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SU13.1-4 | Transplantation — PBL Case

CLINICAL SETTING

Mrs S, a 50-year-old woman with end-stage renal disease, has been on haemodialysis for two years and is deteriorating. She has three potential living donors who have come forward: her husband, her 22-year-old son, and a family friend who quietly tells the coordinator he 'really needs the money and would do it for a fee'. Work-up shows that the husband is ABO-incompatible with Mrs S, the son is a willing and healthy near relative with a favourable HLA match, and the friend is medically suitable but unrelated. The transplant team must work through which donation can lawfully and ethically proceed, what immunological hurdles each donor presents, and how the eventual recipient will be managed after transplantation. The coordinator asks the team: 'Who can donate, who cannot, and what do we tell each of them?'

Trigger 1: Matching the donors: who is immunologically suitable?

Three donors, three different immunological situations. The team must reason through ABO compatibility, HLA matching and cross-matching to decide which donor offers the best immunological prospect and what each mismatch would mean.

DISCUSSION POINTS

  • Why does the husband's ABO incompatibility matter, and what type of rejection would proceeding regardless risk?
  • Why is the son's favourable HLA match advantageous, and what role does the pre-transplant cross-match still play even with a good match?
  • What does the cross-match detect, and how does it relate to the risk of hyperacute rejection?
Click to reveal Trigger 2: Who may lawfully donate? Ethics and the law of organ donation (discuss previous trigger first!)

Trigger 2: Who may lawfully donate? Ethics and the law of organ donation

The friend has offered to donate for money. The son is a willing near relative. The team must apply the legal and ethical framework to decide which donations may proceed and which must be refused.

DISCUSSION POINTS

  • Under THOTA 1994 (amended 2011), how does the law treat near-relative donation (the son) versus unrelated donation (the friend), and why does the friend's offer of payment make his donation unlawful?
  • How do voluntariness and freedom from coercion (including financial coercion) protect the integrity of living donation?
  • What additional safeguards (e.g. authorisation-committee review) exist for unrelated or non-near-relative donation, and what is their purpose?
Click to reveal Trigger 3: After the transplant: immunosuppression and its price (discuss previous trigger first!)

Trigger 3: After the transplant: immunosuppression and its price

Assume the son donates successfully. The team must now plan Mrs S's immunosuppression and anticipate its consequences over the years that follow.

DISCUSSION POINTS

  • What standard triple-therapy regimen would Mrs S receive, and what is the mechanism of each class?
  • What is the central trade-off of lifelong immunosuppression, and which complications must Mrs S be monitored for?
  • If Mrs S later develops slowly rising creatinine over several years with graft fibrosis poorly responsive to treatment, which type of rejection is most likely, and how does it differ from an acute episode?

Group Task Assignments

  • Produce a decision table for the three donors (husband / son / friend) summarising immunological suitability and legal/ethical permissibility, with the reason for each verdict.
  • Draft a labelled comparison of the three immunosuppressive classes used in triple therapy, listing one drug, its mechanism and a key adverse effect for each.
  • Prepare a one-page summary of the THOTA safeguards that distinguish lawful living-related donation from prohibited commercial organ trade.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [SU13.1] How do ABO compatibility, HLA matching and the cross-match determine immunological suitability, and how do the three types of rejection differ in mechanism and time-course?
  2. [SU13.2] What are the classes of immunosuppressive drugs used in triple therapy, their mechanisms, and the trade-off between rejection prevention and the risks of infection and malignancy?
  3. [SU13.3] How does THOTA 1994 (amended 2011) regulate living-related and unrelated donation, and what safeguards prevent commercial trade in organs?
  4. [SU13.4] What ethical principles — voluntariness, freedom from coercion, and respect for autonomy — must govern counselling of potential living donors and their families?