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Kidney Transplant

Chronic Kidney Disease stage 5 (or irreversible kidney failure requiring dialysis) is a life-threatening problem. The options before a patient are life-long dialysis (hemodialysis or peritoneal dialysis). While dialysis is a lifesaving option, it entails undergoing hemodialysis three times a week for 4 hours each time. Even with the best dialysis the patient's creatinine stays at around 5 – 10 mg/dl, which means the patient is never free of toxins. Dialysis is thus capable of replacing lost kidney function by only about 25%. This means there is continuing damage to the vital organs and the blood vessels. Almost 50 percent patients on dialysis die in three years and about 90 percent in five years. If a 100 patients undergo transplant today, 85 of them would be alive 10 years and beyond. Added to this, the high chance of HCV+ infection, which is not easily curable, and the loss of a job (patient comes to hospital three times a week!), dialysis paints a dismal picture.

The definitive treatment for chronic kidney failure is Kidney Transplantation. Transplantation treats and normalizes all the biochemical, hemodynamic and metabolic abnormalities of kidney failure. A transplanted individual's creatinine becomes normal (around 1mg/dl) and replaces lost kidney function by 80 – 100%. Transplantation bestows full functionality to the patient, who can now work, play and even procreate. After 10 years of transplantation, more than 85% of patients are alive and well. Thus transplantation is the best option for chronic kidney failure. (See the survival graph of dialysis and transplantation)

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Only one donated kidney is needed to replace two failed kidneys. The donor kidney is usually placed in the groin of the patient and connections are made between the graft and patient's arteries, veins and the ureter is connected to the bladder. The diseased kidneys are not removed in the majority and so the patient now will have 3 kidneys though only one is functional. For a transplant to succeed, two factors are desirable, although they were earlier thought to be absolutely essential. Blood group compatibility between recipient and donor was (for compatible blood groups click here) hitherto considered a must, but is now not a barrier anymore. Likewise, the recipient must not exhibit any antibodies against the donor tissue, termed a positive cross-match. Even though this is not a contraindication anymore, it definitely carries more risk.

Kidney transplants are of two types. Live (from 1st or 2nd degree relatives) or cadaver (brain-dead donors). Donation from unrelated or commercial donation is not acceptable and is illegal. You cannot buy a kidney. 1st degree relatives are parents, siblings, children and spouse. 2nd degree relatives are uncle, aunts, cousins, in-laws etc where the relationship can be proven by tissue-matching, DNA finger-printing or other means.

Transplantation of an organ from a different individual incites immunological attack from the recipient, which is termed as rejection. Transplantation is possible only because of medications called Immunosuppressants. These medications work by reducing the immunological resistance of the recipient and prevent rejection. These medicines are to be taken life-long. The type of immunosuppression depends on the matching between recipient and donor.

Kidney transplantation involves the donation of a single kidney from a donor. The donor is a medically normal individual, is expected to live a fully normal life after donation and will have no problems. Donors have to be aged above 18 years and preferably below 60 years and should have no medical disorders that can affect the remaining normal functioning kidney later on. So those with diabetes, kidney stones, cardiac disorders, cancers are not accepted as donors. Donors are allowed to donate only after a thorough counseling and medical check-up including kidney function tests. After donation, the donor's kidney function does not decrease and remains the same as prior to donation due to the immense reserve capacity of the kidneys. After donation the donor can continue to work, play and live as before.

Transplantation is a modern medical miracle, which is saving countless number of lives and bestows a great quality of life. For patients with Chronic Kidney Disease stage 5 the first option is to get a transplant. Those who cannot undergo a transplant are condemned to stay on dialysis. The question is not whether transplantation will succeed. Transplants have a success rate 95 – 98% in the modern era. It is dialysis which has a high rate of failure from which there is no return.

Our kidneys remove excess fluid and waste from your blood. When our kidneys lose their filtering ability, dangerous levels of fluid and waste accumulate in your body — a condition known as kidney failure

Marked improvements in early graft survival and long-term graft function have made kidney transplantation a more cost-effective alternative to dialysis.

A kidney transplant is a surgical procedure to place a functioning kidney from a donor into a person whose kidneys no longer function properly. The one who donates kidney is called donor, the one who receives the kidney is called recipient.

