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And when they are open to questions, your questions, Deb up the back here has got a roving microphone
and there's also one upstairs for anyone upstairs who wants to ask any questions.
So, uh-huh, down the front here.
Could you explain please what happens when the body's immune system attacks itself
and would knowledge of that help in the fight to your Holy Grail fight?
So, in that process that we talked about where the lymphocytes run around the body,
the white cells run around the body and look at all the different things and say,
is this part of me, is this not part of me?
Sometimes it gets a bit confused and decides to attack itself, ourselves.
So that's autoimmune disease.
And we do understand, we have learned a lot from autoimmune disease about how these cells function
and that cell function information we certainly use in terms of managing the immune system
and that's gone on to help develop a lot of immunosuppressive drugs that Tobi's been speaking about.
So, there is, yes, there's a great deal of knowledge.
It's a slightly different mechanism, a lot of it's around inflammation
when we get autoimmune disease like rheumatoid arthritis and other things.
But diabetes, type 1 diabetes is a good example where the body makes antibodies that attack the pancreas,
the arid cells in the pancreas and destroys them and no longer makes insulin.
So, yeah, we certainly have learned a lot about the little cells.
This level of complexity, this side here that shows the self-surface,
our cells are covered in millions of molecules.
They all have different functions.
Unraveling how a lot of those functions work is more than a lifetime's work
and that there's a lot of people working on that worldwide
and certainly understanding how those cells interact and how they speak to each other
and what that cell does and how the little locking mechanisms work
and how to stop them locking.
So, yeah, there is a lot of knowledge from autoimmune disease.
It is a very good question.
Without complicating it too much, one of the things we've learned from these autoimmune diseases,
I've only talked really about the attacking cells at this point in time
and they're called CD8 cells and they're the bad guys.
They're the guys that go in and kill.
We've also got really useful group of cells called the regulatory cells
and the regulatory cells can shut down the activity of the attacking cells.
Kind of like the government.
A bit like the air. A bit like the TGA.
And what we've learned, you've asked about autoimmune disease,
what we've learned, how we discovered the regulatory cells
was that a lot of autoimmune diseases are caused by lack of regulatory cells.
So that was the sort of rheumatology field that brought that to bear
and now we've translated that knowledge and said,
okay, if that's happening in autoimmunity, is that happening in transplant?
And oh, yes it is.
And so one of the areas, I mentioned it before,
and there are people in Adelaide that do this stuff, do this sort of regulatory cell work,
do now grow up regulatory cells and one of the treatments that will come
in the next three to five years and we'll be trying,
we'll be giving regulatory cells at the same time as you give a transplant
to try and dampen down the immune response that Rhonda was talking about.
So there's, you know, we try to, we have these conferences where, you know,
we sort of get together and, you know, somebody from, we'll say something,
you know, you'll see here somebody talk about a completely different disease
and someone's like, wow, maybe that applies to my thing.
And off it goes like that.
I actually have a couple so I can't decide which one I want to ask.
Just the whole process when you got the call and stuff like that,
do other people get the call as well and say that, you know,
they're number two on the list, number three on the list
and while that process of matching is all still happening, isn't it?
They're allocated to a specific patient and only that patient is called.
So in the other, before the patient's notified,
all of that has been decided that that will be the patient that's going to receive.
We heard about the imbalance in the supply and demand of the organs.
So I know in the UK there's a debate about assumed consent,
which you have to opt out of.
I think they often cite Spain maybe as an example.
So can you talk about that approach and whether or not it changes
the social dynamic of donation?
Yeah, it's a difficult area.
I know what you're referring to.
We here in Australia at the moment have an opting-in system
rather than opting-out system.
Now the opting-out system, what that means is that it is assumed
that everybody is an organ donor unless they've said they're not an organ donor.
That's the Spanish model, the opting-out model.
In Australia we have an opting-in model which is you sign your driver's licence
or as donate life says, you talk to your family.
And talking to your family and your friends,
it is the single most important thing that you can do
because, and this sounds kind of crazy,
but even if you have indicated on the register or if you've indicated
on your driver's licence that you particularly wish to be an organ donor,
your family can override that wish when it comes to the moment of organ donation.
