Kidney Transplant

A kidney transplant is a surgery done to replace a diseased kidney with a healthy kidney from a donor. It is often needed for end stage renal disease (ESRD), a permanent condition of kidney failure. The procedure may involve risks and complications, but it can significantly improve the quality of life for people with ESRD.

What Kidney(s) Do?

The kidneys, vital for sustaining life, are organs located on either side of the spine, behind the abdominal organs and below the rib cage. They play a crucial role in maintaining a healthy body by performing various important functions.

These functions include filtering the blood to eliminate waste products generated by normal bodily processes, expelling the waste as urine, and reabsorbing water and necessary chemicals back into the body. The kidneys also contribute to regulating blood pressure by releasing certain hormones and stimulate the production of red blood cells through the release of erythropoietin.

The kidneys have a typical structure resembling two kidney bean-shaped organs that produce urine. Urine is then transported to the bladder through the ureters, where it is stored. When the bladder detects it is full, the urine is expelled from the bladder through the urethra.

What are Kidney Diseases?

Renal failure arises when the kidneys cease to function properly. If this condition persists over time (chronic renal failure), it leads to end-stage renal disease, characterized by the build-up of harmful waste substances in the body. In such cases, either dialysis or transplantation becomes necessary for treatment.

Frequent Causes of End-Stage Renal Disease:

Diabetes mellitus
Hypertension (high blood pressure)
Glomerulonephritis
Polycystic Kidney Disease
Severe structural abnormalities affecting the urinary tract

When Kidney Fails…

End-stage renal disease can be managed through various treatments, including hemodialysis, a mechanical process that eliminates waste products from the blood; peritoneal dialysis, which involves passing chemical solutions through the abdominal cavity to remove waste products; and kidney transplantation.

However, it is important to note that none of these treatments provide a cure for end-stage renal disease. Among the available options, kidney transplantation offers the closest approximation to a normal life since the transplanted kidney can replace the failed kidneys. Nonetheless, this approach necessitates a lifelong reliance on medications to maintain the health of the transplanted kidney, some of which may have significant side effects.

Patients with kidney disease may contemplate transplantation either before commencing dialysis or after initiating dialysis. In certain cases, individuals on dialysis who also have severe medical conditions such as cancer or active infections may not be suitable candidates for a kidney transplant.

Why Might I Need a Kidney Transplant?

ESRD is a permanent condition of kidney failure, and it often requires dialysis to remove wastes and other substances from the blood. The kidneys play a critical role in removing urea and liquid waste from the blood in the form of urine, balancing salts, electrolytes such as potassium and sodium, and other substances in the blood, producing erythropoietin, a hormone that aids the formation of red blood cells, regulating blood pressure, and regulating fluid and acid-base balance in the body to keep it neutral.

Some conditions of the kidneys that may result in ESRD include repeated urinary infections, kidney failure caused by diabetes or high blood pressure, polycystic kidney disease or other inherited disorders, glomerulonephritis (inflammation of the kidney’s filtering units), hemolytic uremic syndrome (a rare disorder that causes kidney failure), lupus and other diseases of the immune system, and obstructions. Other conditions, such as congenital defects of the kidneys, may also result in the need for a kidney transplant.

What is a Kidney Transplant?

A kidney transplant is a surgery that involves replacing a diseased kidney with a healthy kidney from a donor. The kidney may come from a deceased organ donor or a living donor. Family members or others who are a good match may be able to donate one of their kidneys. This type of transplant is called a living transplant. People who donate a kidney can live healthy lives with one healthy kidney.

A person getting a transplant most often receives just one kidney. In rare situations, he or she may receive two kidneys from a deceased donor. The diseased kidneys are usually left in place, and the transplanted kidney is placed in the lower belly on the front side of the body.

What are the Risks for Kidney Transplant?

As with any surgery, complications can occur. Some complications may include bleeding, infection, blockage of the blood vessels to the new kidney, leakage of urine or blockage of urine in the ureter, and lack of function of the new kidney at first.

The new kidney may be rejected. Rejection is a normal reaction of the body to a foreign object or tissue. When a new kidney is transplanted into a recipient’s body, the immune system reacts to what it thinks as a threat and attacks the new organ. For a transplanted organ to survive, medicines must be taken to trick the immune system into accepting the transplant and not attacking it as a foreign object.

The medicines used to prevent or treat rejection have side effects. The exact side effects will depend on the specific medicines that are taken. Not everyone is a candidate for kidney transplantation. You may not be eligible if you have a current or recurring infection that cannot be treated effectively, cancer that has spread from its original location to elsewhere in the body, severe heart or other health problems that make it unsafe to have surgery, serious conditions other than kidney disease that would not get better after transplantation, or failing to follow the treatment plan.