Description

Renal transplantation has become the treatment of choice for most patients with end-stage renal disease (ESRD). Kidney transplants are one of the most common transplant operations. Only one donated kidney is needed to replace two failed kidneys, making living-donor kidney transplantation an option. If a compatible living donor isn't available for a kidney transplant, patient’s name may be placed on a kidney transplant waiting list to receive a kidney from a deceased donor. The wait could be a few years

The donated kidney may be from:

  • Living related donor - related to the person receiving the transplant, such as a parents, spouse, sibling, child, or grandparents.
  • Living unrelated donor - such as a cousins
  • Deceased donor - a person who had a brain death and who has no known chronic kidney disease

For Living donation:

Any healthy person can safely donate a kidney. The donor must have good health condition for donation. Recipient family members are screened and a potential donor is chosen from the family. Recipient and donor will be evaluated by the team of doctors at the transplant center. They want to make sure that both recipient and donor are fit for kidney transplant. Need to have several visits over a period of 1 or 2 weeks for evaluation.

After all required consultations and investigations legal clearance should be given by the hospital committee after all the clearance transplant would be posted.

Both recipient and donor, he/she will be placed under general anesthesia before surgery. This means he/she will be asleep and pain-free. These days donor are often operated with small surgical cutswith laparoscopic techniques to remove the kidney.The recipient will have a cut in the lower belly area. The new kidney is placed inside the lower belly. The artery and vein of the new kidney are connected to the artery and vein in pelvis. Blood flows through the new kidney, which makes urine just like the old kidneys did when they were healthy. The tube that carries urine (ureter) is then attached to the bladder.

  • Damaged kidneys are left in place unless they are causing a medical problem, unless they are causing high blood pressure, infections, or are too large for the body.

Kidney transplant surgery takes about 3 to 4 hours. People with diabetes may also have a pancreas transplant done at the same time. This can add another 3 hours to the surgery.

For deceased donor

Recipient will be evaluated by the team of doctors at the transplant center. After the medical clearance recipient is enrolled for cadaver or deceased donor transplant waiting list.

For adults, the amount of time they spend on a waiting list is not often a factor in how soon one get a kidney. Most people waiting for a kidney transplant are on dialysis.

In cadaver transplant a person who meet with an accident or by any other reason becomes brain-dead (or "beating heart") he is considered dead he can be a cadaveric or deceased donor. The donor's heart continues to pump.He is maintained on ventilator and inotropic support. Donor’s attender’s are counselled and after obtaining the written consent donor’s organs are retrieved. A recipient is selected with the coordination of jeevandam team. Recipient who is awaiting in the list should be always ready to attend the hospital whenever there is a call from the hospital. After some required investigations and cross matching with the donor are negative then the recipient is admitted and posted for emergency transplant.

A kidney transplant may NOT be done if you have:

  • Certain infections, such as TB or bone infections
  • Heart, lung, or liver disease
  • Other life-threatening diseases
  • Recent history of cancer
  • Smoking, alcohol or drug abuse, or other risky lifestyle habits

Risks

Specific risks related to this procedure include:

  • Blood clots (deep venous thrombosis)
  • Heart attack or stroke
  • Wound infections
  • Side effects from medicines used to prevent transplant rejection

After the Procedure

Post transplant recipient will need to stay in the hospital for about 7- 10 days and donor will need to stay in the hospital for about 5-7 days(in living transplant). They will need close follow-up by a doctor and regular blood tests for verifying how the transplanted kidney is functioning.

Often, transplant team will ask the patient to stay close to the hospital for the first 3 months as they need to have regular check-ups with blood tests and other’s as required.

Outlook (Prognosis)

Recipient has a better quality of life after the transplant. Those who receive a kidney from a living related donor do better than those who receive a kidney from a cadaver donor. After donating a kidney, donor can usually live safely without complications with one remaining kidney.

People who receive a transplanted kidney may reject the new organ. This means that their immune system sees the new kidney as a foreign substance and tries to destroy it. In order to avoid rejection, all kidney transplant recipients must take medicines that suppress their immune response for the rest of their life. This is called immunosuppressive therapy. Although the treatment helps prevent organ rejection, it also puts patients at a risk for infection. The medicines may also cause high blood pressure and high cholesterol and increase the risk for diabetes.

