The Gift of Organ Donation

(bright pulsing electronic music) - This is Lab Medicine Rounds, a curated podcast for physicians, laboratory professionals, and students. I'm your host, Justin Kreuter, the Bow Tie Bandit of Blood, a transfusion medicine pathologist at Mayo Clinic.

Today, we're really fortunate, we're rounding with Dr. Medhat Askar, Director of Clinical Services for the National Marrow Donor Program, NMDP, Be the Match, here in Minneapolis, Minnesota, and Clinical Professor of Pathology and Laboratory Medicine at Texas A&M Health Science Center College of Medicine in Bryan, Texas.

Additionally, Dr. Askar is the Director of Transplant Immunology, COVID-19, and Facility Director for the Cell Processing Laboratory at Baylor University Medical Center in Dallas, Texas. He is also a Clinical Consultant for the Department of Laboratory Medicine Memorial Sloan Kettering Cancer Center in New York, New York, and the Head of Clinical Immunology Division, Department of Laboratory Medicine Pathology for Harvard Medical Corporation in Doha, Qatar.

In addition to all of these roles, Dr. Askar holds leadership roles for several committees and societies involved with histocompatibility, and so today, we're really fortunate to have Dr. Askar take us through this really important topic, which is fitting for the holiday season, right, transplantation, the ultimate gift that we all can give. So thanks for joining us today, Dr. Askar. - Thank you very much, Justin, for this very kind introduction.

- I know it was a little bit longer, but I mean, all the roles you have, I wanted to do it justice, plus for the audience to understand, you're really bringing a lot of expertise to the table.

- Thank you, I appreciate. - [Justin] So. - I'm glad to be here - As you get started in this, how did you get started in the field of histocompatibility? - It's very interesting. I'm still to meet someone who went to medical school on day one saying, "I wanna become histocompatibility specialist," it's just something we don't normally hear about in medical school.

And I initially started out like most people, very traditional specialty, I started residency in orthopedic surgery back in Egypt, and soon I realized that I want something more. I mean, I hope my surgical colleagues do not get offended, but something really more analytical, where you are confident 100% is that what you see is what you think it is, even if you have to repeat it 100 times.

And the only branch in medicine you can do this legitimately, you cannot cut the patient open different ways and see how that the cut was, did it work for the patient? But you can legitimately repeat testing until you are convinced that you have very accurate result, and that's really what attracted me to lab medicine. But within lab medicine, I wanted to do something very cutting edge and very innovative and also have a very high impact.

And these factors came together in transplant immunology, because especially when I started this in '95 in Egypt, there was hardly any transplant taking place in Egypt, but I was fascinated by it. Something very unique about transplantation, it has such profound impact on patient's life.

Patient come in cardiogenic shock, like they're almost dead, and two years later, they are playing tennis, like which specialty you would have to see this. - That's fascinating. So was that a mentor that helped you find this new role and pathway, or was there a particular patient that you took care of that opened your eyes to these other possibilities in lab medicine? - No, I actually, I took a step back from what I was doing.

I realized that surgery is probably not right for me, and I needed to figure out something else, and by research and talking to people, but I also had influential transplant immunology mentors that I gravitated to. - Wow, this is fascinating.

I wanna make sure that the listeners, for certainly the students that are listening, those of us that may mentor students or just all of us in our careers, to learn from what we're hearing from Dr. Askar, you might start down one pathway, and sometimes, you wanna hit pause, take a step back, really might be the right step forward. I think there's a lotta momentum sometimes, that students feel a little bit of pressure to not be able to hit pause and examine. - Don't let me get started.

I mean, I was laughing stock for my friends, who were training in orthopedic surgery, cardiothoracic surgery, neurosurgery, and they just kept looking at me, why you are wasting your education, when you gonna stop this nonsense and train in a real specialty, and things of that nature. - And here I am, also as a histocompatibility person,

that sees how you're really shaping this society and shaping how transplantation occurs in our world today. This kinda leads me to my next question, which is, transplantation, I think, is, on some levels, may be easy for people to understand, but on other levels, it's quite complex, and it certainly is a big team effort.

