Introduction to kidney transplantation 

Kidney transplantYour kidneys are two very important organs in the body, which help perform many functions to keep the body in optimal balance. Some of these functions include: helping you get rid of waste products, forming urine, controlling levels of important molecules (such as sodium, potassium and chloride), and producing hormones that stimulate the production of red blood cells when the oxygen carrying capacity of the blood is not optimised.

Kidney failure affects some individuals, such as those with diabetes or long term high blood pressure. In other cases, there may be no obvious reason why the kidney begins to malfunction. Either way, kidney failure means that your kidneys are damaged and do not perform their normal functions. There are three main treatment options for kidney failure – dialysis (a way to clean the blood artificially), kidney transplant and no treatment (conservative).

A transplant is a treatment for kidney failure, but not a cure. There are various factors to consider when preparing for a kidney transplant, such as co-existing medical problems, availability of a kidney for transplant from an optimal donor, compliance with treatment after the operation and long term care of the kidney. Transplant patients often have to remain on strong drugs to prevent rejection (called immunosuppressants), which have to be taken on a regular basis and require you to visit the doctor for ongoing monitoring. These factors and many more will be discussed in detail below.


How many people are receiving kidney transplants?

Over the years, there have been an increasing number of people who have suffered from kidney failure and who require kidney transplantation or dialysis. There have been an increased number of people entering dialysis programs, and a lower rate of transplantation due to a shortage of donor kidneys. There remains a shortage of kidney donors – only 6.8% of patients receiving dialysis obtained a transplant in 2002, compared to 11.7% 10 years earlier.

The average waiting time for a kidney transplant in Australia is about four years. Many patients wait for even longer periods of time. In 2004, the annual rate of donor kidney transplants in Australia from patients who had passed away was 11 donors per million of the population. In 2003, the rate was 9 per million of the population. This rate is less than compared to 33.8 in Spain, 24.8 in Belgium, 23.9 in Austria, and 22.1 in the United States.

To try and improve the situation regarding shortages in deceased donor kidneys, there has been an increase in live kidney donations. For example, if you had a relative or family member who was willing to donate a kidney, you may be able to obtain a live donor kidney transplant. These types of donations constituted about 40% of total transplants.


What are the criteria for receiving a kidney transplant?

  • It is preferable if you are less than 65 yrs old and have a life expectancy of at least 5 years;
  • No evidence of chronic infection;
  • No cancer (apart from skin cancers) in the last 5 years;
  • Be compliant and willing to take medications to suppress your immune system for the rest of your life.


Who is likely to need a kidney transplant?

Kidney transplantPeople with the following conditions are at a higher risk of developing kidney failure and complete renal disease, eventually requiring a kidney transplant:

  • Diabetes (type 1 or type 2) (especially if blood sugar levels are poorly controlled).
  • High blood pressure
  • Kidney diseases – for example, conditions that damage parts of the kidney such as the glomeruli (glomerulonephritis), tubules (acute tubular necrosis, acute interstitial nephritis)
  • Heart and major vessel disease
  • High cholesterol levels
  • Liver disease and/or liver failure
  • Recurrent infections of the bladder or kidney, or reflux of urine (also called vesico-ureteric reflux)
  • Diseases of the vessels, blocking blood flow to different areas of the body (eg renal artery blood clots)
  • Inherited kidney conditions – eg polycystic kidney disease, cystinosis, congenital obstructive uropathy
  • Taking medications that are toxic and cause damage to the kidney – non steroidal anti-inflammatory medications, antibiotics, chemotherapy agents, analgesics (pain relievers)
  • Specific cancers – renal cell carcinoma, Wilms tumour, lymphomas, multiple myeloma.
  • Haemolytic uraemic syndrome (HUS)
  • Amyloidosis
  • Severe injury to the kidney, other organs
  • Burn victims


What is the likely outcome of receiving a kidney transplant?

If you have been diagnosed with kidney failure, dialysis is often the only initial treatment option available. 97% of all patients who receive a kidney transplant have been treated with dialysis prior to transplantation occurring. Looking at those patients receiving dialysis, only 23% are on the waiting list for a deceased-donor transplant. Transplantation in end-stage renal patients offers improved survival and quality of life.

The prognosis of kidney transplants depends on many factors, including the type of donor you are receiving the kidney from, co-existing medical conditions, age of the donor and recipient, and compliance with medications that suppress the immune system after the operation.

Kidneys can be obtained for transplantation through living or deceased donors. The rates of living donors are now increasing. Looking at living donors, they undergo a careful workup and preparation prior to removal of the kidney, to ensure that medical issues are optimized and they are fit for surgery. In general, if you receive a live kidney donation, studies have shown that you may do better than compared to receiving a kidney from a donor who has passed away.

Deceased donors can either be brain dead donors or donation after cardiac death (ie the heart stops working) donors. Brain dead donors may still continue to perfuse their organs up to the point where they are removed. On the other hand, donation after cardiac death donors fail to perfuse their organs for a few minutes after death has been pronounced, before being taken to theatre, where the organs are removed.

