Kidney transplantation is a surgical procedure to remove a healthy, functioning kidney from a living or brain-dead donor and implant it into a patient with nonfunctioning kidneys.
Description
Kidney transplantation involves surgically attaching a functioning kidney, or graft, from a brain-dead organ donor (a cadaver transplant) or from a living donor, to a patient with ESRD. Living donors may be related or unrelated to the patient, but a related donor has a better chance of having a kidney that is a stronger biological "match" for the patient.
The surgical procedure to remove a kidney from a living donor is called a nephrectomy. The kidney donor is administered general anesthesia and an incision is made on the side or front of the abdomen. The blood vessels connecting the kidney to the donor are cut and clamped, and the ureter is also cut between the bladder and kidney and clamped. The kidney and an attached section of ureter is removed from the donor. The vessels and ureter in the donor are then tied off and the incision is sutured together again. A similar procedure is used to harvest cadaver kidneys, although both kidneys are typically removed at once, and blood and cell samples for tissue typing are also taken.
Laparoscopic nephrectomy is a form of minimally-invasive surgery using instruments on long, narrow rods to view, cut, and remove the donor kidney. The surgeon views the kidney and surrounding tissue with a flexible videoscope. The videoscope and surgical instruments are
maneuvered through four small incisions in the abdomen. Once the kidney is freed, it is secured in a bag and pulled through a fifth incision, approximately 3 in(7.6 cm) wide, in the front of the abdominal wall below the navel. Although this surgical technique takes slightly longer than a traditional nephrectomy, preliminary studies have shown that it promotes a faster recovery time, shorter hospital stays, and less post-operative pain for kidney donors.
Once removed, kidneys from live donors and cadavers are placed on ice and flushed with a cold preservative solution. The kidney can be preserved in this solution for 24-48 hours until the transplant takes place. The sooner the transplant takes place after harvesting the kidney, the better the chances are for proper functioning.
During the transplant operation, the kidney recipient patient is typically under general anesthesia and administered antibiotics to prevent possible infection. A catheter is placed in the bladder before surgery begins. An incision is made in the flank of the patient and the surgeon implants the kidney above the pelvic bone and below the existing, non-functioning kidney by suturing the kidney artery and vein to the patient's iliac artery and vein. The ureter of the new kidney is attached directly to the bladder of the kidney recipient. Once the new kidney is attached, the patient's existing, diseased kidneys may or may not be removed, depending on the circumstances surrounding the kidney failure.
Since 1973, Medicare has picked up 80% of ESRD treatment costs, including the costs of transplantation for both the kidney donor and recipient. Medicare also covers 80% of immunosuppressive medication costs for up to three years, although federal legislation was under consideration in early 1998 that may remove the time limit on these benefits. To qualify for Medicare ESRD benefits, a patient must be insured or eligible for benefits under Social Security, or be a spouse or child of an eligible American. Private insurance and state Medicaid programs often cover the remaining 20% of treatment costs.
Who Performs the Procedure and Where Is It Performed?
A kidney transplant is performed by a transplant surgeon in one of more than 200 UNOS-approved hospitals nationwide. If the patient has no living donor, he or she must go through an evaluation procedure to get on the UNOS national waiting list and the UNOS Organ Center's UNet database.
Questions to Ask the Doctor
How many kidney transplants have both you and the hospital performed?
What are your transplant success rates? How about those of the hospital?
Who will be on my transplant team?
Can I get on the waiting list at more than one hospital?
Will my transplant be performed with a laparoscopic or an open nephrectomy?
What type of immunosuppressive drugs will I be on post-transplant?
Definition
Kidney transplantation is a surgical procedure to remove a healthy, functioning kidney from a living or brain-dead donor and implant it into a patient with nonfunctioning kidneys.
Purpose
Kidney transplantation is performed on patients with chronic kidney failure, or end-stage renal disease (ESRD). ESRD occurs when a disease, disorder, or congenital condition damages the kidneys so that they are no longer capable of adequately removing fluids and wastes from the body or of maintaining the proper level of certain kidney-regulated chemicals in the bloodstream. Without long-term dialysis or a kidney transplant, ESRD is fatal.
