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(upbeat music)

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- This is Lab Medicine Rounds,

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a curated podcast for physicians,

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laboratory professionals and students.

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I'm your host, Justin Kreuter,

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the bow tie band and a
blood transfusion medicine

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pathologist at Mayo Clinic.

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As the temperatures turn cooler,

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and we've gotten some
snow here in Minnesota,

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we decided to travel south

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and connect with some of our colleagues

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at the other Mayo Clinic campuses
over these winter months.

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Today, we're rounding with Dr. Jaramillo,

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an associate professor

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of laboratory medicine and
pathology at Mayo Clinic

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and director of the
Histocompatibility Laboratory

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at Mayo clinic, Arizona.

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As we head into this holiday season,

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we think it's really
appropriate that we're fit

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putting focus on the ultimate
gift, organ transplantation.

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Thanks for joining us today to discuss

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this very important topic, Dr. Jaramillo.

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- Thanks Justin for the invitation.

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I'm really excited to be here.

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- What's your origin story?

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How did you first get
interested in the ultimate gift?

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How did you first get
interested in supporting

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organ transplantation?

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- Well, it's a long story,

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but I'm gonna make it
as short as possible.

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Of course, we have only 20 minutes,

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but in college I always
wanted to go to medical school

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and then I was quite
interested in immunology.

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And I remember that the HLA
class, it was fascinating.

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I thought it was the most
fascinating class I ever had

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and because the HLA system is actually

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the most complex system that
we have in the genetic systems

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of the human genome,
'cause it has right now

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32,000 different variants.

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So I thought it was just amazing that,

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and HLA, obviously a for
the immunology class,

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it was told, the class is
told to transplantation,

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not really

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for the function of the HLA system.

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So anyway, he happens that in the 1980s,

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my brother was diagnosed
with a kidney disease.

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I mean, we knew that his kidneys
were gonna eventually fail

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and the kidney did, his kidneys did.

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So, he needed a kidney transplant in 2001.

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So, actually I was actually
believe it or not quite excited

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to kind of have these opportunity

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to give my brother a kidney.

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So we are five siblings
and it happens that,

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that was the only one
that was not completely

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genetically compatible.

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So my little sister gave him a kidney.

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And I always talk, as you
say, this was such a gift.

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I gift of love, but also
the gift of science.

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I mean, these are true miracle.

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'Cause we have this
person that is close to me

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that 20 years ago, he got
an organ for my sister

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and he live a wonderful life.

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I mean, he's a retired
lawyer now he's still,

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I mean, that was to me, was amazing.

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And I always, all these years I felt

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that I kinda missed
out in somehow in being

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part of that thing.

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So, of giving him my own kidney.

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So, I always thought that
it was just fascinating.

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That's my a very personally
story that I have.

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- Yeah, I love that very
personal connection to this.

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And also I love that
it highlights the fact

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that this is really one of these places

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where the basic science
research really informs

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the clinical practice
in a very direct way.

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- Correct.

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Yeah, and so that
actually that gear me out

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actually of medical school.

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I was going to medical
school and I switched

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to basic science to get my PhD

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because I really wanted to focus

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on the transplantation
part of medicine, really.

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I mean, more direct involvement
in the genetic analysis.

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And I felt that I could
help the patients more,

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more directly, even though
it sounds kind of weird

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because I don't see in, but I feel

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that I could do a better
job in the lab doing that.

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- So maybe for,

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we've got a very diverse
audience on this podcast.

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We've got physicians, we've
got laboratory professionals.

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We've got students that listen to this,

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maybe can you kinda give us a
flavor for what are the organs

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that we actually can transplant?

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- Yeah, well, there are the
two types of donors, of course,

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the deceased donors.

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You can actually get a heart, of course

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from a deceased donor,
but from live donors,

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live donors can't donate
bone marrow of course.

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You can donate one of your kidneys,

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a one full lung or part of your lung,

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part of the liver of course,

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and part of the pancreas
and part of the intestines

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generally a healthy person can donate

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literally six organs.

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If we count bone marrow
as an organ as well.

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So it is a long list

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of organs and donors can live
a healthy life after that.

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- So, I guess for people that
are interested in potentially

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becoming a donor, or giving this gift,

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I guess, for a deceased
donation it seems like

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when we are at the
department of motor vehicle

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we can register as a donor.

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Is that right?

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And then make our wishes
known to our family?