How do I prepare for a kidney transplant?

If you have been diagnosed with end-stage renal disease, a kidney transplant can offer a new lease of life. However, before you can undergo the transplant, there are several essential preparations that you need to go through. Here is everything you need to know about how to prepare for a kidney transplant.

Evaluation Process for a Kidney Transplant

To get a kidney from an organ donor who has died (cadaver), you must be placed on a waiting list of the United Network for Organ Sharing (UNOS). Before you can be placed on the transplant list, extensive testing must be done. A transplant team carries out the evaluation process for a kidney. The team includes a transplant surgeon, a transplant nephrologist, one or more transplant nurses, a social worker, and a psychiatrist or psychologist. Other team members may include a dietitian, a chaplain, and/or an anesthesiologist.

The evaluation includes the following:

Mental Health Evaluation

Psychological and social issues involved in organ transplantation, such as stress, financial issues, and support by family and/or significant others, are assessed. These issues can greatly affect the outcome of a transplant. The same kind of evaluation is done for a living donor.

Blood Tests

The initial examination is conducted to determine an individual’s blood type, which falls into one of four categories: A, B, AB, or O. Each person belongs to one of these hereditary groups. In order for a successful transplantation to occur, the recipient and the donor should have either the same blood type or compatible types, unless they are participating in a specialized program that allows for donation across different blood types. The following list outlines the compatible blood type combinations:

If the recipient’s blood type is A, the donor’s blood type must be A or O.
If the recipient’s blood type is B, the donor’s blood type must be B or O.
If the recipient’s blood type is O, the donor’s blood type must be O.
If the recipient’s blood type is AB, the donor’s blood type can be A, B, AB, or O.
It is relatively easier to find a suitable match for individuals with AB blood type, as they can accept donations from individuals with any other blood type.

On the other hand, blood type O presents more challenges in finding a compatible match. Although individuals with blood type O can donate to individuals with any blood type, they can only receive kidneys from donors with blood type O. For instance, if a patient with blood type O were to receive a kidney from a donor with blood type A, the body would identify the donor kidney as foreign and reject it.

Tissue Typing

The second examination, known as tissue typing, involves a blood test to assess human leukocyte antigens (HLA). Antigens are markers present on various cells in the body that distinguish each individual as unique. These markers are inherited from parents. Both recipients and potential donors undergo tissue typing as part of the evaluation process.

Ideally, a kidney transplant where the markers of the recipient and the donor perfectly match is considered a “perfect match” kidney. Such transplants have the highest likelihood of long-term success. Most cases of perfect match kidney transplants involve siblings.

However, even if there is a partial or absent HLA match between the recipient and the donor, tissue typing is still performed, allowing for some degree of “mismatch” between the two.

Crossmatch

Throughout a person’s life, their body produces antibodies, which serve to eliminate foreign substances. Antibodies can be generated in response to infections, pregnancy, blood transfusions, or kidney transplants. In the case of having antibodies against a donor kidney, the body might reject the transplanted organ. To prevent this, a test called a crossmatch is conducted when a donor kidney becomes available to ensure that the recipient does not possess pre-formed antibodies targeting the donor.

The crossmatch test involves mixing the recipient’s blood with cells from the donor. A positive crossmatch indicates the presence of antibodies directed against the donor. In such instances, the recipient should not receive that specific kidney unless a special treatment is administered before transplantation to decrease the antibody levels. Conversely, a negative crossmatch indicates the absence of antibodies against the donor, making the recipient eligible to receive the kidney.

Crossmatches are performed multiple times during the preparation for a living donor transplant, and a final crossmatch is conducted within 48 hours before the transplantation takes place.

Diagnostic Tests

Diagnostic tests may be done to check your kidneys as well as your overall health status. These tests may include X-rays, ultrasound, kidney biopsy, and dental exams. Women may get a Pap test, gynecology evaluation, and a mammogram.

Additionally, screening is conducted to detect the presence of viruses, including HIV (human immunodeficiency virus), hepatitis, and CMV (cytomegalovirus), in order to determine the appropriate preventive medications following transplantation. The purpose of checking for these viruses in potential donors is to mitigate the risk of transmitting diseases to the recipient.

Once the transplant team weighs all the facts from interviews, your medical history, physical exam, and tests, they will determine your eligibility for kidney transplantation. If you are accepted as a transplant candidate, you will be placed on the UNOS list. When a donor organ becomes available, you will be notified and told to come to the hospital right away.

Living-Related Transplant

If you’re receiving a kidney from a living family member, the transplant may be scheduled in advance. The donor must have a compatible blood type and be in good health. A mental health evaluation will also be conducted to ensure the donor is comfortable with the decision.