Demographics
Diabetes mellitus is the leading single cause of ESRD. According to the 2002 Annual Data Report of the United States Renal Data System (USRDS), 42% of non-Hispanic dialysis patients in the United States have ESRD caused by diabetes. People of Native American and Hispanic descent are at an elevated risk for both kidney disease and diabetes.
Hypertension (high blood pressure) is the second leading cause of ESRD in adults, accounting for 25.5% of the patient population, followed by glomerulonephritis (8.4%). African Americans are more likely to develop hypertension-related ESRD than Caucasians and Hispanics.
Among children and young adults under 20 on dialysis, glomerulonephritis is the leading cause of ESRD
For a kidney transplant, an incision is made in the lower abdomen (A). The donor kidney is connected to the patient's blood supply lower in the abdomen than the native kidneys, which are usually left in place (B). A transplanted ureter connects the donor kidney to the patient's bladder (C). (Illustration by GGS Inc.)
(31%), and hereditary, cystic, and congenital diseases account for 37%. According to USRDS, the average waiting period for a kidney transplant for patients under age 20 is 10 months, compared to the adult wait of approximately two years.
Description
Kidney transplantation involves surgically attaching a functioning kidney, or graft, from a brain-dead organ donor (a cadaver transplant) or from a living donor to a patient with ESRD. Living donors may be related or unrelated to the patient, but a related donor has a better chance of having a kidney that is a stronger biological match for the patient.
Open Nephrectomy
The surgical procedure to remove a kidney from a living donor is called a nephrectomy. In a traditional, open nephrectomy, the kidney donor is administered general anesthesia and a 6–10-in (15.2–25.4-cm) incision through several layers of muscle is made on the side or front of the abdomen. The blood vessels connecting the kidney to the donor are cut and clamped, and the ureter is also cut and clamped between the bladder and kidney. The kidney and an attached section of ureter are removed from the donor. The vessels and ureter in the donor are then tied off and the incision is sutured together again. A similar procedure is used to harvest cadaver kidneys, although both kidneys are typically removed at once, and blood and cell samples for tissue typing are also taken.
Laparoscopic Nephrectomy
Laparoscopic nephrectomy is a form of minimally invasive surgery using instruments on long, narrow rods to view, cut, and remove the donor kidney. The surgeon views the kidney and surrounding tissue with a flexible videoscope. The videoscope and surgical instruments are maneuvered through four small incisions in the abdomen, and carbon dioxide is pumped into the abdominal cavity to inflate it for an improved visualization of the kidney. Once the kidney is freed, it is secured in a bag and pulled through a fifth incision, approximately 3 in (7.6 cm) wide, in the front of the abdominal wall below the navel. Although this surgical technique takes slightly longer than an open nephrectomy, studies have shown that it promotes a faster recovery time, shorter hospital stays, and less postoperative pain for kidney donors.
A modified laparoscopic technique called hand-assisted laparoscopic nephrectomy may also be used to remove the kidney. In the hand-assisted surgery, a small incision of 3–5 in (7.6–12.7 cm) is made in the patient's abdomen. The incision allows the surgeon to place his hand in the abdominal cavity using a special surgical glove that also maintains a seal for the inflation of the abdominal cavity with carbon dioxide. The technique gives the surgeon the benefit of using his or her hands to feel the kidney and related structures. The kidney is then removed through the incision by hand instead of with a bag.
Once removed, kidneys from live donors and cadavers are placed on ice and flushed with a cold preservative solution. The kidney can be preserved in this solution for 24–48 hours until the transplant takes place. The sooner the transplant takes place after harvesting the kidney, the better the chances are for proper functioning.
Kidney Transplant
During the transplant operation, the kidney recipient is typically under general anesthesia and administered antibiotics to prevent possible infection. A catheter is placed in the bladder before surgery begins. An incision is made in the flank of the patient, and the surgeon implants the kidney above the pelvic bone and below the existing, non-functioning kidney by suturing the kidney artery and vein to the patient's iliac artery and vein. The ureter of the new kidney is attached directly to the kidney recipient's bladder. Once the new kidney is attached, the patient's existing, diseased kidneys may or may not be removed, depending on the circumstances surrounding the kidney failure. Barring any complications, the transplant operation takes about three to four hours.