And I guess we all get a bit more how on earth could they do that,
but I think and I'm not involved in those conversations
I think between the donor coordinators and families
must be some of the most difficult conversations that anybody could possibly have
that you could easily understand in that situation that, you know,
someone's going to say, well, no, you're not going to take the,
I'm pro-organ donation but that's my dad or that's my sister or that's my child
and, you know, I'm not going to let that organ go.
And the last thing that we want as transplant professionals is if we had a system
such as the, as you described, where we had assumed consent,
the minute we did an operation and we took an organ against the wish of the family,
that would be on the front page of, you know, every page, paper in the country
and it would shut the system down for, you know, probably the next 10 organ donors.
So the donate life message is the right message, I think,
and that is that we tell everybody and you talk to your family
and you say you want to be an organ donor
and that, you know, encourage them to respect your wishes.
There's still a process in Spain, even though it's an opt-in system,
they still do get consent from the family.
It's not that the organs are taken against families wishes by any imagination.
It just means that all families, all potential donors are approached.
So there's a different sort of set up to start with.
And it's not that, I wouldn't like anyone to think that, you know,
if you were in Spain, your organs are taken automatically, that's not what happens.
It's a very complex, there's a lot of differences between Spain and here.
We're closer, particularly in South Australia,
and we don't have a chance to say how good we are here,
but our organ donation rate is much closer to the American donation rate
and it's much higher than in some of the other states.
And again, it's to do with very good quality conversations
and having all the systems in place that support organ donation around the place.
So we have a good high rate here.
I'm Sally Tidderman and the medical director of organ donation here in South Australia.
So I just add a point there that South Australia's got a donation rate of 20 donors per million,
which is up where some of the best in the world are,
and we've got that with an opt-in system.
So the Australian government has made a decision that it's possible in Australia
to reach the good high rates with an opt-in system
and that we don't need to go to an opt-out system.
The Australian government takes the view that it's an altruistic act,
it's a gift to be an organ donor and therefore there should be no coercion
or no presumption that that would be the case.
So two factors really.
We know that we can get to high rates with an opt-in system
and the ethic of the Australian way is the altruistic ethic.
I recovered from breast cancer eight and a half years ago
and I was told after a year by the blood bank
I couldn't donate blood for at least another four years
and I haven't followed that up since.
And I found out this evening, even though I'm registered as an organ donor,
that it's unlikely that any of my organs would be acceptable because of heart cancer.
What is there circulating in my immune system that would compromise the recipients?
Well I guess the issue is, as Tabe is saying,
it's a cautionary process obviously.
We don't know exactly what's going to be there
and if that's going to have any implication.
As immunosuppressed, following the transplant,
we don't want to have any risk factors in there
where we can have a cancer cell that might be there, might be quiescent,
it might not be doing much in your organs.
At this stage it could just be sitting there
that would then, in the setting in the recipient,
where there isn't the immune system watching it all the time
and just keep tapping it on the shoulder saying,
behave yourself.
You know, where that's not happening,
that there's a risk that that could then proliferate in the recipient.
So there is a general caution obviously that we don't take
that people who have malignancies are not eligible then
to be organ donors or blood donors for that reason.
How close is science to growing new human organs
so that donors are no longer needed?
That's an excellent question.
That's an excellent question.
Science is wonderful.
We can grow new, we can take cells now, pre-custodial cells,
and we can make red blood cells.
But the volume and the amount of the red blood cell that we can make
would be smaller than the tiniest amount that you could possibly think,
so we can make those cells.
And the amount of money that it costs to drive those cells
to become that particular cell is astronomical.
So we can, the proof of concept is there,
but at the moment it's not practical.
Most of the organs that we transplant,
particularly the organs that,
there's two organs that I'm mainly involved with.
One is the transplantation of beta cells for diabetes.
And if we could potentially grow beta cells that make insulin
and treat diabetes, that would be a tremendous thing.
And with that, we can do that in the test tube as well.
But most of the other organs, the liver, for example,
the heart, the lungs, the kidney,
are made of multiple different cell types, multiple cell types.
So you'd have to be able to grow each one of the individual cells,
and then you'd have to get each one of those individual cells
to get into the right configuration.
And then you'd have to get them to talk to each other,
then you'd have to make the blood vessels grow in
to be able to supply them appropriately.
And you'd have to make that process happen in a sterile environment
over a period of, you know, more nine months,
because we know that's how long it takes to, you know, to grow that.
And the logistics of achieving that are really very, very high.