Preparing for the Transplant

Before the transplant, your transplant team will provide you with information about the procedure and answer any questions you may have. You’ll also be asked to sign a consent form.

If you’ve been on routine dialysis before the procedure, you’ll receive dialysis before the operation. For a planned living transplant, you’ll need to fast for 8 hours before the procedure. In the case of a cadaver organ transplant, you’ll need to start fasting as soon as you’re told a kidney is available.

You may be given a sedative to help you relax, and your transplant team may ask for additional preparation depending on your medical condition.

Preparing for Kidney Transplant

During this period, which encompasses the time a patient spends on the deceased donor waiting list or prior to completing the evaluation of a potential living donor, the recipient undergoes various tests to ensure the safety of the transplant operation and their ability to tolerate the necessary anti-rejection medication. The specific tests conducted depend on factors such as age, gender, the cause of renal disease, and other concurrent medical conditions. Some of the tests may include, but are not limited to:

General Health Maintenance:

Comprehensive metabolic laboratory tests
Coagulation studies
Complete blood count
Colonoscopy
Pap smear and mammogram (for women)
Prostate examination (for men)

Cardiovascular Evaluation:

Electrocardiogram (ECG)
Stress test
Echocardiogram
Cardiac catheterization

Pulmonary Evaluation:

Chest x-ray
Spirometry

There are certain conditions or circumstances that may result in the exclusion of a transplant recipient, which can include:

Irreparable cardiovascular disease
History of metastatic cancer or ongoing chemotherapy
Active systemic infections
Unmanageable psychiatric illness
Current substance abuse
Existing neurological impairment with significant cognitive decline and no surrogate decision-maker.

What Happens During a Kidney Transplant?

A kidney transplant is a complex surgical procedure that requires careful preparation and monitoring. By understanding what to expect during the surgery, you can approach the procedure with greater confidence and peace of mind. If you have any questions or concerns about the surgery, be sure to talk to your healthcare provider to get the information you need to make informed decisions. When the day of the surgery arrives, you will be taken to the hospital and will undergo the following procedure:

Hospital Admission and Preparation

You will be asked to remove your clothing and wear a hospital gown. An IV line will be started in your arm or hand, and additional catheters may be placed in your neck and wrist to monitor your heart rate, blood pressure, and blood samples. A urinary catheter will also be inserted into your bladder.

Anaesthesia and Positioning

You will be positioned on the operating table, lying on your back. The surgery will be performed under general anaesthesia, which means that you will be asleep during the procedure. A tube will be inserted through your mouth into your lungs, and a ventilator will breathe for you during the surgery. Your anaesthesiologist will closely monitor your heart rate, blood pressure, breathing, and blood oxygen levels during the procedure.

Surgical Procedure

Once you are under anesthesia, the surgeon will make a long incision in your lower abdomen on one side. The donor kidney will be inspected visually before being implanted. Then, the donor kidney will be placed into your belly, with the left kidney implanted on your right side and the right kidney implanted on your left side. This makes it easier to access the ureter, which will be connected to your bladder.

The renal artery and vein of the donor kidney will be sewn to the external iliac artery and vein. After the attachment of the artery and vein, the blood flow through these vessels will be checked for bleeding at the suture lines. The donor ureter, which is the tube that drains urine from the kidney, will be connected to your bladder.

Closure and Post-Operative Care

The incision will be closed using surgical staples or stitches. A drain may be placed in the incision site to reduce swelling, and a sterile bandage or dressing will be applied. You will be taken to a recovery room where you will be closely monitored for any complications. The length of the hospital stay will vary depending on your condition and your healthcare provider’s practices.

What happens after a kidney transplant?

Kidney transplantation is a lifesaving procedure that replaces a diseased kidney with a healthy one from a living or deceased donor. After the surgery, the road to recovery can be a long one. Understanding what happens after a kidney transplant can help you prepare for your hospital stay and the recovery process. Here’s what you can expect:

IN THE HOSPITAL

After the surgery, you will be taken to the recovery room where your vital signs will be closely monitored until you are stable and alert. Depending on your condition, you may be moved to the ICU for more intensive care. In time, you will be transferred to a regular nursing unit as you recover and prepare to go home. Expect to spend several days in the hospital following your transplant.

URINE OUTPUT

If you received a kidney from a living donor, it may start producing urine right away. However, in a cadaver kidney, urine production may take longer. You may need to continue dialysis until urine output is normal. A catheter will be placed in your bladder to drain urine, and the amount will be measured to check the new kidney’s function.

FLUIDS AND MEDICATIONS

You will receive IV fluids until you are able to eat and drink on your own. Your transplant team will closely monitor your antirejection medications to ensure that you are receiving the best dose and combination of medicines. Blood samples will be taken frequently to check the status of the new kidney and other body functions, such as the liver, lungs, and blood system.