And so I'm curious, since we have a broad audience, what are a few things that you think healthcare professionals in general, laboratory professionals, clinicians/students, should understand about organ transplantation? - I would say, it is really the most altruistic form of human nature to give someone parts of you. It's really, there isn't anything like that, so it involves a lot of ethics, a lot of higher thinking, a lot of system thinking and societal thinking.

And also, there is this fact that we have organ shortage worldwide, so we are stewards of a very scarce resource. So every patient you give a transplant, you are taking it away from somebody else, so it's really how you make the balance between serving the patient you are looking at, but keeping in mind the wellbeing of the entire society. Not many branches of medicine have this intellectual part.

There is also, as you mentioned, it is probably the most interdisciplinary, and it is, you have so many specialties, medicine and pharmacy and even dentistry. Patients need to get clearance from dentistry to make sure that they don't develop problems with that. It affects everyone, so we talked about having a new life, so probably obstetrics colleagues have that, but they have it for a very limited subset, for women and childbearing age.

But anyone can be recipient of transplant, even one year old, 70 year old, men, women, everyone, so it's really fascinating field to be in. - One of the things in your answer that makes me, that kind of resonates with me is this concept of,

I think a lotta times in healthcare, we're thinking about the, you know, at Mayo Clinic, "The needs of the patient come first," is our motto. We're always thinking about the patient that is in front of us, and I'm certain that early in your surgical career, there's a lot of focus on, this is the patient in front of us. This is the correct decision to make for this patient. But like you're saying, when you're talking about organ transplant, it gets more complex.

I think for a lotta people maybe a little, I mean, ethics might be something that is intuitive as a challenge that comes in with transplant, but just to talk about thinking about it in terms of a systems way of thinking, that might be a little bit novel for some of our listeners to think about.

Can you maybe elaborate about, maybe for you as somebody, who was practicing first in orthopedic surgery and then making this transition to systems thinking, what has that been like, and how do you navigate that now? - Yeah, I mean like in surgery, the best solution for the patient is naturally is gonna be the best solution for the society.

You want your patients, whatever intervention you're gonna do them to help them, reconstruction or whatever to make them more functional, is what is gonna help with the society. Of course, there are challenges in terms of cost and whatnot, but in organ transplantation,

when we had a 70 year old man who needs a second heart transplant, see, the levels of complexity, and by giving, so for this patient, this is the only life saving option, but you are taking it away from a 20 year old young man, who never received that transplant before, and so what's best for this patient might not be what's best for the entire society as a whole. - Wow, what a fascinating area of practice.

Maybe now I was wondering, if we could kind of like pull back the curtain a little bit for our listeners, and can you talk a little bit about how does the laboratory and histocompatibility, how does it actually support organ transplantation? You mentioned a lot of the complexity and a lot of the interdisciplinary. How about in the laboratory? What kind of work happens behind the scene that enables this transplant to be as successful as possible? - Yeah, so the lab function.

Actually, it's interesting. I'm actually overseas giving, just to give a talk this morning about how lab can support solid organ transplant, so this is the subject of the talk I give. And we really need to keep in mind that, this is something I always tell medical students who are thinking about careers, tell them that transplantation is the most sophisticated way of doing medicine. So, imagine how infectious disease doctors struggle with multi-drug resistant microorganism.

Imagine the level of complexity in giving this for a patient under immunosuppression. So it is just everything we do in transplantation is way more complex than what you do for non-transplant patient.

And keeping that in mind, we do a series of tests for determining the type of tissues of the patient, and the categorically, we try to do tests to help us determine how to avoid unacceptable mismatches, like differences in tissues between the donor and the recipient, that is gonna elicit either immediate or very short term complication, such as hyperacute rejection. If you have very high level of donor specific antibodies,

those can lead to hyperacute rejection, and there is also the next layer once we do that is to maximize compatibility, to get the closer tissues, and that will help us in mid range and long term outcomes. The closer the nature of the tissues of the donor and recipient, the better survival advantage you get.