Since 1973, Medicare has picked up 80% of ESRD treatment costs, including the costs of transplantation for both the kidney donor and the recipient. Medicare also covers 80% of immunosuppressive medication costs for up to three years. To qualify for Medicare ESRD benefits, a patient must be insured or eligible for benefits under Social Security, or be a spouse or child of an eligible American. Private insurance and state Medicaid programs often cover the remaining 20% of treatment costs.
Patients with a history of heart disease, lung disease, cancer, or hepatitis may not be suitable candidates for receiving a kidney transplant.
Diagnosis/Preparation
Patients with chronic renal disease who need a transplant and do not have a living donor registered with United Network for Organ Sharing (UNOS) to be placed on a waiting list for a cadaver kidney transplant. UNOS is a non-profit organization that is under contract with the federal government to administer the Organ Procurement and Transplant Network (OPTN) and the national Scientific Registry of Transplant Recipients (SRTR).
Kidney allocation is based on a mathematical formula that awards points for factors that can affect a successful transplant, such as time spent on the transplant list, the patient's health status, and age. The most important part of the equation is that the kidney be compatible with the patient's body. A human kidney has a set of six antigens, substances that stimulate the production of antibodies. (Antibodies then attach to cells they recognize as foreign and attack them.) Donors are tissue matched for 0–6 of the antigens, and compatibility is determined by the number and strength of those matched pairs. Blood type matching is also important. Patients with a living donor who is a close relative have the best chance of a close match.
Before being placed on the transplant list, potential kidney recipients must undergo a comprehensive physical evaluation. In addition to the compatibility testing, radiological tests, urine tests, and a psychological evaluation will be performed. A panel of reactive antibody (PRA) is performed by mixing the patient's serum (white blood cells) with serum from a panel of 60 randomly selected donors. The patient's PRA sensitivity is determined by how many of these random samples his or her serum reacts with; for example, a reaction to the antibodies of six of the samples would mean a PRA of 10%. High reactivity (also called sensitization) means that the recipient would likely reject a transplant from the donor. The more reactions, the higher the PRA and the lower the chances of an overall match from the general population. Patients with a high PRA face a much longer waiting period for a suitable kidney match.
Potential living kidney donors also undergo a complete medical history and physical examination to evaluate their suitability for donation. Extensive blood tests are performed on both donor and recipient. The blood samples are used to tissue type for antigen matches, and confirm that blood types are compatible. A PRA is performed to ensure that the recipient antibodies will not have a negative reaction to the donor antigens. If a reaction does occur, there are some treatment protocols that can be attempted to reduce reactivity, including immunosuppresant drugs and plasmapheresis (a blood filtration therapy).
The donor's kidney function will be evaluated with a urine test as well. In some cases, a special dye that shows up on x rays is injected into an artery, and x rays are taken to show the blood supply of the donor kidney (a procedure called an arteriogram).
Once compatibility is confirmed and the physical preparations for kidney transplantation are complete, both donor and recipient may undergo a psychological or psychiatric evaluation to ensure that they are emotionally prepared for the transplant procedure and aftercare regimen.
Aftercare
A typical hospital stay for a transplant recipient is about five days. Both kidney donors and recipients will experience some discomfort in the area of the incision after surgery. Pain relievers are administered following the transplant operation. Patients may also experience numbness, caused by severed nerves, near or on the incision.
A regimen of immunosuppressive, or anti-rejection, medication is prescribed to prevent the body's immune system from rejecting the new kidney. Common immunosuppressants include cyclosporine, prednisone, tacrolimus, mycophenolate mofetil, sirolimus, baxsiliximab, daclizumab, and azathioprine. The kidney recipient will be required to take a course of immunosuppressant drugs for the lifespan of the new kidney. Intravenous antibodies may also be administered after transplant surgery and during rejection episodes.
Because the patient's immune system is suppressed, he or she is at an increased risk for infection. The incision area should be kept clean, and the transplant recipient should avoid contact with people who have colds, viruses, or similar illnesses. If the patient has pets, he or she should not handle animal waste. The transplant team will provide detailed instructions on what should be avoided post-transplant. After recovery, the patient will still have to be vigilant about exposure to viruses and other environmental dangers.
Transplant recipients may need to adjust their dietary habits. Certain immunosuppressive medications cause increased appetite or sodium and protein retention, and the patient may have to adjust his or her intake of calories, salt, and protein to compensate.