Studies have shown that patients who have undergone kidney transplantation do better than those on dialysis, in the long term. Most patients who have a kidney transplant live for an average of ten – fifteen years longer than if they were only receiving dialysis. This benefit of prolongation of life is seen especially if you are younger when you receive the kidney transplant. Most people also report more energy, less restrictions on life and a decreased number of complications than if they continued to stay on dialysis.

The graft survival rate for kidneys from living donors is approximately 95% at 1 year and 76% at 5 years. On the other hand, the graft survival rate for kidneys from deceased donors is lower, approximately 89% at 1 year and 61% at 5 years. Thus we can see that graft prognosis is affected by the source of the donor kidney.

Looking specifically at diabetic patients, recurrence of diabetic changes occurs in most of these patients within 4 years of transplantation. However, only a very small percentage (1.8%) of kidney losses in this population are due to diabetic nephropathy (kidney disease).

After you have a kidney transplant, there may be acute complications such as rejection of the kidney, kidney failure and infection. In the longer term, other major causes of morbidity and death in kidney transplant patients include: high blood pressure, high cholesterol levels, heart and major vessel disease (a ten fold increase in risk), diabetes, malignancy (cancers) and osteoporosis. The incidence of developing cancers tends to be related to the degree and length of treatment with drugs that suppress the immune system.


What questions may you be asked before having a kidney transplant?

Kidney transplantIf you are undergoing a kidney transplant, you will be seen by a number of medical staff and health professionals who will ask you a series of questions, to ensure that any underlying medical problems are treated appropriately and special tests organized, if needed. Where possible, you should be assessed by the surgeon and/or kidney specialist doctors from the transplant team.

Some of the following questions may be asked:

  • What is your past medical/surgical history?
  • If you have any disease of the heart or major arteries, this can be an important risk factor in the periods before and after the operation. The length of time you have had heart problems for, any risk factors contributing to the disease (i.e. smoking, alcohol consumption, high blood pressure, high cholesterol levels) previous medical therapy and surgical interventions for heart disease are important areas to discuss.
  • Your history of kidney disease should also be discussed – date of onset of issues contributing to kidney disease, past treatments, type of dialysis / duration of dialysis (if you are or have been on dialysis), difficulties experienced during dialysis, complications, daily urine output (if you are still producing any). Have you had any previous kidney biopsies, transplants?
  • Diabetes – duration of disease, progress and treatment.
  • Any other lung disease, disease of the peripheral arteries in the legs and arms, ulcer disease, cancers and infections (hepatitis, HIV, EBV, CMV ,etc) are also important.
  • What medications are you currently on, and what medications have you taken in the past?
    • Have you experienced any side effects or have there been any factors that have affected your ability to take the medications?
    • Are you allergic to any medications or other substances that you are aware of?
  • Smoking history – how much do you smoke?
  • Alcohol use / drug history – how much alcohol do you drink, do you use any other substances?
  • Social situation – have you got a good support system in the period that you will need to be attending hospital for an operation, and after the operation, to give you a hand with any issues that need to be addressed?


Examinations done before undergoing kidney transplantation

When your doctor examines you prior to undergoing a kidney transplant, the following areas may be covered:

  • What is your normal blood pressure, heart rate, respiratory rate and temperature?
  • Skin, muscles and bones of the body
  • Lymph node
  • Head and Neck (including eyes, ears, nose and throat, teeth, thyroid)
  • Cardiovascular system – full examination of the heart and major vessels, looking specifically for any signs of system failure, murmurs (due to abnormal blood flow through heart valves), pulses.
  • Respiratory system – Examination of the lungs for their function, any signs of infection.
  • Abdominal system – Examination of the abdomen for any fluid collection, areas of tenderness.
  • Nervous system


Tests performed before undergoing kidney transplantation

Kidney transplantBefore your operation, the following test are routinely performed:

  • A range of blood tests – Blood group, Full blood picture, Urea & Electrolytes, blood clotting profile, liver function tests, calcium levels, phosphate levels, blood sugar levels, testing for specific viruses – hepatitis B, C, cytomegalovirus CMV, Epstein Barr Virus (EBV), HIV serology.
  • Regular blood tests to make sure you have not built up any antibodies.
  • Electrocardiogram (ECG – a special electrical reading of the heart’s activity)
  • X-rays of the lung and heart.
  • If you are still producing urine, this is sent off for further analysis and testing, to make sure there is no infection present.
  • If you have any heart problems or issues with any arteries or blood vessels in the body, a baseline ECG and X-ray of the chest should be performed.

More specific investigations are guided by the clinical choice and decision of your doctor. Note that it is important to have your blood tested, because each time a donor kidney is available, a potential patient to receive the kidney is chosen based on the best blood and tissue match. Just like receiving blood from someone else, you can only receive a kidney from someone who has a compatible blood group to you. There must also be no antibodies to the donor kidney.


What happens during a kidney transplantation procedure?

Prior to the operation, a needle is inserted into one of the veins in the back of your hands or up the arm to provide you with fluids and medications, to put you to sleep and provide you with some pain relief (this is also known as being ‘anaesthesized’ before the operation). If you are receiving a kidney from a donor who has passed away, the organ is kept in iced water or a special solution whilst awaiting preparation for transplantation.

