Anzai gazed at his palm, where Mariko's hand had been only a moment before, and instinctively made a fist to keep her warmth there.

"Mr. Anzai, calm yourself. Everything's going to be fine. Please rest over here," a nurse said, and led him into the waiting room. She sat him down upon a couch, then brought him some coffee from a vending machine. She handed Anzai the hot paper cup, which he grasped with both hands. His thoughts were churning over the events of the night before.

Soon after talking with the coordinator, he'd arranged for a taxi to take them to the hospital. Mariko threw such a tantrum the entire ride over, he feared she'd have an actual fit.

When they arrived, she calmed herself somewhat, but cried for what seemed forever. She was never so emotional during the last transplant.

Mariko was moved immediately into the ICU for testing. After verifying her dialysis data and checking her blood pressure and pota.s.sium count, she was subjected to dialysis and transfusions. She was screened thoroughly for infectious diseases. They seemed to a.s.sume that the thought of undergoing an operation was making her nervous. By the time she was informed about the details of the operation and asked to give her approval, she seemed an empty husk.

"You're still okay with this?" asked Yoshizumi. Anzai naturally agreed. Yoshizumi then peered into Mariko's face. "And you, Mariko?" he asked.

"Is that person really dead?" she responded despairingly.

Yoshizumi understood what she was getting at and explained that the donor was brain dead. There was no chance of her coming back to life.

The tests confirmed Mariko's eligibility. They had prepared all last evening for today's procedure by shaving off any body hair around her abdomen and covering her with a sterilized sheet from the waist down to prevent razor burn infections. They also prescribed immuno-suppressants. Anzai spent the entire night sitting in a chair at her bedside.

Odagiri was a very perceptive woman. She understood Mariko's nervousness and fitful anger and talked with her throughout the night. Anzai was still concerned, but everyone was handling the situation with great patience.

They received word at 1:30 pm that the transplant would begin. When Yoshizumi came to Mariko's bedside to relate the information, her eyes widened in fear, to such an extent that Anzai feared they would pop right out of her head. Her lips quivered. Her teeth chattered.

"Don't be afraid, it's just like before. Everything will work out fine, I promise, "Yoshizumi said gently and gave Mariko a pat on the head.

She'd opened her eyes wide again and asked the same question, still rigid from fright.

"Is the person giving me this kidney really dead? Is she really, truly dead? Won't she come back?"

Yoshizumi was gone now. He was at the UH...to get Anzai's daughter a kidney from a "truly" dead person.

Anzai looked up at the nurse's face. She returned his gaze with compa.s.sion. He glanced absentmindedly at the clock behind her. It was 5:35.

10.

Bringing one a.s.sistant with him, Yoshizumi went into the dressing room and changed into a green surgical outfit. Although he was accustomed to wearing it, it always felt crude when he put it on. He then entered the washroom nearby. Yoshizumi stood in front of the two stainless steel sinks that lined the wall and stared at his own face in the mirror, covered in mask and surgical hat.

He and the a.s.sistant opened the sink plugs, washing their arms with filtered water.

Next, they put a disinfectant solution into their palms and smeared it thoroughly over their arms. They then each took a scourer in their hands and scrubbed vigorously. After working up a fine lather, they rinsed it off with the shower nozzles and cleaned their fingertips and nails with a small brush. This process was repeated three times.

Proper hygiene and a sterile environment were always necessary for any operation, but one had to be particularly attentive to these issues in transplant surgery. A transplant recipient's immunity had to be regulated in order to stave off rejection of the new organ.

While this did increase the chances of success, the treatment severely weakened the recipient's resistance to bacterial infection. If the new kidney became infected, the patient could actually die. The surgeons therefore took the utmost care in the pre-op disinfection procedures.

They entered the OR, put on gowns handed to them by a specialized nurse, and slipped on latex gloves. Yoshizumi flexed his fingers a few times to stretch out the gloves until they fit comfortably.

Yet another a.s.sistant was busy disinfecting the donor's skin. Only her abdomen was left exposed, draped on all sides by sterile green cloth. More than just covering the body, the cloth served to prevent any lingering bodily bacteria from infecting the operating field, and to keep the surgeon's focus from straying. The green color dampened the visual impact of blood.

