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Monday, June 15, 2009

Impossible, Improbable, & Wonderful

Last Friday the first chatter about an upcoming movie began hitting the blogosphere. My Sister’s Keeper got my attention because it involves a kidney donation situation.mysisterskeeper I picked up the novel Friday and read it to see what was coming.

SPOILER ALERT: I may relate things in this brief plot summary that you don’t want to know before you see the movie. Or better yet, read the book. Consider yourself warned.

This family (Mom is Cameron Diaz) has two children, son Jesse and daughter Kate. The daughter develops a rare form of leukemia. Her best chance to survive involves a transplant from an HLA identical sibling – which her brother is not. The parents select an identical embryo and give birth to a sister, Anna (Abigail Breslin). Her cord blood is used to transplant Kate.

Kate does well for several years, but then relapses. Anna then donates lymphocytes, granulocytes, and bone marrow for further procedures for Kate. After the second transplant the tumor may be licked, but the drugs to control graft-vs-host disease toast Kate’s kidneys. For some reason she has to have an exact HLA match. Her dialysis has “stopped working.” Unless Anna hands over a kidney, Kate will die. She sues for medical emancipation at this point (and gets Alec Baldwin for her lawyer), setting up the conflict for the book.

So let’s start with what is wonderful about this book. It may be the best picture of the effect of chronic illness on a family that I have encountered. Too many depictions have saintly parents working tirelessly to produce a miracle for their child, with no ill effects on others besides the medical establishment. From my read, Anna suffers the physical effects of donating to her sister, but seems to be rather well-adjusted compared to the rest of the family. The whole family exists in a state of readiness, waiting for another crisis or illness to disrupt their lives. The brother feels invisible, and both parents admit they have, at some point, “given up on him.” He brings his own pathology as well. The book makes the family members neither saints nor ogres, but human beings trying to take on a bad situation as best they can. I hope the movie can convey this as well as the prose.

What bothered me about the book is the kidney transplant situation. I cannot name a center in North America that would consider using a 13 year old donor, even if she were willing and the circumstances dire. The descriptions of dialysis would imply in-center hemodialysis. It is unclear why this procedure has “stopped working.” Can’t they do more? I see patients survive hemodialysis, even after cancer treatments, for years. We usually require 5 years cancer-free before we consider survivors as transplant candidates. OK, I understand that the kidney was the appropriate organ to set up the dramatic conflict in the story. I guess I will grant some literary license on this point; however, I can’t figure out where Kate’s nephrologist was in the subsequent proceedings. The emancipation trial presents testimony from a psychiatrist, the head of the hospital ethics committee, and Kate’s oncologist. The latter is who testifies to Kate’s renal needs. Huh? This is a book – you don’t have to pay extra for another character! It would have required a bit more research to bring the nephrologist in and somehow make it realistic, perhaps explaining how this extraordinary set of circumstances came to be.

LAST SPOILER WARNING!!!!! PROCEED AT YOUR OWN RISK!!!!!

So we have covered the wonderful and the impossible. What is improbable? Well, when I first heard the plot summary, my reaction was, “the only way we take 13 year old donors is as cadavers.”

Yup, after the trial, Anna is in a car accident with a massive head injury and ends up giving a kidney to her sister after all. Impossible? No. Improbable? Yes.

There is a lot more to the story than what I’ve discussed here. The book is an excellent read, although as a nephrologist I had to really suspend disbelief and forgive some literary license. I still ended up sobbing into the better part of a box of Kleenex at the end. I am told they altered the ending of the movie, but previewers tell us we will still like it. I guess I will have to wait another 10 days or so to find out with the rest of the world.

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