Breaking the blood group barrier
Three and a half-year-old Pratyasha had been suffering from chronic kidney disease for the last three years. She was suffering from reflux nephropathy, which is a structural abnormality in the kidneys.
This refers to urine refluxing its way back to the kidneys instead of exiting the body through the bladder. Her parents and doctors were in a fix. “First of all, we did not have any blood group compatible donor for Pratyasha. Her parents’ blood group did not match hers’. Another thing to be kept in mind was the fitness of the donor. We could not find any fit donor for her,” says Dr Sidharth Sethi, Consultant, Pediatric Nephrology and Pediatric Renal Transplant at Medanta, The Medicity as he begins to outline the problems involved in treating the child. The options available to him included dialysis. However, as Dr Sethi bluntly informs, “carrying out dialysis with a three-year-old child whose kidney is permanently damaged is not feasible.” He explains this with the help of an example. “let’s take 100 kids into account and carry out long-term dialysis on all of them. After 10 years, only 10 out of 100 kids will survive.” The rest will not make it through due to dialysis and catheter complications that arise as a natural consequence of the children’s small bodies.
If not dialysis, then a kidney transplant could have been done through ‘swap.’ This time, the problem lay in finding willing donors. The doctors at Medanta could have exchanged the kidney with someone else’s from another family. An ABO incompatible transplant proved to be the only solution for Pratyasha. The breakthrough of this treatment is that Pratyasha has received a kidney from an incompatible donor. This was thought to be impossible. Traditionally, taking into account her blood group, the transplant could only have occurred with someone having blood group B or O. Medanta has proven that blood group is no longer a barrier for carrying out successful kidney transplants. The doctors decided to change the approach and in April, Pratyasha became the youngest girl to have undergone an ABO incompatible kidney transplant.
An ABO incompatible kidney transplant was previously considered impossible. But in the breakthrough that was achieved at Medanta, her mother with blood group A+ donated a kidney to Pratyusha who is B+. Before Pratyasha, Medanta had already done India’s first ABO incompatible kidney transplant on a 12-year-old boy in October 2014.
Dr Prasun Ghosh, Associate Director of Renal Transplantation, described Pratyasha as “immunologically challenged.” He describes the difficulty in connecting the blood vessels of her mother, an adult, with her own tiny renal arteries and veins. “This was surgically challenging to do.” Planning and execution are crucial when it come to carrying out transplant surgeries. Dr Ghosh elaborates, “With a transplant surgery, your first chance may be your patient’s last chance. You must give your best shot in your first attempt, because you might not get another attempt afterwards. To be sure of what you are doing is the essence of such a surgery. This is the basic principle that we were taught in medical college.”
The process begins, Dr Sethi says, with reducing the number of antibody-producing cells in Pratyasha’s body. After this, the antibodies have to be selectively removed from the patient’s body. Previously, this used to be done through plasmapheresis, which refers to the removal, treatment, and return or exchange of blood plasma or its components through blood circulation. It is performed outside the body. “This involved the risk of bleeding. Nowadays, however, an immunoadsorption column is used to serve the same purpose in a more efficient manner. Since the child’s blood group was A+, we had to remove anti-A antibodies,” he explains.
After spending six months in search of a fit, compatible donor Dr. Sethi chose to carry out an ABO incompatible transplant. This has a success rate of 95 per cent, with the greatest risk being hyperacute rejection. “Hyperacute rejection arises in the operation theatre itself whilst the surgery is going on. In this case, the patient’s body immediately rejects the new kidney.” Thankfully, this did not happen in Pratyasha’s case. Her body has accommodated the new kidney. It has been two and a half months since she is leading a normal life along with her parents.
The risk of hyperacute rejection is one per cent in normal compatible transplants, but five per cent in an incompatible transplant. “Rejection of the kidney does not mean death,” clarifies Dr Shyam Bansal, Associate Director, Kidney Institute, Medanta – The Medicity. “In the case of rejection, you can undergo a second transplant. Out of the 1,500 kidney transplants that Medanta has done, around 30-40 were done for the second time on the same patient.” One of the main reasons why kidneys fail even after transplants is because the patient stops taking regular medicine. After a transplant is done, the patient needs to take medicine regularly for the rest of his or her life. Failing to do so results in complications in the body.
From Orissa, Pratyasha’s father says that that his employer, Honda Motorcycle, had provided a lot of financial support for this cause. For quite some time, Pratyasha did not have an appetite. “She would not feel hungry and she wouldn’t eat food. This meant that she wasn’t growing properly. Then she began losing weight and when this became a serious issue we approached a local doctor, who recommended that we go to Apollo Hospital. From there, we went to Medanta in search of a solution for our daughter’s renal problem,” he says.