Rejecting Rejection

new hope for kidney transplant patients

In the "old days" – five years ago – an estimated 30 percent of U.S. patients needing a kidney transplant were turned down due to blood compatibility issues between the recipient and the donor.

"People die waiting for kidneys," said Stanley C. Jordan, MD, director of kidney transplantation and transplant immunology at Cedars-Sinai Medical Center.  "If you don’t get a kidney, you have to be on dialysis. And being on dialysis is not a good life."

The patients who surviving on dialysis while hoping for a matching donor became the inspiration behind Dr. Jordan’s 20 years of extensive research into various aspects of immunology and transplantation.

All people fit into one of four blood types: A, B, AB and O. Everyone is compatible with some blood types, but not all of them. If a recipient received a kidney from a donor in an incompatible group, the recipient’s body would reject the kidney. Therefore, if a patient and a donor were deemed to be ABO incompatible, the transplant was cancelled.

Dr. Jordan believed that if he could reduce a kidney recipient’s blood antibodies that would immediately  "attack" a transplanted kidney from a donor who was in an incompatible blood group, then he could offer dialysis patients a new chance at life.

In 1990 the first incompatible transplant was performed at Cedars-Sinai Medical Center after the patient was treated with intravenous immunoglobulin (IVIG) to help reduce antibodies that prevent transplantation. This treatment was successful and led to the development the Transplant Immunotherapy Progam at Cedars-Sinai. While leading two National Institutes of Health controlled clinical trials, Dr. Jordan realized that the addition of another treatment, plasmapheresis,  would make ABO incompatible transplantation possible.

Plasmapheresis removes the plasma portion of the blood. This is where the antibodies are that seek and destroy ABO incompatible organs. A person may have to undergo several sessions of plasmapheresis before surgery to bring the levels of antibodies down. After at the last plasmapheresis treatment, the kidney recipient receives an intravenous infusion of immune globulin to replace the antibodies the body needs to fight infections and to help prevent the harmful antibodies from returning.

When the recipient's antibodies against the donor's blood type have dropped to very low levels, the transplant can take place. The transplant recipient may have to undergo several more plasmapheresis and immune globulin treatments after the transplant.

"We can usually transplant 75 to 80 percent of the people we see," Jordan says, noting that about 20 percent of dialysis patients die every year. "I tell patients, 'If you have a donor, don't worry about the blood group issue' because now we have the techniques to allow transplantation."

Patients have journeyed to Jordan's office from as far away as Singapore and Australia for their transplant. Doctors from all over the world also come to learn how to perform incompatible transplants.

"The biggest problem in transplantation is that we know how to save lives, but we don’t have enough organs," Jordan says. "If we are able to widely implement ABO incompatible kidney transplants, we will add 1,500 to 2,000 new transplants a year."