Yoshizumi walked around the body and positioned himself at its left. The first a.s.sistant came over and stood opposite. Yoshizumi exchanged a glance with him, then surveyed the room, checking to see that everyone else was ready.

"Seventeen minutes since heart failure," Yoshizumi heard the nurse announce.

"Alright, let's begin."

A scalpel was pa.s.sed into Yoshizumi's dexterous right hand.

From a round hole opened in the cover sheets, the body's abdomen shone under the lights. Yoshizumi placed his hands upon it and made the careful first incision. Blood oozed out vividly from his precise line. He secured the slit with forceps to stop any further arterial leakage. He spread open the incision by hand and, pulling the outer layers, cut through the peritoneum. He clamped a number of smaller forceps into the body cavity. Blood from numerous veins still permeated die area, but time was scarce and he could not afford to stop all of it. Yoshizumi staunched the blood as best he could and sped up the incision until the digestive organs were exposed. He lifted the upper part of the fiver with a spatula-like tool to see more clearly inside, then pa.s.sed the device over to his a.s.sistant.

Yoshizumi immediately recalled the face of the donor's husband. He could not drive it from his head. There was something very peculiar about him. The man's eyes were vague, yet somehow alive with conviction, trembling as if possessed. And when he shook his hand, Yoshizumi almost called out involuntarily, for it felt like plunging into boiling water. He had feigned calmness, despite wanting nothing more at that moment than to break away from him.

Yoshizumi shook his head once again. He forcibly erased Toshiaki from his mind to focus on the operating table. There were much more important things in need of his immediate attention.

Many think that the kidneys are in the vicinity of the waist, but they are actually higher, located just behind the bottom-most rib of the rib cage. In order to reach the kidneys, internal organs such as the stomach and pancreas had to be systematically moved out of the way.

He tied off all visible arteries in the colon and pancreas area and cut them away. The a.s.sistant sucked out the contents of the stomach through a tube. When everything looked clean, Yoshizumi severed the esophagus. At this point, almost every digestive organ in the upper body was cleared. His goal was now within close reach. Had Yoshizumi been extracting a kidney from a living person, he could not be so careless, but dealing now as he was with a dead body, an abbreviation of time necessitated this indifferent handling. Again, the nurse dictated time since heart failure.

"Twenty-three minutes."

Yoshizumi and his a.s.sistant removed digestive organs from the peritoneal cavity, turning them over and placing them on a tray between the donor's legs. On top of the green cover sheets, these organs took on the appearance of some morbid exhibition. Since all peripherals had now been removed, only the kidneys remained. The a.s.sistant widened the incision with his hands to give a better view for Yoshizumi. The neatly hollowed s.p.a.ce allowed for more room in which to work. He could see both kidneys perfectly now. They were a neat pink color and glittered with reflected light. Yoshizumi was pleased at their excellent condition.

With such an un.o.bstructed view, he easily located the aorta abdominalis into which the balloon-tip catheter had been inserted. The swollen balloons were at exactly the correct junction, indicating that perfusion had been a complete success. He looked down to find the ureter, a minute threadlike tube running from the kidney to the bladder. In order to ensure an easy extraction, Yoshizumi peeled away the surrounding tissue, then severed the ureter near the ileum, leaving only the kidney veins and arteries to be cut. If these incisions were miscalculated, it would impede the transplant later on. Yoshizumi could no longer be so haphazard. He progressed cautiously as he peeled away extraneous blood vessels.

"Thirty minutes."

When extracting both kidneys, they were not severed and taken out one at a time, but were removed simultaneously, with the blood vessels between them still attached. Only then were they separated.

Yoshizumi ordered that preparations be made for transport. After both kidneys had been extracted, they would be separated so that one could be delivered to the .

Upon checking to see that the a.s.sistants had set up the storage device, which contained extracellular fluid, he cut off the upper portions of the lower kidney arteries and motioned that the perfusate now be stopped. He then promptly cut the aorta abdominalis. The a.s.sistant held both kidneys gently and shifted them over to a lower area. A nurse supported the a.s.sistant, keeping close watch on the delicate blood vessel tips. The two kidneys were now attached only to the arteries and veins stretching from the lumber artery. Yoshizumi cut these now.

OK, he thought to himself.