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- Correct, yeah.

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Yeah, it does pretty much
the best way of doing it.

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So, you are actually are in the system

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or otherwise at the time of your eventual

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death by an accident, there
may be some emotional issues

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when the family, when
somebody ask in the hospital

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to the families, hey,
there is a possibility

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that your loved one can be an organ donor.

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However, you are approaching the family

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in a very, probably the
worst time of their lives.

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That is very tough for them
to make a rational decision

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at that moment.

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So yeah, the best way is
to just have your wishes

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kind of registered in your license.

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Yeah.
- I see.

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And then if people are
interested in donating,

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let's say a kidney or
something, for example,

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is that just reach out
to their local hospital

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and let them know that they're
interested in being a donor.

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- Correct, yeah.

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Most live donors, there are
about 6,000 live donations

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in the United States every
year, last year, for example.

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But of course from a family member

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to a family member member,

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but many people use, feel that the need

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to donate a kidney

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or easily, there are many,
many people that register

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as bone marrow donors.

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But yeah, if you feel
that you want to donate,

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it's usually a kidney, of course,

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'cause it's the kind of the easiest,

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the less risky organ to give,

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people usually come to
the hospital and say,

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I wanna be a donor.

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I wanna donate my kidney.

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I'm healthy.

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I wanna give this, have
this gift to somebody

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that will need a kidney
otherwise that person

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will continue to have a pretty
horrible life on dialysis.

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And dialysis is not a
healthy way to leave.

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I mean, these people that
do have the conventions,

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they come in to do it.

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- So, we'll put a couple
of links down there

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for those that are listening,

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helpful links to kind of get in touch.

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If you're more interested
in more information,

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I'll put links to National
Marrow Donor Program

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and that kind of information.

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Dr. Jaramillo, how does your work

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in the Histocompatibility
Laboratory, in the broad stroke,

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how does it support transplantation?

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- Yeah, we actually,
the HLA Lab is actually,

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even though we do complex analysis,

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it's actually quite simple.

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We really literally do two things.

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We do an initial genetic
analysis or the HLA system,

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the geodetic system of 11 genes.

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And it used to have a kind
of an initial assessment

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of the genetic matching
between the recipient

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and the potential donors.

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And that's kind of a
minor risk assessment.

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I mean, if you happen to have a good match

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with the kidney donor, that's great.

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If you don't, it's not a contraindication

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to transplantation, but
your risk assessment

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on having a rejection down
the road is a little higher

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just as, very, very low.

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Then, the most important
thing is that we do

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an immunological analysis
of your antibody profile.

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And that is really kind of
when the matching happens.

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'Cause if you have an antibody
present against the donor,

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then you will have a
rejection of that organ.

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So, we make sure that
if you have antibodies,

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we avoid those antibodies
and to pick a donor

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for which that patient
doesn't have any antibodies

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and guaranteed that, that
organ is gonna last several

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and several years.

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So it that's literally what we do.

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- I see.

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And I imagine that (chuckles)

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it sounds like you're
probably not giving yourself

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enough credit.

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Yes, you see talk about
more than 32,000 genes,

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but it sounds like
you're really interacting

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with a number of different physicians,

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nurses from different specialties.

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Could you kinda give our
audience kind of a flavor

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of how does this work
to do this kind of dance

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to match donor and recipient

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and have a successful transplant?

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- Well, for live donors,

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we do have time

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to type the entire families

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and then we can actually pick and choose

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in a timely manner the
best donor for that patient

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based first on the antibody profiles.

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And then

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if your siblings are a
full match, that's perfect.

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For deceased donors, we need to do this

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in a very, very fast way.

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So, we actually type the
donors in what we call a stat,

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we turn three hours and
then by a computer analysis,

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because it's almost
impossible to do it by hand,

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we do the antibody profile
against the genetic profile

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of the donor to try to find out

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what is the best at this point,

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if it is a disease
donor, we try to find out

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who has the best recipient for that donor

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and not the other way around.

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So, a recipient that
doesn't have antibodies

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against that donor.

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So, that's basically what we do.

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So, it's basically a genetic profile

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against antibody profile of the recipient

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and we just try to find kind of the best

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holes in the antibody
profile of the recipient.

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- Wow!

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It strikes me too that as
managing this and getting it right

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and getting it as best as possible,

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and there's all kinds
of ethical challenges

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to navigate as well.