Risks
As with any surgical procedure, the kidney transplantation procedure carries some risk for both a living donor and a graft recipient. Possible complications include infection and bleeding (hemorrhage). A lymphocele, a pool of lymphatic fluid around the kidney that is generated by lymphatic vessels damaged in surgery, occurs in up to 20% of transplant patients and can obstruct urine flow and/or blood flow to the kidney if not diagnosed and drained promptly. Less common is a urine leak outside of the bladder, which occurs in approximately 3% of kidney transplants when the ureter suffers damage during the procedure. This problem is usually correctable with follow-up surgery.
A transplanted kidney may be rejected by the patient. Rejection occurs when the patient's immune system recognizes the new kidney as a foreign body and attacks the kidney. It may occur soon after transplantation, or several months or years after the procedure has taken place. Rejection episodes are not uncommon in the first weeks after transplantation surgery, and are treated with high-dose injections of immunosuppressant drugs. If a rejection episode cannot be reversed and kidney failure continues, the patient will typically go back on dialysis. Another transplant procedure can be attempted at a later date if another kidney becomes available.
The biggest risk to the recovering transplant recipient is not from the operation or the kidney itself, but from the immunosuppressive medication he or she must take. Because these drugs suppress the immune system, the patient is susceptible to infections such as cytomegalovirus (CMV) and varicella (chickenpox). Other medications that fight viral and bacterial infections can offset this risk to a degree. The immunosuppressants can also cause a host of possible side effects, from high blood pressure to osteoporosis. Prescription and dosage adjustments can lessen side effects for some patients.
Normal Results
The new kidney may start functioning immediately, or may take several weeks to begin producing urine. Living donor kidneys are more likely to begin functioning earlier than cadaver kidneys, which frequently suffer some reversible damage during the kidney transplant and storage procedure. Patients may have to undergo dialysis for several weeks while their new kidney establishes an acceptable level of functioning.
Studies have shown that after they recover from surgery, kidney donors typically have no long-term complications from the loss of one kidney, and their remaining kidney will increase its functioning to compensate for the loss of the other.
Morbidity and Mortality Rates
Survival rates for patients undergoing kidney transplants are 95–96% one year post-transplant, and 91% three years after transplant. More than 2,900 patients on the transplant waiting list died in 2001. The success of a kidney transplant graft depends on the strength of the match between donor and recipient and the source of the kidney. According to the OPTN 2002 annual report, cadaver kidneys have a five-year survival rate of 63%, compared to a 76% survival rate for living donor kidneys. However, there have been cases of cadaver and living, related donor kidneys functioning well for over 25 years. In addition, advances in transplantation over the past decade have decreased the rate of graft failure; the USRDS reports that graft failure dropped by 23% in the years 1998–2000 compared to failures occurring between 1994 and 1997.
Alternatives
Patients who develop chronic kidney failure must either go on dialysis treatment or receive a kidney transplant to survive.
Resources
Books
Cameron, J. S. Kidney Failure: The Facts. New York: Oxford University Press, 1999.
Finn, Robert, ed., et al. Organ Transplants: Making the Most ofYour Gift of Life. Cambridge, MA: O'Reilly Publishing, 2000.
Mitch, William, and Saulo Klahr, eds. Handbook of Nutrition and the Kidney, 4th edition. Philadelphia: Lippincott, Williams, and Wilkins, 2002.
Parker, James, and Philip Parker, eds. The 2002 Official PatientSourcebook on Kidney Failure. San Diego: Icon Health Publications, 2002.
University Renal Research and Education Associates (URREA); United Network for Organ Sharing (UNOS). 2002 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1992–2001.Rockville, MD: HHS/HRSA/OSP/DOT, 2003. http://www.optn.org/data/annualReport.asp..
U.S. Renal Data System. USRDS 2002 Annual Data Report.Bethesda, MD: The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2003.
Periodicals
Waller, J. R., et al. "Living Kidney Donation: A Comparison of Laparoscopic and Conventional Open Operations." Postgraduate Medicine Journal 78, no. 917 (March 2002): 153.
Organizations
American Association of Kidney Patients. 3505 E. Frontage Rd., Suite 315, Tampa, FL 33607. (800) 749-2257. info@aakp.org. http://www.aakp.org.
American Kidney Fund (AKF). Suite 1010, 6110 Executive Boulevard, Rockville, MD 20852. (800) 638-8299. helpline@akfinc.org. http://www.akfinc.org.
