Kidney Transplant

Kidney transplantation surgically places/ implants a healthy kidney from a living or dead person (donor) into the patient’s body (donee/ recipient). While people typically have two kidneys, only one is required for a normal, healthy life. The donated kidney does enough of the work that two failed kidneys used to do to keep a person healthy and symptom free. The patient may receive a kidney from a family member, a spouse or a close friend. They are known as living-related donors. The most compatible match is usually a sibling, as their genetic make-up may closely match. In addition, the patient can also receive a kidney from a recently deceased person, known as a cadaveric donor. Transplant is by far the best means of treatment, as the “replacement kidney” can substitute almost fully the lost functions of the failed kidneys, and allow the patient to lead a normal life.

 A kidney transplant is most often placed in the lower belly without removing the failed kidneys. The artery and vein of the new kidney are joined to an artery and a vein in the pelvis next to your bladder. The ureter (the tube that drains urine from the kidney to the bladder) attached to the new kidney is joined to your bladder or to one of your ureters. In a child, the blood vessels from a large adult kidney transplant are often joined to the child’s aorta (the largest artery in the body) and inferior vena cava (the largest vein in the belly). The blood type compatibility of donor and patient should match for kidney transplant. For this, blood samples from the donor and patient are mixed. If there is no reaction (negative cross-match), the donor’s kidney is safe to use.

How transplant works:

During a transplant, the surgeon places the new kidney inside lower abdomen of the patient and connects the artery and vein of the new kidney to the patient’s artery and vein. The patient’s blood flows through the donated kidney, which makes urine, just like original kidneys did when they were healthy. The new kidney may start working right away or may take up to a few weeks to make urine. Unless own kidneys are causing infection or high blood pressure, they are left as it is.

The kidney is always at risk for rejection, so it is vital for the donee (who receives kidney) to take all medicines and drugs as prescribed by the doctor in a disciplined manner. A kidney from a living donor has a better chance of lasting than one from a nonliving donor. The chance that kidney disease will come back in the transplant depends on the original cause of kidney failure.

Compatibility requirement of kidney donor:

Potential donors will have blood, urine and radiology tests to determine suitability for donation. A full physical examination will be done and psychology evaluation may also be required.

Before surgery, special x-rays will be taken of the donor’s kidneys, including either a renal arteriogram or spiral CT scan to check the kidney anatomy. Additional blood tests called tissue or HLA typing may also be done to determine the quality of matching between the donor and the recipient.  The closer the match, the less likely the kidney will be rejected.

Laboratory tests and other tests for matching donor kidney and recipient kidney

1. Immunological tests: A blood sample is taken for the following tests:

• Blood type.
  The blood type (A, B, AB, or O) must be compatible between the donor and recipient.  Blood type requirements of the kidney donorare the most important matching factor.
• Human leukocyte antigens (HLAs).
  Your cells carry six important HLAs, three inherited from each parent. Family members are most likely to have a complete match. Kidneys can be received by a patient even if the HLAs aren’t a complete match as long as the blood type is compatible.
• Cross-matching antigens.
  The last test before implanting an organ is the cross-match.  A small sample of blood from both the donor and recipient will be mixed in a tube to see if there’s a reaction. If no reaction occurs, the result is called a negative cross-match, and a transplant operation can proceed.

2. Laboratory tests. A blood sample is taken to:

• Assess the hematological system, clotting mechanism, and baseline kidney function
• Screen for abnormal electrolyte balance and for glucose intolerance which might occur post transplant
• Screen for venereal disease, pancreatitis, and liver abnormalities, until the cause is found (fluid overload, acute or chronic hepatitis). Also screen for Hepatitis B and the HIV virus.
• Look for past or present viral activity
• If the donor is CMV positive, the recipient may need to receive Cytogam and gancyclovirpost transplant to prevent reactivation of the disease.

3. Blood Type	Can receive kidney from:	Generally can donate a kidney to:
O	O	O, A, B, AB
A	A, O	A, AB
B	B, O	B, AB
AB	O, A, B, AB	AB

4. An EKG will be performed to assess heart function. A chest x-ray will be used to assess the lungs for the presence of any abnormalities.
5. A medical history review and physical examination.  An extensive review of all systems, including previous illnesses and surgeries and past family medical history.  Any abnormalities found are investigated further before invasive tests are performed.
6. A psychological evaluation will be used to:
   • Provide emotional support and kidney transplant information to the donor
   • Assess the donor’s motivation.
   • Help the staff work with the donor and family prior to, and after kidney transplant surgery.
7. Female donor candidates may undergo a gynecological exam and mammography.
8. Kidney function tests. Urine samples are taken to:
   • Screen for kidney disease or any abnormalities
   • Determine the absence or presence of a urinary tract infection.
   • Assess the amount of protein excreted in a 24-hour period. An increased secretion of protein would need to be evaluated before resuming the evaluation; the creatinine clearance is to determine adequate kidney function and to ensure that the 24 hour collection is an adequate one.
   • Determine glomerular filtration rate (GFR) which measures “how fast” the kidney can clear a known substance.
9. An intravenous pyelography test may be used. This test involves an injection of dye into a vein in your arm. The dye circulates through your body, into your kidneys, and then into your urinary tract.  X-rays are taken to identify the structure of the kidney, veins, arteries, the ureter, and other anatomy.
10. A Helical CT Scan is done in some transplant centers and is used to evaluate the internal structure of the kidney and look for the presence of cysts, tumors, etc.
    • Some transplant centers will perform a renal arteriogram if there is a question of an abnormal finding on the Helical CT Scan.  The renal arteriogram is an x-ray which looks at the vasculature of each kidney: the number of blood vessels to and from each kidney, or any evidence of vascular disease that might rule out donation.  This test requires an observation period post-exam of 6-8 hours and in some instances may require hospitalization.  This is the last test done.
    • The above process is completed before transplant is carried out.

Risk of Rejection:

Patient should intake anti rejection medicines (immunosuppressants) as per doctor’s advice to keep the body from rejecting new kidneys. There are two common types of rejection:

• Acute Rejection – Usually occurs anytime during the first year after transplant and can usually be treated successfully.
• Chronic Rejection – Usually occurs slowly over a long period of time. The causes are not well understood and treatment is often not successful.

Patients with kidney transplant are at higher risk of diabetes, high blood pressure, cardiac disease, bone disease, anemia, gout, anxiety, and even cancer. This is because the immune system is compromised in kidney transplant patients due to side effects of medications, and other reasons. Kidney transplant patients may require certain vaccinations prior to transplant and should refrain from from certain vaccinations after transplant. Patients should consult with their doctor in minute details regarding the precautions that they should take to remain in good health for a long period of time. Smoking is a big NO in kidney patients even after successful kidney transplant as the lungs are susceptible to infections and may even cause cancer. Skin disease and skin cancer is also possible in transplant patients and therefore one should avoid direct contact with sun exposure to the extent possible. It is important to maintain good oral hygiene and hygiene in cooking and handling of consumable items  like food and water to prevent bacterial and viral infections.

Follow up

Follow on check up and timely intake of medications is extremely important for kidney transplant patients even if one feels that they are completely fine. Under no circumstances a transplant patient shall skip or stop medication on their own as this may lead to complications and even death. One should regularly visit their doctor at required intervals for health check up. Kidney transplant patients must consult a dietitian/ nutritionist in consultation with their nephrologist for right intake of required nutrition and doing away with food items which may interfere with their general well being. Both donor (who gives the kidney) and donee (who receives the kidney) should monitor their health and visit the doctor at prescribed intervals.