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I'm kind of curious, what's your thoughts

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for what's on the horizon
for HLA in histocompatibility

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in the next couple of years you think?

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- There has been a very rapid developments

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in the molecular assays that we do.

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And this has been happening
in the last two, three years,

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that we are getting
right now slowly getting

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into all the HLA labs in
the country and in the world

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better testing, molecular
testing for the genetic analysis

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that we do with the donors.

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So, that is happening right now

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and also we are getting
better kind of what they call

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high resolution testing of
the antibody profile as well.

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So, we can actually, I
think we are getting better

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and better in hiring a
better profile analysis

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of the genes that the donors have

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and/or the antibodies
that the patients have.

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So we can actually have
kind of a better assessment,

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risk assessment.

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And the other way we
can actually get organs

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to patients that are highly sensitized,

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meaning that they have a very
wide profile of antibodies.

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We can actually, with these
new tools find these people

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the right donor, the right organ.

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And that is internally what
is happening in the HLA.

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In transplantation though, I think

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the field of xenotransplantation is been,

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that concept has been around forever.

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So, is basically xenotransplantation

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is transplantation from a non-human,

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from another species.

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And actually the best
species to get organs from

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is the pig.

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'Cause the pig actually

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you can have some breeds
of pigs that are in between

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120 pounds to 200 pounds.

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So, their physiology is
very similar to humans.

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They have the pretty much the
air in the size of the organs

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are quite similar.

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So, if you have a patient
that he weighs 180 pounds,

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you can find a pig that weighs 180 pounds.

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The kidneys, the heart, the
livers are gonna be basically

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exactly the same size.

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So it's perfect for that patient,

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but only until now, I mean,
last year in John Hopkins,

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there was really the first pig to human

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experimental transplant.

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And it was successful
because this is a genetically

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modified pig where they actually were able

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to reduce the expression of
what, of the HLA of the pig,

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which is called SLA
swine leukocyte antigen.

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In humans is human leukocyte antigen.

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In pigs is swine.

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00:16:32,830 --> 00:16:34,260
This is called SLA.

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00:16:34,260 --> 00:16:39,260
They were able to attain this
kidney in an experimental

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00:16:41,400 --> 00:16:46,400
brain dead patients for several days.

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So, that was really, really exciting.

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That is not gonna have replace,

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00:16:53,824 --> 00:16:55,774
it is not gonna get us out of business,

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but we'll give an organ to these patients

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that I have mentioned before,

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they have a very large
profile of antibodies

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for which is basically
impossible to find them

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00:17:12,400 --> 00:17:17,400
a good human donor in the donor pool.

300
00:17:17,930 --> 00:17:19,350
- So, when I hear you saying,

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00:17:19,350 --> 00:17:21,320
correct me if I'm misunderstanding.

302
00:17:21,320 --> 00:17:24,740
Is that the xenotransplantation
you see as like,

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00:17:24,740 --> 00:17:28,230
really a bridge to get us a
little further down the road

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00:17:28,230 --> 00:17:30,863
to when we might find the
definitive transplant.

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00:17:32,662 --> 00:17:35,690
- It could be a temporary bridge here

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00:17:35,690 --> 00:17:40,450
until, or depending on how good

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00:17:42,844 --> 00:17:44,670
the genetic manipulation of the pig.

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00:17:44,670 --> 00:17:45,833
It could be forever.

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00:17:47,996 --> 00:17:51,353
It could be a permanent organ
that, that person can have,

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00:17:52,550 --> 00:17:55,485
otherwise that person would have

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to find a human donor for.

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00:17:58,870 --> 00:18:02,900
I personally was really excited about it

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00:18:02,900 --> 00:18:05,410
because I remember
writing papers about these

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00:18:05,410 --> 00:18:06,243
back in the '90s.

315
00:18:06,243 --> 00:18:09,165
And he was like, oh,
he's gonna happen next.

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00:18:09,165 --> 00:18:11,530
And it never happened
because it's so complex.

317
00:18:11,530 --> 00:18:13,953
So now, it really happened.

318
00:18:16,550 --> 00:18:17,910
- That's wonderful.

319
00:18:17,910 --> 00:18:20,240
And then I guess the other
part you were talking about

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00:18:20,240 --> 00:18:22,920
what's happening in the laboratory about

321
00:18:22,920 --> 00:18:25,500
getting better molecular assay's,

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00:18:25,500 --> 00:18:28,410
getting a better antibody profile.

