As the local person it falls upon me to welcome you all.

What I want to talk about is a new way of transplanting people, whom hither to have been turned away and I have adopted St Sebastian as the patron St of this process. In this Christian medicine Sebastian was shot through with arrows and miraculously survived. Since Sebastian survived and the process of doing the transplant in this way, is a bit like exposing the transplant being shot through with arrows but it miraculously survives.

What are antibodies? Why do they matter? What is the anti body washing? How successful is it? How dangerous is it? When can you have it? When can I have it? Don’t hold your breath! Because whatever impression you may have got, at the moment health authorities are refusing to support it. Antibodies is part of our natural defence against infection. We have got thousands of different types of antibodies in each of us and each of them fights off a particular type of invader. We are all born with a wide range of antibodies to fight off infection, but if we see particular infections or particular invaders we produce an antibody response just against that. That’s why vaccination works, even the vaccine produces antibodies and it protects you in the future. That’s a good thing. Antibodies are very small you cannot actually take pictures of them.

There are two types of antibodies you can get that would react against a kidney transplant, which was put into you. One of them is if you have blood group antibodies, you may know you have different blood groups and you have to put a blood transfusion that is compatible into someone else. The reason for that is that for some combinations of blood groups you have antibodies against the red cells in the blood and it would mash up if you get an incompatible transfusion. The same chemicals are found on the transplanted kidney also. So when you do a kidney transplant, conventionally you have to follow the same rules as a blood transfusion. So that if for example; I’m blood type A and my blood group O partner wanted to give me a kidney, that would be prohibited, because my antibodies would kill off the transplant. You could also get antibodies against tissue types, many people who have had a previously failed transplant will have them, and pregnancy sometimes induces tissue type antibodies and they can be exacerbated if you have already got them by blood transfusions. It is quite a big problem, one in five people waiting for a transplant have got tissue type antibodies and that means if you are waiting for a kidney from someone who has died you just may not get one allocated to you because the antibodies will stop it. In addition about one hundred transplants a year in the UK from living donors are prohibited by antibodies. That’s on a background of about 450 living donor transplants and 1300 transplants from diseased donors each year.

There is another background to this, and if you want to bump up the transplant numbers from living donors it is not just a matter of doing these fancy transplants, this is the annual rate of kidney transplantation per million population in our centre here against the rest of the UK. Around the country if all the units got up to about this rate you would be doing another 2-3,400 living donor transplants a year in addition. There is a long way to go, both in terms of increasing living donor activity generally and also perhaps in a few units doing these specialised types of transplants I’ll tell you about.

What actually happens is the antibody washing is currently only suitable for people who have got living donors; some experimental or slightly different types of treatment are being assessed, for those without living donors trying to get transplants from deceased donors, but at the moment if you have not got a suitable living donor this is no good for you. What actually happens is that you select your donor recipient very carefully, the treatment is physically more stressful than having an uncomplicated transplant, so if you have a lot of medical complications sadly it may not be suitable and we have turned people away, because of their heart disease, or other problems. There is a long process of people understanding that they are putting themselves under stronger risks.

The laboratories are doing a lot of work, and then we develop a plan. What actually happens is that we do antibody-washing three or seven times before the transplant. You do lots of tests in the laboratory to measure antibody levels, and when the antibody levels are right down you do the transplant operation, which for the surgeons is the same as usual, but you give more powerful drugs to the person getting the transplant. The transplant donor has nothing else done to them that are different from any other type of transplant. So that the donor is not put at extra risk, apart from the psychological stress of knowing the whole thing is a bit more risky. Then after the transplant you do more antibody washing. There are several different machines you can use for antibody washing, this is a picture of one and there is one round the back in the trading stands area. Superficially it looks rather like a dialysis machine, it is just the filters here, one we use has got two filters on, a dialysis machine has only got one. The filters are made of different stuff, so that antibodies from the blood will pass out of the blood and can be thrown away and ultimately finish up in the rubbish bag at the bottom. When you do this two types of antibodies one called G and one call M as you can see those zig zag down over a series of treatments and when we have got the level right down somewhere there, you can do the transplant.

I do not want to be technical about this, but this shows one of the reasons why this can be a risk. These are the level of antibodies, one of our patients had over some years at about this level that had prohibited the transplant. Put the transplant in and there you go a week later and you are up to far, far high levels than they ever had before. So one of the issues with this is you’re taking people who have already been vaccinated against a transplant you are giving them, you put it in the body which is capable of making a really big response to try reject it. We can treat that in this one the antibody levels kept going up despite us trying to remove them every day. Though actually the antibodies against the transplant, which are these bottom lines, then went away on their own.

You can get rejection; these brown lines within this kidney tissue section are antibody sticking on the graft and were causing rejection there, were treated and were reversible. We do not fully understand why the transplants work actually, we can get rid of the transplant antibodies before the transplant, but after the transplant they either they do not come back, or sometimes they come back but don’t cause rejection. This is a very high intensity specialist treatment. There are only two centres in the UK that have done more than one, and there are only a couple of places that have actually done one. It isn’t something that every transplant unit should try and do.

Results. The simple way I put is that you are exposed to twice the normal death rate if you are the recipient, so the normal death rate probably about 1 in 100 and it goes up to 1 in 25, or 1 in 50 according to general level of fitness and health. Twice the transplant failure rate, so normally 1 in 20 would fail in the first year, this goes up to 1 in 10. Twice the risk of unusual complications, like infections or strain on the heart. Having said that, the other side of the coin is nine out of 10 transplants are successful. The death rate of one in 50 would mean that 49 people survive, people’s lives are transformed and in the UK I think 10 transplants from living donors have been done in last three or so years, and those transplants are all still functioning. A further transplant was tried in somebody who had a kidney from some deceased donor and was not successful and the recipient survived, so perhaps you could say the success rate in the UK is 10 out of 11.

Boy is there politics! These are all the various committees and so on we’ve gone to. Of the transplants currently performed or planned to be performed in the UK, none of them has been fully funded by the NHS and they are all done a bit on the side. All with the help of charitable funding. It probably costs about twice as much as a standard transplant, these are some of the treatments and fancy drugs you might get, but even if a transplant costs twice as much you save loads of money.

So in summary using this technique I think many more transplants could be performed, it is a risky and stressful treatment and currently only suitable with living donors. It should be offered into specialist centres, not in every transplant unit. It is still not established as an NHS treatment. Thank you for listening!



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