National Kidney Foundation. 30 East 33rd St., Suite 1100, New York, NY 10016. (800) 622-9010. http://www.kidney.org.
United Network for Organ Sharing (UNOS). 700 North 4th St., Richmond, VA 23219. (888) 894-6361. http://www.transplantliving.org.
United States Renal Data System (USRDS). USRDS Coordinating Center, 914 S. 8th St., Suite D-206, Minneapolis, MN 55404. (612) 347-7776. http://www.usrds.org.
Replacement of a diseased or damaged kidney with one from a living relative or a legally dead donor. The former's tissue type is more likely to match, reducing the chance of rejection; but removal puts the donor at risk, and a kidney from a dead donor is more likely to be available. The new kidney is implanted and its blood vessels and ureter sewn in place. A near-normal life may be resumed within two months, but the drugs that prevent rejection leave the patient vulnerable to infection. See alsotransplant.
The donor kidney is typically placed inferior of the normal anatomical location.
Kidney transplantation or renal transplantation is the organ transplant of a kidney in a patient with end-stage renal disease. Kidney transplantation is typically classified as deceased-donor (formerly known as cadaveric) or living-donor transplantation depending on the source of the recipient 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.
The first documented kidney transplant in the United States was performed June 17, 1950, on Ruth Tucker, a 44-year-old woman with polycystic kidney disease, at Little Company of Mary Hospital in Evergreen Park, Illinois, a Chicago suburb. Although the donated kidney was rejected because no immunosuppressive therapy was available at the time – the development of effective antirejection drugs was years away – Tucker's remaining diseased kidney began working again and she lived another 5 years before dying of an unrelated illness.[citation needed] Thereafter, successful kidney transplantations were undertaken in 1954 in Boston and Paris. The Boston transplantation was done between identical twins to eliminate any problems of an immune reaction. The first kidney transplant in the United Kingdom did not occur until 1960, when Michael Woodruff performed one between identical twins in Edinburgh. Until the routine use of medications to prevent and treat acute rejection, introduced in 1964, deceased donor transplantation was not performed. The kidney was the easiest organ to transplant, tissue-typing was simple, the organ was relatively easy to remove and implant, live donors could be used without difficulty, and in the event of failure, kidney dialysis was available from the 1940s. Tissue typing was essential to the success: early attempts in the 1950s on sufferers from Bright's disease had been very unsuccessful. In 1954, at Brigham Hospital Dr. Joseph E. Murray and Dr. J. Hartwell Harrison performed the world's first successful renal transplant between genetically identical patients, for which Dr. Murray received the Nobel Prize for Medicine in 1990. The donor is still alive as of 2005; the recipient died eight years after the transplantation.
The major barrier to organ transplantation between genetically non-identical patients lay in the recipient's immune system, which would treat a transplanted kidney as a "non-self" and immediately or chronically, reject it. Thus, having medications to suppress the immune system was essential. However, suppressing an individual's immune system places that individual at greater risk of infection and cancer (particularly skin cancer and lymphoma), in addition to the side effects of the medications.
The basis for most immunosuppressive regimens is prednisolone, a corticosteroid. Prednisolone suppresses the immune system, but its long-term use at high doses carries a multitude of side effects, including glucose intolerance and diabetes, weight gain, osteoporosis, muscle weakness, hypercholesterolemia, and cataract formation amongst others. Prednisolone alone is usually inadequate to prevent rejection of a transplanted kidney. Thus other, non-steroid immunosuppressive agents are needed, which also allow lower doses of prednisolone.
Indications
The indication for kidney transplantation is end-stage renal disease (ESRD), regardless of the primary cause. This is defined as a drop in the glomerular filtration rate (GFR) to 20-25% of normal. Common diseases leading to ESRD include malignant hypertension, infections, diabetes mellitus and glomerulonephritis; genetic causes include polycystic kidney disease as well as a number of inborn errors of metabolism as well as autoimmune conditions including lupus and Goodpasture's syndrome. Diabetes is the most common cause of kidney transplant, accounting for approximately 25% of those in the US. The majority of renal transplant recipients are on some form of dialysis – hemodialysis, peritoneal dialysis, or the similar process of hemofiltration – at the time of transplantation. However, individuals with chronic renal failure who have a living donor available may undergo pre-emptive transplantation before dialysis is needed.
