transplant procedure for the life of your kidney. These will be discussed in detail during the evaluation process. If rejection is suspected the recipient may need additional plasmapheresis treatments. Blood tests and a kidney biopsy will be done to determine if the rejection is due to the antibodies returning.
Plasma Exchange (also known as Plasmapheresis) and Intravenous Immunoglobulin (IVIG)
Plasma exchange removes a part of your blood called plasma. It is replaced with a solution such as albumin, saline or fresh frozen plasma. This treatment is performed in the hospital as an outpatient and takes approximately 2 hours to complete. You may require four to seven treatments to reduce the blood group antibody level. The plasma is removed because most of the antibodies in the body are found in it. After the treatment, you will also receive a medication called intravenous immunoglobulin (IVIG). This reduces the likelihood of antibodies that have been removed from reproducing themselves. Upon completion of each treatment, we will monitor your blood group antibody level. Usually, after the fourth treatment, the blood group antibody level has been lowered to a safe level. If your level is low enough you will be able to be transplanted with your donor’s kidney.
For plasmapheresis to take place, there must be a way to remove and return the patient’s blood during the treatments. If the patient is on dialysis, he /she will already have a fistula, graft or Permacath. If the patient is not yet on dialysis, he/she will need to have a Permacath inserted. A Permacath is a special IV that is inserted into a large blood vessel in your neck or upper chest and is threaded into the right side of the heart. This is done as an outpatient hospital procedure. This catheter will remain in place until the treatments have been completed. This catheter insertion site is covered with a sterile dressing that cannot become wet so patients are advised to take baths instead of showers.
How Successful are Incompatible Transplants?
The current advances in medications and technology has now allowed transplantation between incompatible donors and recipients. Though still considered experimental, there is extensive experience in Japan and now in the United States in performing such transplants. Using the current treatment program, the published kidney transplant success exceeds 85 percent at one year. Tissue Incompatible transplant results exceed 80 percent at one year depending upon the type of incompatibility and, in certain groups, success rate is much higher.
What are the Requirements for Transplantation?
All potential willing donors for the patient must be evaluated. If no compatible donors are found, then any medically eligible incompatible donors will be considered. An incompatible transplant is more complicated and higher risk than a compatible transplant and requires increased time and effort on the part of the recipient and the transplant team. The patient and family must be agreeable and committed to the visits, therapies, diagnostics tests and procedures that this type of transplant requires
Many insurance companies cover all or most of the costs related to the incompatible transplant. Your insurance will be reviewed by the Financial Coordinator and she will discuss any direct costs or financial responsibilities that you may incur.
For more information or to discuss your eligibility for the Program for Incompatible Transplants, please contact Eleanor Simchera, RN, BSN, CNN, CCTC, at Saint Barnabas Medical Center at 973-322-2331 or Tatiana Alvarez, RN, BSN, CCTC at Newark Beth Israel Medical Center at 973-926-7262.
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