A successful kidney transplant requires close follow-up with your doctor and one must always take there medicine as directed.

Recipients are recommended to follow the following

  • Follow the diet transplant team recommends.
  • Drink to of fluids
  • Do not drink alcohol.
  • Do not smoke.
  • Weight must be in the range that has been recommended.
  • Regular exercise program is recommended.
  • All medicines that are prescribed are to be taken strictly without missing a single dose.
  • Report any changes in medicines and any new or worsening medical problems to the transplant team immediately.
  • Need to have regular visits with the transplant team.
  • Make sure the transplant team has the correct phone numbers so they can contact right away if a kidney becomes available. Always make sure that you can be contacted quickly and easily.
  • Have everything ready in advance to go to the hospital in case of a cadaver.

ABO – Incompatible Kidney Transplantation

Kidney or renal transplantation is the transplant of a kidney into a patient with end-stage renal disease. Kidney transplantation is typically classified as deceased-donor (also known as cadaveric) or living-donor transplantation depending on the source of the donor organ. Living-donor renal transplants are further characterized as genetically related (living-related) or non-related (living-unrelated) transplants, depending on whether a biological relationship exists between the donor and recipient.

Renal transplantation has become the treatment of choice for most patients with end-stage renal disease (ESRD). Kidney transplants are one of the most common transplant operations. Only one donated kidney is needed to replace two failed kidneys, making living-donor kidney transplantation an option. If a blood group compatible living donor isn't available for a kidney transplant, an ABO incompatible transplant can be performed. If no donor is available in the family, then the patient may get on to the waiting list to receive a kidney from a deceased donor. The wait could be about four years.

Related donors are preferred because the excellent genetic matching confers a low rejection risk and thus a longer life for the transplant kidney. This added to a huge shortage of cadaver donors makes those patients who have related donor fortunate indeed. Most patients on the cadaver list die waiting for a kidney. Related donors (father, mother, siblings, spouse, cousins, in-laws) usually step forward to donate.

However, even if they were deemed medically fit to donate, they were rejected if their blood groups weren’t matching. For e.g. blood groups A and O can donate to A; B and O can donate to B; anyone (A, B, AB and O) can donate to AB; and only O can donate to O. (for compatible blood groups click here).


Any transplants done against these rules would cause immediate rejection of the kidney. Due to this blood group divide, up to 40% of donors were deemed unsuitable earlier. Non-matching blood groups are called ABO incompatible. ABO-Incompatibility was an absolute contraindication to transplantation.

Now, due to medical advances and newer technologies, transplanting across any blood group is a routine affair. ABO incompatible transplantation involves two processes; removal of existing antibodies and preventing rebound formation of antibodies. The methods of removing existing antibodies are plasmapheresis, double filtration plasmapheresis (DFPP) or Immunoadsorption. An adult human may have a total blood volume of about 5 liters of which 2 liters are red blood cells, white blood cells and platelets. The remainder 3 liters are plasma which contains all protein, antibodies and clotting factors. Plasmapheresis removes these 3 liters which is replaced by plasma or albumin. (For a list of blood groups and antibodies click here)


ABO incompatible transplantation differs from a compatible transplant only in the procedures performed prior to the surgery. After transplantation the risk of rejection, risk of infection and the longevity of the kidney are the same in both the kinds of transplants.

Across the world ABO incompatible transplantations are being done regularly in Sweden, Germany, USA and Japan. The first cadaveric kidney transplantation was performed in USA in 1950. ABO-incompatible transplantation was already performed as early as in the 1970s, but due to hyperacute rejection, the results were discouraging. But, due to a severe shortage of available deceased donor organs, most ABO-incompatible kidney transplantations have taken place in Japan. Published data demonstrate an excellent long-term outcome of ABO-incompatible living donor kidney patients in Japan. Similar successful short-term results have been shown for protocols developed in Europe and the United States.

An ABO incompatible transplant costs only about 15% more than that of a related transplant and almost similar to a cadaveric transplant. The slightly higher cost is due to the cost of the extra medications and the Immunoadsorption device or plasmapheresis. For a patient who has no blood group matched donors, the costs of prolonged dialysis and the high risk of death while waiting for a cadaver transplant, more than justify the small extra cost of an ABO-incompatible transplant.

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