So that's at the like operational level, but there are also so many other things that the lab does in terms of communication and education for interdisciplinary teams and helping them interpret our test results and how to apply it in different clinical contexts.

- So, that's kind of, maybe you could for our listeners, you're talking a lot about how we're determining compatibility, and that's really in this, I think about that, maybe our listeners are thinking about that in kinda the acute phase of when a transplant decision is made to proceed. Is the laboratory involved with the care of the transplant patient beyond the acute transplant? What does that look like? - So,

historically, maybe a decade ago or so, it was the idea that we gonna do as much compatibility assessment at time of transplant, pre-transplant, in donor selection, and at time of transplant, and we did our best, and then we gonna hope that we're gonna manage the patient with immunosuppression. But actually, that turned out to be easier said than done, because these patients develop new immune responses to the grafts and really ongoing monitoring becomes necessity rather than commodity.

And actually, there are very exciting new tests developing for determining tissue injury of the graft, such as cell-free DNA and non-invasive liquid biopsy techniques, so there are a lot of developments that we need, like ongoing partnership between the lab and the clinical transplants team, to ensure that these transplanted organs last as long as they possibly can.

- That really dovetails into kinda my final question, which I'm sure all the listeners are really interested to hear, what do you predict is on the horizon for histocompatibility? - I think for the longest time and until now, we struggle with the organ shortage. There aren't enough organs to give to everyone who have end stage organ failure, and there are fundamental solutions

that are starting to emerge, that have been contemplated for the longest time, but now we are seeing them really emerging more into reality, such as xenotransplantation, which is using organs from animals because, at least hypothetically, you can mass produce them to satisfy all the needs. There is also the technology of gene editing, that facilitates transforming these organs from animals into a more acceptable immunologically format, if you may, for the immune system of the recipient.

There is also the area of bioengineering of organs from stem cells through 3D printing, so there are so many exciting things happening at this time, and hopefully, it will all help to address the problem of organ shortage. - Wow, that's fascinating. It really kinda highlights for our listeners just how dynamic this field is, right. You've mentioned several different ways and fronts that we're working on to improve organ transplantation.

Is there something, advice that you share, like when you have people say like, "How can I support organ transplantation?" Maybe they don't, people don't work in a histocompatibility laboratory, but how could the general public, how could somebody support organ transplantation? - I think understanding that we cannot have more organs than we need, and we really need to promote the concept of organ donation, however, both in deceased donor setting and in live donor settings.

And actually, a couple of our colleagues, as you know, actually donated their kidneys just to set example for people to follow. So if you are unable to donate an organ during your life, I think the minimum you do is to become a registered donor, when God forbid, the time comes.

And I think helping in, as much as possible, to educate the public and promote that how every deceased donor can save up to 8 lives and can impact up to 75 others, so there is just this exponential benefit to the society that can come from everyone contributing and increasing the awareness of the problem for organ transplantation.

- And just to clarify for the listeners, when you say 8 lives, that's 8 vital organs that are transplanted, and up to 75 people can be touched, that's tissues that can be donated. - Yes. - Phenomenal, so I think, that really kinda tops off why we're having this conversation, why this episode is our holiday episode. So thank you so much, Dr. Askar, for rounding with us and to talk about the ultimate gift of organ transplantation.

You certainly, this podcast episode, I think, serves to help educate people about transplantation, and hopefully, this encourages listeners to share this episode and also to promote registering as donors. - Thank you very much, Justin, it's a pleasure. - And to all of our listeners, thank you for joining us today. We invite you to share your thoughts and suggestions via email. Email them to [email protected]. And if you've enjoyed this podcast, please subscribe.

Until our next rounds together, we encourage you to continue to connect lab medicine and a clinical practice through insightful conversations. (bright pulsing electronic music)