The first a.s.sistant scooped up the kidneys and placed them into a stainless steel tray.

"Thirty-six minutes," the nurse stated.

"We're separating the kidneys. Get the coordinator in here."

The nurse ran out of the room. Yoshizumi took the two lumps sitting on the tray into his hands and examined them carefully, checking the arrangement and length of each blood vessel with scrupulous care. Every kidney's anatomy varied subtly depending on the person.

At times, the shape of the blood vessels did not quite match up. A close inspection was imperative at this point to ensure a smooth transplant.

Yoshizumi carefully separated the two precious organs. Odagiri entered in an operating gown and with a shipping bag, from which a container was quickly removed.

"Take the right one," he said. "It looks fine, and it should do just fine. It has a healthy ureter, artery and vein all intact."

"Time?"

"Thirty-eight minutes," the nurse responded.

"Got it." Odagiri timed her watch while Yoshizumi placed the kidney into the container. She picked up the bag and left the room after a brief thank you. She was now responsible for the organ until it reached the neighboring prefecture. A two-hour drive awaited her.

Without even waiting for Odagiri's departure, the first a.s.sistant began setting up the cold storage container for the other kidney. He ran a perfusate through the kidney and watched as the meter sprang to life. He adjusted the pressure until the meter indicated SO.

"Forty minutes," the nurse announced.

"There, it's done."

However, the procedure was only half finished. Yoshizumi now had to return to the CCH and perform Mariko's transplant. They immediately rounded up all of their equipment and exited the OR.

Yoshizumi gave a quick word to the head doctor. "We have one more procedure to attend to. We're heading back to the central hospital now. Thank you for all your help."

The doctor responded vaguely. Yoshizumi turned around and was about to go meet up with his a.s.sistants when the doctor muttered something under his breath. "Why the liver...?"

"Hm?"

Not grasping the doctor's meaning, Yoshizumi stopped in his tracks and turned back, looking questioningly at the doctor, whose brow was furrowed.

"It's the donor's family," said the doctor, sounding perplexed. "Her husband from the School of Pharmaceutical Sciences, to be more exact. He requested that we remove the donor's liver as well...he wants her liver cells."

"What for?" Yoshizumi's eyes widened. He could not even begin to fathom such a request.

"Dr. Yoshizumi!" his two a.s.sistants called, waiting impatiently outside the door. He looked back and forth between them and the doctor, whom he wished to hear out in more detail, but there was simply no time to do so.

"If you'll excuse me, "Yoshizumi said and took off.

11.

Soon after the kidney extraction, Kunio Shinohara commenced perfusion of the liver.

Toshiaki had called him around two o'clock to say that Kiyomi's operation was soon approaching, and Shinohara had been standing by in his office after finishing his usual business. In order to obtain liver cells with high viability, they could not afford to waste a second. Shinohara had made various preparations in advance so that he could leave for the OR at any moment. He had also caught hold of one of his medical students and primed him for a.s.sistance.

He was contacted again by Toshiaki at 5:50 when the extraction was underway.

Shinohara, along with the student, brought everything to the hospital. He placed cultivation liquid into an incubator, setting it to 37 C. He put on an operating gown and awaited word that the transplant crew had completed their operation. Shinohara then entered the OR at 6:15. He laid out a plan of action to his student, allowing him to ready the perfusion equipment and HEPES buffer solution.

Kiyomi's abdomen was left open. The liver shone with a tan color and looked to be in good condition. It appeared to have no imperfections of any kind. The transplant team had been very expeditious. It would be easy, he thought, to procure viable, fresh cells. He felt strangely moved by the thought that Toshiaki's wife had been beautiful down to her liver.

He wiped the area around the organ with care and judged arterial elasticity by pushing with his fingertips. Meanwhile, his student led a tube from the buffer, pa.s.sed it through a pump, and attached it to a polyethylene cannula. After clamping back the liver artery, Shinohara cut away the hepatic vein on the left side and swiftly inserted the cannula. The student flipped on the pump switch. Blood flushed out from the left side of the liver; it gradually turned a yellow ochre, the organ's actual color. The student confirmed the flow rate as adequate and the buffer was circulated for twenty minutes.

