Part 3 (1/2)
It was customary for one of them to come from Yos.h.i.+zumi's hospital, partly because it handled coordination duties. His hospital's two most highly compatible patients were summoned for tests, and the more suitable one ultimately underwent the operation. If it looked like there were no viable candidates in the local region at all, they would search via the national hub of kidney transplants, Sakura National Hospital in Chiba, to s.h.i.+p the kidneys to some other part of the country. When the transportation of the organ could not be executed swiftly, however, chances were that the kidney would not take. The organ lost its freshness and weakened if it took too long to s.h.i.+p. It wasn't without reason that recipients were selected first by region.
Yos.h.i.+zumi cradled the receiver on his shoulder and began typing. The coordinator's data appeared on screen: a list of prospective recipients, ranked from highest to lowest by compatibility. He scrolled down, briefly surveying the entire list.
”Number 1, Mariko Anzai, and Number 2, Matsuzo Iwata, are the prospective candidates. Ms. Anzai will be under your care.”
Yos.h.i.+zumi had heard that name somewhere before. He wrinkled his forehead, then gasped in surprise. After taking a moment to collect himself, he scrolled up and peered closely at Number 1. Mariko Anzai. Yes, he knew that name. She was 14 years old and had already had one transplant, at the CCH transplantation division. Yos.h.i.+zumi looked at Mariko's HLA type. It was consistent with the donor's. Zero mismatches.
Mariko Anzai.
There was no mistaking it now.
It was the same girl Yos.h.i.+zumi had operated on two years before.
She had received her father's kidney, but the transpalnt had failed. The operation itself was a success, and no serious rejection symptoms had appeared. Yet, the kidney did not a.s.similate with her body and finally had to be extracted. Yos.h.i.+zumi bit his lower lip. He had much to regret about the case.
HLA, or Human Leukocyte Antigen, is a genetic marker found on the surface of human cells. The HLA of pathogenic cells differs from one's own. When illness attacks, unrecognized HLA types are regarded as intruders and subse- quendy destroyed as a natural immune system response. Because HLA is also found on the surface of transplanted organ cells, the organ is incompatible whenever its antigen type differs from the recipient's. For this reason, transplants between people of similar HLA types are preferred. Only, unlike the simple ABO blood types, HLA types are quite complex. There are six cla.s.ses of HLA: , , C, DR, DQ, and DP, and each encompa.s.ses ten or more subcla.s.ses. In transplant medicine, the most advanced a.n.a.lysis compares A, B, and DR types. Each of these three antigen cla.s.ses is inherited, one from each parent. In other words, three cla.s.ses and six pairs of antigens can be a.n.a.lyzed. The abundance of antigen cla.s.ses, however, was a troublesome factor. Finding a donor with a sixfold match was not easy. Even between siblings, the chances of full compatibility were only one in four, and the probability of perfect compatibility with someone outside of the family was less than one in ten thousand. Because of this, many transplants were performed despite one or even two mismatches. This, however, meant that the organ had a higher chance of being rejected.
In Anzai's case, the transplant had taken place between father and daughter, and tissue compatibility was high. It should have been a successful transplant. Yet, it failed, and the reason was that Yos.h.i.+zumi and his team had failed to gain the trust of Mariko Anzai.
Yos.h.i.+zumi breathed in deeply. He gazed upon Mariko's name at the top of the display and pressed his fingertips around his temples to interrupt the unpleasant memories bubbling up in his head. He told himself to concentrate on the work at hand and spoke to Odagiri, who was waiting patiently.
”So Mariko Anzai has no mismatches.”
”Correct,” she replied. ”There are no other donors in this area with such perfect compatibility. Please take some time to review the data.”
It was true. None with just one mismatch, either. There were, however, five candidates with two mismatches. One of them, the third name on the list, had been selected as the other candidate for this donor's kidneys. He was 51 years old, had a five-year dialysis history, and was currently under care in a neighboring prefecture. A woman who was number 2 on the list couldn't be reached.
