On December 21, Sergio Hijano (Bossòst, Vall d’Aran, 1978) returned to the operating room. Unfortunately, it is not an unknown place for him. Fortunately, the intervention, led by the head of urology at the Hospital Clínic, Antonio Alcaraz, concluded successfully and the recovery has proceeded along normal lines. It was an absolutely exceptional surgery: Hijano has become the first Spanish patient to undergo six, six!, kidney transplants, according to the National Transplant Organization (ONT) and the second in the world to reach this figure, which did not has been surpassed, according to the verifications of the Barcelona hospital center.
Behind the small and apparently weak figure of Sergio Hijano hides a man with a mentality worthy of an Olympic medalist to overcome failures. The failures of the implants in this case. He says it and the doctors corroborate it. “At no time have I lost hope. It is a fundamental thing. Psychologically, I have never thrown in the towel because, if not, I would not have reached six grafts. As long as there are options, I prefer to try them. The day they tell me that there are no transplant options, well, I will think differently,” he explains. One of his fellow workers decided to quit after two rejections. He became afraid of the scalpel and has preferred to continue with dialysis. He has been in treatment for 30 years and with its consequences: he has lost his sight and suffers the physical deterioration associated with the aggressiveness of the therapy.
Let’s hope it lasts for many years; “we leave the record here”
Hijano’s life was twisted just to enter the world. “They caused my birth with forceps, they damaged my kidneys and then the doctors decided to annul me, so to speak, because they saw that I was getting sick and that there was no solution.” Seven days after the birth, an uncle took the baby from Vielha to the Vall d’Hebron hospital in Barcelona. “They did tests on me and saw that there was no solution, I had lost my kidneys, they had become waterlogged. Then they started with medication until they were 9 years old. At that age I started dialysis.”
(His partner, Mónica, from Barcelona, was even earlier. She started dialysis at the age of 6 and has three transplants, the last one more than two decades ago. It is common for romantic relationships to arise during treatment: three times a week, four hours per session. “The good thing about having a partner with the same disease is that you don’t have to explain much because we understand our problems,” says Hijano).
“As a child I left home at 4 in the morning for dialysis in Barcelona and returned at 7 in the afternoon”
Having a kidney pathology four decades ago in the Vall d’Aran was an added sentence. The boy was picked up by a taxi at four in the morning to take him to the Ader center (Association for Kidney Patients) in Les Corts, Barcelona, and he returned home at seven in the afternoon. Three times a week. Skipping school. Child torture that failed to break him. “Mentally I always handled it well, I have always thought that, unfortunately, there are people who are worse off than me,” he says. But he asked his parents to get him a transplant at the earliest opportunity. “And yes, at 10 years old they called me for one, for the first one, but when I was ready to go into the operating room, me and another colleague, the surgeon came to tell us that the kidneys had been damaged, that they had the wrong refrigerator. and they had frozen them.”
About two years later, this time, he received the first graft. “It only lasted a year and a half because I was very young and my body didn’t assimilate it. After another two years of waiting, he received the long-awaited call again. “What happened? That in this second transplant, due to bad luck, I caught a virus and they had to remove my kidney. It only lasted 9 months. And, well, dialysis again until the third year.” This worked for 4 years, until his body rejected it. Sergio was 20 years old and had three failed transplants: “You think that something is happening here, or it’s my body or it’s that medicine is not advancing, but hey, you don’t lose hope. They preferred that I be transplanted and be out of the (hemodialysis) machine, because the machine punishes a lot, the truth is, it punishes the physique, it punishes the bones, everything.”
Hijano, between surgeon Antonio Alcaraz and Fritz Diekmann, head of the kidney transplant section at the Clínic
About 30 years old, and after a few years of dialysis at the Arnau de Vilanova hospital, in Lleida – far from home but not as far as Barcelona –, fourth attempt and the most successful: it lasted 8 years. The fifth transplant, performed in the Vall d’Hebron and with a kidney from a cadaver donor like the previous ones, caused problems from the beginning, weighed down by a virus and inflammation of the organ that caused constant visits by the patient to the hospital.