So we may well get to the point of being able to replace individual cell types,
and we may well be able to give stem cells
that if you put them in the right place,
will, through the right signals, turn into the cells that you want.
But I think being, looking forward, I think being able to grow,
you know, the kidney in the box, or the liver in the box,
or the heart in the box is probably not going to happen,
or certainly not my lifetime.
I think there's a question up the top here.
I am a registered organ donor.
The thing is, I'm in my 80th year,
and judging by siblings dead and alive,
I should expect another 10.
But the question is, when I'm 90-odd,
are any of my bits and pieces still of any use?
That's a good question.
Well, the answer is, of course, yes.
So we would certainly look at, we consider,
and Sally would back this up,
we consider every person a potential organ donor in some form.
So corneal transplant, so if the eyes are good,
we would potentially consider corneal transplantation.
Heart valves potentially usable.
We do try to, in the kidney world,
we will often, instead of,
the normal way of doing kidney transplant is take,
we have a kidney donor,
one kidney goes to one person,
one kidney goes to another person.
But what we'll actually do for older people,
and over the age of 75,
we'll actually look and see if we could transplant
two of those kidneys together into one person.
So somebody that kidneys weren't quite good enough
to support a person by themselves,
we might use the two together.
So we look for every conceivable possible organ
that we could, a possible transplant that we could do.
So I would encourage you to retain your,
stay on the register.
I understand, roughly,
the system where the person who's receiving an organ
decides that they're, their body decides
that they're not going to accept this.
This is outside my realm.
But I was interested to hear that the organ,
which is being transplanted in from the donor,
has its own immune response
to being transplanted into the recipient.
And I'm just wondering, what is that mechanism?
Does it call on the recipient's whole system to respond?
Yes, it does.
About 90% of the rejection that we see
is started by the transplant itself.
So it's actually, it's actually the immune cells,
it's the, as I said before, the passengers
that are in that organ that actually
drive that rejection process.
And that's the process that happens in the first week,
and it's the strongest type of rejection that we see.
It's nasty, difficult to treat rejection
when it actually happens.
The rejection, although the transplant's starting it,
it's the recipient that's causing it.
So the transplant makes it happen,
says, hey, look, I'm foreign, you know, I shouldn't be here.
And all the, all the recipient's body is doing,
is doing exactly what it should do,
and saying, hey, there's a great big invader in there,
let's fight that invader.
But it's a, acute rejection starts because of,
generally because of the transplant.
The other type of rejection is what we call chronic rejection,
and that is predominantly from the recipient,
the recipient's body.
And that's the sort of rejection that,
that's about 10 to 15% of the rejections that we see.
That's a much lower level, and it's a much chronic,
much more chronic process.
So that's the sort of stuff that can happen
five, seven, 10 years down the track,
rather than within the first week.
That's a good question.
Another one from up the top.
The Red Cross doesn't seem to want my blood anymore.
It seems curious that the body is wanting to reject any organs,
but will accept someone else's blood readily enough, doesn't it?
Well, blood, well, not always.
Yeah, no, blood is tolerated quite well, obviously.
Well, Red Blood cells are tolerated quite well.
They have to be OVO matched, of course,
and they're not, that doesn't like them.
And we always say that the human leukocyte antigen,
which is a blood system, is like a blood group,
but on white cells, you know,
so it's the same sort of thing.
But, yeah, there are reactions to blood transfusions, definitely,
and there's some of them caused by white cells,
and some of them caused by red cells that, you know,
minor groups on red cells that react badly as well.
So it is a type of transplant in its own way,
but a different sort of type of transplant.
I could just add to that.
What we've said before was that every cell in your body's got
these HLA molecules that Rhonda showed here,
except your red blood cells.
So that's the major difference, and Rhonda's quite right.
The blood groups are different,
and if you get the blood groups wrong,
you can have very nasty reactions.
But if you get the blood groups right, as we do,
as we do, you don't get those sort of blood reactions.
There was a story in the media in the last couple of years
about a girl who, having had a transplant,
no longer needed the immunosuppressant drugs,
and whilst it appeared in the media,
we never heard any follow-up on that,
so I wondered if you knew anything about that case
and what had been more research done.
Oh, yeah.
That's right.
They're very, very interesting.
Those sort of patients.
There are many of them.