An estimated 20,000 people in all of j.a.pan were registered for kidney transplants. Yet, within that group, the annual number who actually received organs hovered at around 200.
Then there were the dialysis patients, who numbered 120,000 nationwide. The consideration awarded to transplants for patients with chronic renal failure was too small. Compared to Europe and America, j.a.pan was known for having an extremely high dialysis patient-to-transplant operation ratio. By no means did this indicate that j.a.pan's medical techniques were behind the times. Instead, it was public unease about regarding brain death as actual death that was the primary source of hesitation, for doctors and patients alike, to promote such procedures. Praying for a new kidney, patients were forced to deal with a long life of dialysis, a process both physically and financially straining, while those fortunate enough to receive a kidney were able to enjoy a normal social life.
”One more thing. Just in case candidate Number 1 can't accept the kidney, it's been decided that Number 5 will also come to the hospital for testing,” said Odagiri. ”She is 36 years old with two mismatches and a three-and-a-half year dialysis history.”
”Got it.”
He printed out the charts for the two main candidates. In the instance that Mariko had contracted some serious illness, the 36 year-old woman would take her place on the selection ladder, Yos.h.i.+zumi compared schedules with the coordinator and solidified their arrangements.
He was to perform the extraction first, at the university hospital. He would then pa.s.s one of the kidneys along to Odagiri, who would then s.h.i.+p it to the neighboring prefecture, while Yos.h.i.+zumi brought the other to the CCH to conduct an immediate transplant. Odagiri planned everything in great detail. Time between the extraction and the transplant was critical. Once the donor's heart stopped they would be running on a tight schedule. It was the coordinator's responsibility to make sure all the surgeons, a.s.sistants, nurses, and recipients were on the same page.
When all preliminaries had been exhausted, Yos.h.i.+zumi thanked her and hung up. It seemed that Yos.h.i.+zumi's chance at self-redemption had come at last. Mariko Anzai. I'll save the kid if it's the last thing I do.
Just two days after the consent forms were signed, Kiyomi's heart rate began its inevitable decline. Her breathing maintained a certain regularity, if only through the respirator. However, her body's faculties were finally reaching their limits. Her vital signs were falling.
”We've arranged for the transplantation unit from the City Central Hospital to come here this evening,” the doctor said to Tos.h.i.+aki. ”Once Kiyomi's heart stops, we'll need to extract her kidneys promptly. We need to prepare her femoral artery beforehand. For this purpose, we'll be conducting a simple operation tonight. After her heart stops, a cannula will be inserted into the artery to cool her kidneys.”
The securing of the arteries was soon completed. When Tos.h.i.+aki returned to the ICU, he saw that Kiyomi's thigh was marked for insertion of the cannula. Her medication had been stopped, but her blood pressure remained steady, wavering around 100. The doctor explained they would likely need to wait until morning. And Kiyomi's warmth will last only just as long, thought Tos.h.i.+aki absently. Moment by moment, her body was changing into a mere object for donation. Unable to shake the reality of it from his mind, Tos.h.i.+aki spent the night at his wife's bedside.
At 10 pm the nurse came in as usual. She emptied Kiyomi's bed pan, swabbed her nostrils and the inside of her mouth, wiped the perspiration from her back with a towel, and changed her body position to prevent bed sores. She did all of this without the faintest sign of annoyance. In fact, she sometimes cast a sympathetic smile at Tos.h.i.+aki as she worked.
Tos.h.i.+aki had never been seriously ill. He had, of course, spoken with many medical pract.i.tioners throughout his career, but realized that he knew nothing, until now, of the actual work that doctors and nurses did.
”I'm truly grateful, ”Tos.h.i.+aki said, bowing his head. ”I think Kiyomi is, too, for all you've done for her.”
The nurse stopped what she was doing and said, smiling, ”I'm happy to hear that. I'm sorry we weren't able to help her.”
”It's okay,” he countered, flushed. ”You did everything you could. All of you.”