Contraindications and requirements
Contraindications include both cardiac and pulmonary insufficiency, as well as hepatic disease. Concurrent tobacco use and morbid obesity are also among the indicators putting a patient at a higher risk for surgical complications.
Kidney transplant requirements vary from program to program and country to country. Many programs place limits on age (e.g. the person must be under a certain age to enter the waiting list) and require that one must be in good health (aside from the kidney disease).
Significant cardiovascular disease, incurable terminal infectious diseases and cancer often are transplant exclusion criteria. In addition, candidates are typically screened to determine if they will be compliant with their medications, which is essential for survival of the transplant. People with mental illness and/or significant on-going substance abuse issues may be excluded. HIV was at one point considered to be a complete contraindication to transplantation. There was fear that immunosuppressing someone with a depleted immune system would result in the progression of the disease. However, current research does not bear out this fear; in fact there are findings that immunosuppressive drugs and antiretrovirals may work synergistically to help both HIV viral loads/CD4 cell counts and prevent active rejection.
Sources of kidneys
Since medication to prevent rejection is so effective, donors need not be genetically similar to their recipient. Most donated kidneys come from deceased donors, with some coming from living donors. However, the utilization of living donors in the United States is on the rise. In the year 2006, 47% of donated kidneys were actually from living donors (Organ Procurement and Transplantation Network, 2007). It is important to note that this varies by country: for example, only 3% of transplanted kidneys during 2006 in Spain came from living donors (Organización Nacional de Transplantes (ONT), 2007).
Living donors
More than one in three donations in the UK is now from a live donor,[1] and almost one in three in Israel.[2] The percentage of transplants from living donors is increasing. Potential donors are carefully evaluated on medical and psychological grounds. This ensures that the donor is fit for surgery and has no disease which brings undue risk or likelihood of a poor outcome for either the donor or recipient. The psychological assessment is to ensure the donor gives informed consent and is not coerced. In countries where paying for organs is illegal, the authorities may also seek to ensure that a donation has not resulted from a financial transaction. In the UK the Human Tissue Act of 2004 dictated that donors must prove a familial or long term relationship or enduring friendship, for instance by providing photographs of themselves together spread over a period of time, or a birth or wedding certificate. Purely altruistic donation to strangers has recently been accepted by the Human Tissue Authority in the United Kingdom, and as of December 2007 only four people had been given permission to do this under the HTA. The decision must be approved by a panel, whereas the typical donation based on relationship is required only to go through an executive.[3] There is good evidence that kidney donation is not associated with long term harm to the donor.[4]
Traditionally, the donor procedure has been through a single, 4 to 7 inch incision but live donation is being increasingly performed by laparoscopic surgery. This reduces pain and accelerates recovery for the donor. Operative time and complications decreased significantly after a surgeon performed 150 cases. Live donor kidney grafts tend to perform better than those from deceased donors.[5] Since the increase in the use of laparascopic surgery, the number of live donors has increased. Any advance which leads to a decrease in pain and scarring and swifter recovery has the potential to boost donor numbers. In more recent development, robotic surgery has been used. In January 2009, the world's first all-robotic kidney transplant was performed at Saint Barnabas Medical Center through a 2 inch incision. The same team performed eight more robotic-assisted tranplants during the six-month period after the first transplant.[6]
The recent removal of a donor kidney through a bodily orifice has been said to be interesting for this reason, though it was rendered more possible because the woman had a previous hysterectomy.[7] The extraction was performed using Natural orifice transluminal endoscopic surgery, where an endoscope is inserted through an orifice, then through an internal incision, so that there is no external scar. The donor was able to leave hospital within 48 hours. The recent advance of Single port access surgery requiring only one entry point at the navel is another advance with possible potential for more frequent use.
In 2004 the FDA approved the Cedars-Sinai High Dose IVIG therapy which reduces the need for the living donor to be the same blood type (ABO compatible) or even a tissue match[8]. The therapy reduced the incidence of the recipient's immune system rejecting the donated kidney in highly-sensitized patients[8].