DIET AND ACTIVITY

Your diet will slowly progress from liquids to more solid foods as tolerated. Your fluids may be limited until the new kidney is working fully. Typically, by the day after the procedure, you may start moving around. It’s important to get out of bed and move around several times a day. Take pain relievers for soreness as advised by your healthcare provider. Avoid aspirin or other pain medications that may increase the chance of bleeding.

POST-TRANSPLANT EDUCATION

Before discharge, members of your transplant team will teach you how to care for yourself at home, including care for your incisions. They will also explain when to call for help if you experience any complications. You will be ready to go home when your vital signs are stable, the new kidney is functioning well, and you do not need constant hospital care.

AT HOME

Once you’re home, it’s important to keep the surgical area clean and dry. Avoid submerging the incision in water until the skin heals to reduce the risk of infection. Your stitches or surgical staples will be removed during a follow-up office visit. Do not drive until your healthcare provider tells you it’s okay. Avoid any activity or position that causes pressure on the new kidney.

MONITORING YOUR HEALTH

Check your blood pressure and weight at home every day. Increases in these may indicate that your kidneys are not filtering fluids properly, and you need to see your transplant team promptly. Notify your healthcare provider immediately if you experience fever, redness, swelling, or bleeding from the incision site or an increase in pain around the incision site, as these may be signs of rejection or infection.

What is done to prevent rejection?

Tailored Medication Regimes

Antirejection medications, also known as immunosuppressants, are continually being developed and approved. The healthcare team will tailor medication regimes to meet the patient’s individual needs. Typically, several antirejection medications are given initially, and the doses may change frequently depending on the patient’s response.

However, it is essential to note that because these medications affect the immune system, patients are at higher risk for infections. A balance must be maintained between preventing rejection and making the patient susceptible to infection.

Risk of Infection

Patients who have undergone a kidney transplant are especially at risk of infections, such as oral yeast infections (thrush), herpes, and respiratory viruses. Therefore, it is crucial to avoid contact with crowds and anyone with an infection for the first few months after surgery.

Side effects of Anti-inflammatory Medication

Prednisone, taken orally or intravenously, is used at low dosages to minimize side effects. However, potential side effects of prednisone may include:

Changes in physical appearance, such as facial puffiness and weight gain.
Irritation of the stomach lining.
Increased risk of bruising and slower healing.
Elevated blood sugar levels (steroid-induced diabetes).
Unexplained mood changes, including depression, irritability, or high spirits.
General muscle weakness or joint and knee pain.
Infrequent occurrence of cataract formation with long-term use.

Side effects of Anti-proliferative Medications:

Azathioprine (Imuran®) may lead to:

Thinning of hair.
Irritation of the liver.
Decreased white blood cell count.

Mycophenolate mofetil (CellCept®) may cause:

Abdominal aches and/or diarrhea.
Decreased white blood cell count.
Decreased red blood cell count.

Mycophenolate sodium (Myfortic®), with the same active ingredient as mycophenolate mofetil, generally presents a similar side effect profile, but it is enterically coated to potentially reduce abdominal discomfort and diarrhoea.

Sirolimus (Rapamune®) may result in:

Decreased platelet count.
Decreased white blood cell count.
Decreased red blood cell count.
Elevated cholesterol and triglyceride levels.

Side effects of Cytokine Inhibitors:

Cyclosporine (Neoral®, Gengraf®) may cause:

Kidney dysfunction.
Tremors.
Liver irritation.
Excessive body hair growth.
High blood pressure.
Swollen or bleeding gums.
High potassium levels in the blood.
Increased blood sugar levels (drug-induced diabetes).

Tacrolimus (Prograf®) may lead to:

Kidney dysfunction.
High blood pressure.
High potassium levels in the blood.
Increased blood sugar levels (drug-induced diabetes).
Tremors.
Headaches.
Insomnia.

Side effects of Antilymphocyte Medications:

Antithymocyte globulin (Thymoglobulin®) given intravenously may cause:

Decreased white blood cell and platelet counts.
Sweating.
Itching.
Rash.
Fever.

Muromonab-CD3 (OKT3®) administered intravenously may result in:

Chills.
Fever.
Diarrhea.
Headache.
Shortness of breath.

Side effects of Anti-interleukin-2 Receptor Antibody (Zenapax® or Simulect®):

These drugs, given intravenously, rarely cause side effects but may include:

Chills.
Headache.
Allergic reaction.

Side effects of Alemtuzumab (Campath®):

Fever.
Chills.
Rash.
Shortness of breath.
Decreased white blood cell counts.