The nurse's smile turned ambiguous. She looked away from him as she resumed her duties.
”Working in the ICU, sometimes I just don't know,” she said timidly, almost to herself.
”You can give your all to the patients. They still die almost every day. What are we doing here? It's just too depressing sometimes. ICU nurses quit much faster than in other departments. Still..Her words cut off there as she finished with the cleaning. She put Kiyomi's clothing back on and turned around to face Tos.h.i.+aki, hands at her sides, r ”When people say nice things to you, it makes you want to go on.”
With that, she exited the ICU.
9.
Kiyomi remained in quiet stasis until morning. Soon after the minute hand ticked past noon, her blood pressure began to drop rapidly. By 1:00 pm it had fallen below 95 and, an hour later, was below 80. The ICU soon became a swarm of doctors and nurses as they bustled in and out, driving Tos.h.i.+aki and his father- in-law into the corner of the room. It was such a marked contrast to the quiet that followed the brain-death examination.
”The CCH transplant team will be arriving at two thirty,” said one of the doctors, looking at his wrist watch. ”They'll start by inserting a catheter. The extraction will begin once she loses her pulse.”
”May we be present when she pa.s.ses on?”
The doctor nodded.
”You'll have five minutes to say your farewells, after which Kiyomi will be brought to the OR.”
The hissing of the respirator was inaudible in all the commotion. Kiyomi's blood pressure was now down to 75.
Yos.h.i.+zumi, accompanied by Odagiri and two staff members, entered the university hospital. They brought with them a minimal, but essential array of surgical equipment and perfusion containers for Kiyomi's kidneys. This being a university hospital, there was plenty of technology at their disposal, but Yos.h.i.+zumi never forgot to have his own by his side for an extraction. Because speed was so imperative, it only made sense to use his own familiar tools.
After exchanging greetings with the hospital staff, Yos.h.i.+zumi left Odagiri in the waiting room and went into the ICU to check on the donor. Her blood pressure was nearing 65 and her heart rate was down to 30 beats per minute. Once her blood pressure fell below 50, circulation would no longer be complete, and cells in her extremities would begin to decay. Since the donor's family had consented to the procedure, the catheter was going to be inserted into her femoral artery now so that they would be ready when the pressure fell below SO. The head doctor showed the donor's data to Yos.h.i.+zumi for confirmation. Odagiri was then informed via intercom that the catheter was being inserted.
Fifteen minutes later, Yos.h.i.+zumi and his a.s.sistants prepared the perfusion equipment.
They spread the donor's legs slightly and placed the machinery between her feet. One of the a.s.sistants soon began to adjust the equipment settings while another disinfected the area around her thighs, whereupon a silicon double balloon-tip catheter was readied. When sterilization was complete, Yos.h.i.+zumi looked at the donor, standing at her left side, and patiently confirmed that the femoral artery and vein were well secured. After a quick glance to see that his team was on full standby, he inserted the balloon-tip catheter into the donor.
He carefully advanced the catheter until the balloon arrived at the right spot. Yos.h.i.+zumi indicated his approval to the a.s.sistants with a single nod and told them exactly what to do.
They connected a perfusion pump to the end of the catheter. He then guided the catheter into the femoral vein and had it connected as well. All preparatory steps were now complete. Her blood pressure was at 62, and her heart rate had fallen further.
Yos.h.i.+zumi and his crew temporarily exited the ICU to wait it out. Noticing the family, he signaled for them to be let in and headed to the doctor's office. He hadn't met the family yet, and it was indeed his belief that he should keep a low profile with them. For the bereaved, a transplant surgeon was no better than a hyena s.n.a.t.c.hing away the body of a relative. He did plan to meet with them just once, before the actual operation, but it was the coordinator's task to intermediate between them. No need to risk upsetting the family.Yos.h.i.+zumi sipped some coffee in the office, reclined on the couch, and looked up at the ceiling.
Mariko Anzai's face came to him.
SHE sensed the change.