Sergio Hijano recounts his adventure with naturalness and integrity until his voice begins to tremble and a few tears appear behind his horn-rimmed glasses. It is the moment when he remembers his brother. The patient – who moved his residence to Barcelona seven years ago – had decided to put himself in the hands of the Clínic. “For the sixth transplant they told me that it was better from a living donor than from a cadaver, with all the surgery that was involved, apart from the fact that I could have to wait years for a more or less good organ to arrive. My brother (7 years older) didn’t think about it.” On December 21 they entered the operating room. Dr. Alcaraz chose to extract the fifth graft to place a new kidney there and leave it on the other side for a hypothetical seventh transplant. A terrain that no one has trodden and that the patient does not want to approach. “Let’s hope that the sixth goes well, that it lasts for many years. We leave the record here,” he exclaims, recovering his smile.
The first five implants were from a deceased donor, the sixth was a donation from his brother
What would have become of this person without the altruistic and anonymous donors? “It is very important that people realize that thanks to the organs of a deceased person, many people can be given life. I think there should be more, not just kidney, but any organ.”
The challenges of the intervention
A gap for the seventh
Sergio Hijano could not have been in better hands. Antonio Alcaraz, head of the urology and kidney transplant service at the Clínic, is a world pioneer in the use of minimally invasive surgery and has performed some 1,700 kidney grafts, a record number. His team has signed unprecedented interventions, such as complete kidney transplantation vaginally or through the navel. He has also carried out several fifth transplants and the only sixth, Hijano’s, an extraordinarily complicated surgery, only available to highly experienced specialists.
“We had two fundamental challenges,” explains the doctor: “One is the immunological challenge. Every time we expose a patient to a transplant we expose them to different proteins, and the patient will generate a series of antibodies. Another is the surgical challenge, where are you going to place the organ? There are some areas where we usually put them, in the lower part of the abdomen, on one side or the other of the body. We can also put it in the left lumbar fossa, replacing the left kidney. but after several transplants it begins to get complicated, we have to look for spaces in already operated surgical areas. And it is not a cumulative effect, but rather a multiplier of complexity.”
To begin with, the specialists proposed that the kidney to be implanted come from a living donor. “We know that in general the long-term viability of these kidneys is between 10 and 15% higher than those from a deceased donor,” explains Alcaraz. Second step, having ideal logistical conditions: “Having the appropriate surgical team, an ideal schedule for the entire nursing team, so that the patient could enter and do all the immunosuppressive treatment perfectly organized… Everything had to be planned to try that could end with the success it has ended with.”
The surgeon maintains that each transplant is a world, that he learns from everyone. “Something theoretically as simple as connecting an artery with another artery, a vein with a vein and removing urine to the bladder or to some other place that we believe is necessary becomes more complicated. “This is the case today, due to the surgical areas that are occupied or unused because the irrigation no longer reaches them.”
Although the patient hopes that it will not be necessary to undergo surgery again, the surgeon has foreseen the possibility – and has left a gap – that a seventh transplant may have to be performed. An unprecedented but feasible fact, in the doctor’s opinion: “99% of patients are transplantable. We simply have to look for the options, clearly explain to the patient the probabilities of success, which are undoubtedly reduced transplant by transplant, and the risks to which we subject them. The immune system has memory, and someone who has seen six previous transplants has a lot of memory, so there is a higher risk of rejection.”
Rejection. Cursed word among doctors and patients, and the subject of intense research. In the near future the paradigm of transplants will change. “We will see, I have no doubt,” says Alcaraz. “Organs have already been obtained from genetically manipulated animals and have been tested on humans, which indicates that it is absolutely advanced: it is about humanizing these organs so that we have the minimum rejection. Another avenue would be the creation of small implantable dialysis machines, which bioengineering is working on, or the generation of artificial kidneys from the patient’s pluripotent cells. There is already kidney tissue from the patient that produces urine; another thing is whether we are able to make it implantable in the patient. We are on the way, I have no doubt that this is going to happen, what I hope is to be there to see it.”
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