Primary cultures on liver cells were a standard procedure in modern-day laboratories all around the world. Liver cells were extracted and cultured, then subjected to drugs and the changes observed to investigate their various regenerative mechanisms. However, procuring cells from living people was difficult unless you had ties to clinical medicine, so the many researchers, like Toshiaki Nagashima, who worked in pharmaceuticals used raw materials from rats. Though they were good to work with, rat liver cells were of a slightly different structure than human cells, especially in the arrangement of their enzymes.

Currently, the most popular way to get liver cells of high viability was to take them from transplant organ donors. The quality of the cells differed according to age, so in most cases donors from about age 18 to 30 were preferred. Many of the donors selected were those who had died in car accidents. They differed from patients who'd died of illness in that they had not been receiving any drugs for treatment. There were no worries as to the effects of such drugs on the liver.

The perfusion was running smoothly. Shinohara's a.s.sistant removed a second buffer from the incubator, into which he had mixed a collagenase and sodium chloride solution. The perfusion solution was then exchanged with this mixture. They waited for yet another twenty minutes. The collagenase would ease the unbinding of the liver cells.

Shinohara gazed somewhat hesitantly upon the innards taken from Kiyomi's covered body. The sheets did nothing to hide her delicate curves. He thought back to the wedding two years ago between Toshiaki and the corpse that now lay before him. As the best man, Shinohara, who wasn't used to giving speeches, spoke nervously in front of the entire gathering. Kiyomi had just turned 23, but her carefree expression and the innocent look in her eyes had been more that of a high school student. When he complimented her on being such a ravishing bride, this corpse had blushed and looked over bashfully to Toshiaki. How had things been going for them? Shinohara couldn't seem to recall any details.

The left side of the liver now appeared nominal. He pushed around gently. It felt soft to the touch, indicating that the collagenase had done its job. Shinohara checked his stopwatch.

The perfusion period was complete. As he prepared some Leibovitz solution, he told his student to inform Toshiaki, who was waiting outside, that it would only be a little longer.

Shinohara cut off the left side of the liver with a scalpel. After checking its weight, he transferred it into the temperature-controlled Leibovitz solution. When he shook the flask lightly, the liver sample broke up slowly. Some more shaking would do it. The rest was lab work.

Before leaving the OR, Shinohara capped the flask to prevent bacteria from getting in.

Toshiaki, who was leaning against the wall in the hallway, snapped to attention like a rubber band and ran up to Shinohara. His face was jaundiced and lifeless, but as soon as he recognized what was in Shinohara's hand his bloodshot eyes livened up immediately. He sighed with joy.

"Everything went well," said Shinohara as coolly as possible. "I haven't swashed it yet, though. Be gentle when running it in the centrifuge. About SO G's should do it. And be sure to dispose of any debris that seeps through the gauze. I a.s.sume you know all this already, but I just want to make sure..."

"Yes, of course."

Toshiaki plucked the flask from Shinohara's hand and placed it into an ice box. He grasped it like some sacred object and thanked Shinohara earnestly as he made to leave. He would now return to the lab to purify the cells. Was he deceiving Kiyomi's parents by doing this? Toshiaki kept close watch over the box, an overt obsession in his tear-stricken eyes. No matter how Shinohara looked at it, these [were not the actions of a sound human being, and he suddenly regretted what he had done. He tried to convince himself that he had not just taken a vital organ out of his friend's dead wife, that he had not yielded to Toshiaki's insane desire.

"Nagashima, you sure you're okay? Is that all you need?"

Toshiaki stopped. He turned around slowly and glared back at Shinohara, then spoke in a low voice.

"Why wouldn't I be okay?"

"Don't you feel like you're doing something weird here? Are you just going to leave her folks behind? How about her remains? Shouldn't you want to be with her right now?"

"Her remains? What are you talking about?"

He seemed taken aback by the question. Shinohara felt cold. Toshiaki's face slowly changed in appearance as he gazed pitiably upon the box clutched at his side. His harried expression was gone. Toshiaki stroked the box quietly and there was a disturbing gleam in his eyes.

"I'll be back in three hours "Toshiaki said. "But please, don't be mistaken. Kiyomi isn't dead yet."

He left Shinohara to stand there by himself with only the sound of hurried footsteps fading along the wintry hallway of the ICU.

12.