Organ trade
For the main article on this subject, see Organ trade
In the developing world some people sell their organs. Such people are often in a situation of grave poverty,[9] or exploited by salespersons. People travelling to make use of such kidneys, sometimes known as "transplant tourists", are not looked upon favorably by organizations such as the NKF. These patients may have increased complications due to poor infection control and lower medical and surgical standards. One surgeon has said organ trade could be legalized in the UK to prevent such tourism, but this is not seen by the National Kidney Research Fund as the answer to a deficit in donors.[10]
Although brain-dead (or "heart-beating") donors are considered dead, the donor's heart continues to pump and maintain the circulation. This makes it possible for surgeons to start operating while the organs are still being perfused. During the operation, the aorta will be cannulated, after which the donor's blood will be replaced by an ice-cold storage solution, such as UW (Viaspan), HTK, or Perfadex. [Depending on which organs are transplanted, more than one solution may be used simultaneously.] Due to the temperature of the solution (and since large amounts of cold NaCl-solution are poured over the organs for a rapid cooling of the organs), the heart will stop pumping.
"Donation after Cardiac Death" donors are patients who do not meet the brain-dead criteria, but due to the small chance of recovery have elected, via a living will or through family, to withdraw support. In this procedure, treatment is discontinued (mechanical ventilation is shut off). After a time of death has been pronounced, the patient is rushed to the operating room where the organs are recovered. At this point, the storage solution is flushed through the organs itself. Since the blood is no longer being circulated, coagulation must be prevented with relatively large amounts of anti-coagulation agents such as heparin. It is important to note that several ethical and procedural guidelines must be followed, most importantly is that the organ recovery team should not participate in the patient's care in any manner until after death has been declared.
Compatibility
If plasmapheresis or IVIG is not performed, the donor and recipient have to be ABO blood group compatible. Also, they should ideally share as many HLA and "minor antigens" as possible. This decreases the risk of transplant rejection and the need for another transplant. The risk of rejection may be further reduced if the recipient is not already sensitized to potential donor HLA antigens, and if immunosuppressant levels are kept in an appropriate range. In the United States, up to 17% of all deceased donor kidney transplants have no HLA mismatch. However, it is important to note that HLA matching is a relatively minor predictor of transplant outcomes. In fact, living non-related donors are now almost as common as living (genetically)-related donors.
In the 1980s, experimental protocols were developed for ABO-incompatible transplants using increased immunosuppression and plasmapheresis. Through the 1990s these techniques were improved and an important study of long-term outcomes in Japan was published. [1]. Now, a number of programs around the world are routinely performing ABO-incompatible transplants. [2]
In 2004 the FDA approved the Cedars-Sinai High Dose IVIG protocol which eliminates the need for the donor to be the same blood type. [3]
Procedure
Since in most cases the barely functioning existing kidneys are not removed because this has been shown to increase the rates of surgical morbidities, the kidney is usually placed in a location different from the original kidney (often in the iliac fossa), and as a result it is often necessary to use a different blood supply:
Occasionally, the kidney is transplanted together with the pancreas. This is done in patients with diabetes mellitus type I, in whom the diabetes is due to destruction of the beta cells of the pancreas and in whom the diabetes has caused renal failure (diabetic nephropathy). This is almost always a deceased donor transplant. Only a few living donor (partial) pancreas transplants have been done. For individuals with diabetes and renal failure, the advantages of earlier transplant from a living donor (if available) are far superior to the risks of continued dialysis until a combined kidney and pancreas are available from a deceased donor.[citation needed]
These procedures are commonly abbreviated as follows:
"SKP transplant", for "simultaneous kidney-pancreas transplant"
"PAK transplant", for "pancreas after kidney transplant"
(By contrast, "PTA" refers to "Pancreas transplant alone".)
The pancreas can come from a deceased donor as well as a living one. A patient can either receive a living kidney followed by a donor pancreas at a later date (PAK, or pancreas-after-kidney) or a combined kidney-pancreas from a donor (SKP, simultaneous kidney-pancreas.)
Transplanting just the islet cells from the pancreas is still in the experimental stage, but shows promise. This involves taking a deceased donor pancreas, breaking it down, and extracting the islet cells that make insulin. The cells are then injected through a catheter into the recipient and they generally lodge in the liver. The recipient still needs to take immunosuppressants to avoid rejection, but no surgery is required. Most people need two or three such injections, and many are not completely insulin-free.