So, for example, I can tell you that the United States
government poured a huge amount of money
into trying to identify tolerant patients.
That is patients who completely accepted their organs.
And in the whole of North America,
330 million people,
the American government could identify 20 people
in that situation who'd become tolerant to their grants.
And those 20 people have been studied in great depth.
And I can tell you quite a lot about that
because you could understand that,
how that process happened,
and then we could try, as I was saying before,
to trick the immune system to do that all the time.
Europe did the same thing,
and in the whole of Europe,
they could identify 11 people in that situation.
So, yes, there are a number of people in Australia,
and I'm personally aware,
we've got three here in South Australia,
and I'm aware of one in New South Wales,
and there's probably another one in Victoria.
So, there are a few of them around.
And those people are very fortunate to be tolerant
of their organs because the truth,
the sad truth of the matter is that for 99.99% of people,
if you stop the immune suppressing drugs,
the immune system will come back
and do what it's supposed to do and get rid of that invader.
Yeah.
I'm a bit nervous.
I've got a couple of comments.
First is Sam.
I think it's fantastic that you're sitting there
and doing so well.
It's brilliant.
I'm interested in what they're doing at the Alfred with lungs.
I live with someone who has a rare lung condition,
pulmonary hypertension, who's only 13,
who goes to bed most nights
and says, I'd like new lungs,
but we are okay at this stage.
And my next point was,
how do we create greater social awareness
between the three of you there,
or many people in the audience as well,
of the importance of,
once we're finished with our bodies,
to allow them to go and give other people life,
like the man in Greece,
or I think it was in Greece whose son got...
Yeah.
Which was a great way to have a positive outcome
to a sad situation.
Well, that's probably one for us.
We have an ongoing awareness campaign,
and we try to get out to as many people as we can.
Donate Life has staff all around Australia.
Each state has a Donate Life office in it,
staff by organ and tissue donor coordinators
who obviously go out spreading the word
across the medical fraternity
and all the patients that they come across,
and they have communications people like me
who go around and spread the word as well.
We try with Donate Life Week to kind of have a blitz, I guess,
if you like, and make ourselves very visible
for that one concentrated period.
It's not something, obviously,
to use a cliche that will happen overnight,
because people take time to take in the messages
to keep seeing the advertisements
or keep, you know, having those conversations
or discussing it with people
or perhaps finding out that someone they love needs a transplant
or that someone they love has passed away
because they couldn't get a transplant
and also perhaps that they have friends or family
who want to be organ donors, and perhaps they didn't know that.
So it's something that is going to take quite a few years, I think,
for people to become just, I guess,
a little bit more than shallowly aware of it
and to perhaps understand a little bit more of what's behind it,
that it's not just a, oh, we want your organs and tissue.
It's more of a, it's actually a wonderful thing to do
because you are going to help so many people,
potentially help so many people.
You know, and as Toby mentioned about advances in science as well
and in medicine, there might be other ways down the track
that can add to the fact that you get people donating organs and tissue.
But people like you here tonight, it's fantastic that you're all here
and obviously you'll go away and spread the word further
and talk about what you've heard tonight
and hopefully ask people to sign the register
and to talk about it with their friends and families.
And the more people we are managing to reach through things like this
but also in the mall and everywhere else, then the better it will spread.
I don't like to use the word viral campaign because...
but it is a medical forum.
But it is one of those, you tell 10 people, they tell 10 people
and it does eventually spread.
Spain didn't get its really good donation rate overnight.
It really didn't. It took it years.
We're quite new in the process.
We've been going for two full years in terms of a national system.
So it will take us some time too.
But rest assured, we're actually, you know, doing everything we can.
And we just ask you to continue doing that as well, please.
Does that answer the question?
Slightly?
You need to put it in the question.
Yeah.
So we'd like to thank you all very, very much for coming tonight.
It's been really fabulous to see such a great response.
And working for Donate Life, working with our IOS has been really great.
Obviously we've got a great venue here.
It's quite a handy spot to get to.
We'd like to thank Toby and Rhonda and Sam for coming along
to share their perspectives on donation and transplantation.
And to encourage you to just talk to your friends and family
and to feel free, there's contact numbers on the information around the place
to give us a call if you've got any questions
or to come up and speak to us if you see us.
And hopefully we'll be able to do this kind of thing in the not too distant future again.
So thank you very much.
Thank you.