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00:18:28,410 --> 00:18:32,180
You were highlighting that
then it's gonna be the ability

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00:18:32,180 --> 00:18:35,973
for us to identify a patient
that's highly aluminized

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00:18:35,973 --> 00:18:38,003
that has lots of antibodies.

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00:18:39,198 --> 00:18:41,950
These patients who used to not
be able to get a transplant,

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00:18:41,950 --> 00:18:44,300
you're saying is now
getting the transplant

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00:18:44,300 --> 00:18:46,950
'cause there these
improvements in the laboratory?

329
00:18:46,950 --> 00:18:47,783
- Yes, correct.

330
00:18:47,783 --> 00:18:52,040
Yeah, he's basically trying
to have a very small hole

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00:18:53,278 --> 00:18:57,720
that we couldn't see
before, like a small window.

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00:18:57,720 --> 00:18:59,970
So if you don't have any antibodies there,

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00:18:59,970 --> 00:19:01,780
the window is as big as a door.

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00:19:01,780 --> 00:19:03,840
If you have a lot of antibodies,

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00:19:03,840 --> 00:19:05,490
you literally have no window.

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00:19:05,490 --> 00:19:09,570
So, now with these new
tests, we can actually find

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00:19:09,570 --> 00:19:13,506
small windows to that possibility.

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00:19:13,506 --> 00:19:14,590
And that is very exciting.

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00:19:14,590 --> 00:19:19,590
We are actually seeing
that now in the practice

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00:19:19,660 --> 00:19:21,830
that we are able to
transplant these people

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00:19:21,830 --> 00:19:26,290
that have been waiting
for a kidney for 10 years,

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00:19:26,290 --> 00:19:29,700
but now that we can actually do it,

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00:19:29,700 --> 00:19:31,250
we can actually find them a donor.

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00:19:31,250 --> 00:19:34,560
So that is, and the
taste is getting better,

345
00:19:34,560 --> 00:19:38,960
not necessarily better in
resolution, but faster.

346
00:19:38,960 --> 00:19:43,320
So that's the thing that
we can actually type

347
00:19:43,320 --> 00:19:46,800
a deceased donor in hydro solution

348
00:19:46,800 --> 00:19:49,613
in a timely way and then do it.

349
00:19:50,920 --> 00:19:52,033
- That's wonderful.

350
00:19:53,286 --> 00:19:55,080
I think, my sense is people

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00:19:55,080 --> 00:19:56,660
that are on the donor waiting list,

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00:19:56,660 --> 00:19:58,220
things that are happening faster,

353
00:19:58,220 --> 00:20:00,630
exciting developments
that have (chuckles).

354
00:20:00,630 --> 00:20:02,573
- Yes, of course.

355
00:20:02,573 --> 00:20:03,406
- So, thank you so much.

356
00:20:03,406 --> 00:20:04,720
We've been rounding with Dr. Jaramillo

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00:20:04,720 --> 00:20:08,530
talking about the ultimate
gift of organ transplantation.

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00:20:08,530 --> 00:20:10,990
Again, in the show notes,
we're gonna have some links

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00:20:10,990 --> 00:20:13,320
to some of the organ
transplant organizations

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00:20:13,320 --> 00:20:14,870
here in the United States.

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00:20:14,870 --> 00:20:17,838
And we'll also have a link to
that paper from Johns Hopkins

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00:20:17,838 --> 00:20:19,925
that Dr. Jaramillo mentioned for us.

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00:20:19,925 --> 00:20:22,310
Thank you so much, Dr. Jaramillo.

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00:20:22,310 --> 00:20:23,227
- Terrific.

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00:20:24,340 --> 00:20:26,950
- To all of our listeners,
thank you for joining us today.

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00:20:26,950 --> 00:20:28,700
We invite you to share your thoughts

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00:20:28,700 --> 00:20:30,490
and suggestions by email.

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00:20:30,490 --> 00:20:35,490
Please direct any suggestions
to mcleducation@mayo.edu.

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00:20:36,110 --> 00:20:38,450
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00:20:38,450 --> 00:20:40,840
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00:20:40,840 --> 00:20:42,670
And until our next rounds together,

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00:20:42,670 --> 00:20:45,920
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00:20:45,920 --> 00:20:50,000
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00:20:50,000 --> 00:20:52,583
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