Post operation
The transplant surgery lasts five hours on average. The donor kidney will be placed in the lower abdomen and its blood vessels connected to arteries and veins in the recipient's body. When this is complete, blood will be allowed to flow through the kidney again. In most cases, the kidney will soon start producing urine. The final step is connecting the ureter from the donor kidney to the bladder.
Depending on its quality, the new kidney usually begins functioning immediately. Living donor kidneys normally require 3–5 days to reach normal functioning levels, while cadaveric donations stretch that interval to 7–15 days. Hospital stay is typically for four to seven days. If complications arise, additional medications diuretics may be administered to help the kidney produce urine.
Immunosuppresant drugs are used to suppress the immune system from rejecting the donor kidney. These medicines must be taken for the rest of the patient's life. The most common medication regimen today is a cocktail of tacrolimus, mycophenolate, and prednisone. Some patients may instead take cyclosporine, rapamycin, or azathioprine. Cyclosporine, considered a breakthrough immunosuppressive when first discovered in the 1980s, ironically causes nephrotoxicity and can result in iatrogenic damage to the newly transplanted kidney. Blood levels must be monitored closely and if the patient seems to have a declining renal function, a biopsy may be necessary to determine if this is due to rejection or cyclosporine intoxication.
Acute rejection occurs in 10% to 25% of people after transplant during the first sixty days. Rejection does not necessarily mean loss of the organ, but may require additional treatment and medication adjustments. [4]
Complications
Problems after a transplant may include:
Transplant rejection (hyperacute, acute or chronic)
Imbalances in electrolytes including calcium and phosphate which can lead to bone problems amongst other things
Other side effects of medications including gastrointestinal inflammation and ulceration of the stomach and esophagus, hirsutism (excessive hair growth in a male-pattern distribution), hair loss, obesity, acne, diabetes mellitus (type 2), hypercholesterolemia, and others.
The average lifetime for a donor kidney is ten to fifteen years. When a transplant fails a patient may opt for a second transplant, and may have to return to dialysis for some intermediary time.
Prognosis
Kidney transplantation is a life-extending procedure.[11] The typical patient will live ten to fifteen years longer with a kidney transplant than if kept on dialysis.[12] The years of life gained is greater for younger patients, but even 75 year-old recipients (the oldest group for which there is data) gain an average four more years' life. People generally have more energy, a less restricted diet, and fewer complications with a kidney transplant than if they stay on conventional dialysis.
Some studies seem to suggest that the longer a patient is on dialysis before the transplant, the less time the kidney will last. It is not clear why this occurs, but it underscores the need for rapid referral to a transplant program. Ideally, a kidney transplant should be pre-emptive, i.e. take place before the patient starts on dialysis.
Australian Aboriginal activist Charles Perkins, is the longest surviving Australian receiver of a kidney transplant, living twenty-eight years on his donor organ.[citation needed]
Denice Lombard of Washington, D.C., received her father's kidney on August 30, 1967 aged 13 and is still alive and healthy forty years later.
^ ab Jordan SC, Tyan D, Stablein D, et al. (December 2004). "Evaluation of intravenous immunoglobulin as an agent to lower allosensitization and improve transplantation in highly sensitized adult patients with end-stage renal disease: report of the NIH IG02 trial". J Am Soc Nephrol15 (12): 3256–62. doi:10.1097/01.ASN.0000145878.92906.9F. PMID 15579530.
^ McDonald SP, Russ GR (2002). "Survival of recipients of cadaveric kidney transplants compared with those receiving dialysis treatment in Australia and New Zealand, 1991-2001". Nephrol. Dial. Transplant.17 (12): 2212–9. doi:10.1093/ndt/17.12.2212. PMID 12454235.
^ Wolfe RA, Ashby VB, Milford EL, et al. Comparison of Mortality in All Patients on Dialysis, Patients on Dialysis Awaiting Transplantation, and Recipients of a First Cadaveric Transplant. NEJM 1999: 341, 1725-1730.
^ "National Data Reports". The Organ Procurement and Transplant Network (OPTN). dynamic. http://www.optn.org/latestData/step2.asp. Retrieved on 2009-05-07. (the link is to a query interface; Choose Category = Transplant, Organ = Kidney, and select the 'Transplant by donor type' report link)
^ Official Website of Sindh Instituite of Urology & Transplant