A small cut is made in lower right or left side of the lower abdomen, to allow the kidney to be transplanted into the body. Your pre-existing kidneys are not usually removed. The operation can last up to three – four hours, followed by a period in recovery afterwards. The main artery and vein supplying the kidney is mobilized from the donor’s body. Any excess fat is removed from around the kidney. The ureter (tube carrying urine from the kidneys to the bladder) is also freed. The artery and vein of the new kidney are subsequently connected to the main artery and vein near your bladder. The ureter of the new kidney is then connected to your bladder, so that urine can flow.


What are the common complications associated with kidney transplants?

Kidney transplantIn a small number of patients, there may be leakage of urine from the urethra (tube transporting urine to the outside of the body). This usually occurs within the first two months after the operation. It is due to a disruption of the connection of the transplanted kidney to your ureter (tube carrying urine from the bladder to the kidneys). You may also experience symptoms such as pain, develop a fever and swelling of the abdomen. A rarer side effect is the development of clots in the arteries or veins of the transplanted kidney. This is a more serious complication, ultimately resulting in diminished urine output, and eventually no urine output at all. Infections and sepsis may occur after the operation. This may be due to organisms infecting the kidney at the time of operation, after the operation or due to your immune system being suppressed by the medications needed to prevent rejection of your transplanted kidney. In the first few months after the procedure, bacterial infections are more commonly encountered, whereas viral infections are more frequent later down the track.

The kidney may be rejected by the body, regardless of the preparation before and after the procedure. If you have suffered from one rejection episode, there is a 20% chance you will continue to suffer from recurrent rejection episodes. Rejection episodes are classified according to the time period in which they occur after the operation. Acute rejection occurs in the first three months, late acute rejection occurs at about six months and is strongly linked to the withdrawal of medications needed to suppress the immune system. Chronic rejection occurs more than one year after the operation.

You may experience symptoms such as decreasing urine coming out from the bladder and high blood pressure. Acute dysfunction of the kidney can sometimes occur after the operation, due to a number of causes. If dysfunction occurs immediately, common causes include necrosis and death of the kidney’s tubules and obstruction of the vessels or ureters supplying the kidney. If dysfunction occurs about a week or more after the operation, acute rejection episodes, obstruction, and toxicity due to immunosuppressant medications (eg Cyclosporin A) may be implicated. More than a year after the procedure, chronic rejection and other insults to the kidney may also cause dysfunction.

Longer term complications can be due to exacerbation of pre-existing medical conditions, transplant complications and medication related effects. If you have any underlying diseases such as atherosclerosis, this can be worsened after the operation. You are also at a very small risk of developing cystic disease in your kidney/s. Transplant complications can also be delayed – ie. chronic rejection and graft failure after 10-25 years can occur. Unfortunately, the recurrence of primary disease (such as diabetes) may be seen in your transplanted kidney. Some patients who have received a transplant will also develop a type of malignancy, most commonly of the skin. It has also been reported that there is a three fold increase in most common malignancies, (except breast and prostate cancers), and a 1000 fold increase in lymphomas. The death rate of renal transplant patients is approximately 3% per year, due to complications such as infections, heart disease and cancer.


What usually happens after a kidney transplant?

Kidney transplantAfter the operation, you may feel drowsy and uncomfortable for a period of time in recovery. Over the next few days, a temporary tube (catheter) is placed into your bladder, to drain urine into a bag. This gives the doctors an indication of how well your new kidney is working. There are also some tubes draining excess fluid or blood away from the site of the operation. These are normally removed in the first two to three days after the operation.

Daily blood tests are performed, to keep an eye on your new kidney’s function and to detect any early signs of rejection. The nurses and doctors will keep a close eye on your fluid intake and output, recording everything that goes into the body and what comes out. You may experience some discomfort, especially around the wound site – pain relief medications will be available, as required to keep you comfortable.

You will have to remain in hospital for an average of about 7 days after the operation. This stay is affected by things such as your response to the new kidney, whether any complications arise, and your recovery after the operation. It is important that you keep mobile after the surgery, perform chest and deep breathing exercises, to prevent the risk of any clots in the lung or legs, and also minimize your risk of chest infection. A few scans of the kidney will normally be performed in the first few days following your procedure, to ensure that they are functioning properly.

After you have returned home, it is important to relax and prevent any strain on the wound site. You should take care of the wound, to prevent any infection from developing. If you develop any increased redness, discharge or fever around the wound site, you should contact your doctor immediately. You will need to see the kidney transplant doctors on a regular basis, to monitor your progress and deal with any complications that may arise.

You will be started on medications to help suppress your immune system, to prevent rejection of your new kidney. These are essential to the survival of your new kidney as your body’s immune system would normally mount an immune response against the graft which it identifies as new or foreign (similarly to how it identifies bugs as foreign). These medications thus prevent your immune system attacking the new kidney by preventing antibodies being formed (which normally attack the new kidney and it’s blood vessel supply). After you leave the hospital, you will have to continue on these medications for the rest of your life. Some of these immune-suppressing medications include: Prograf (Tacrolimus), Cyclosporin, Azathioprine, Prednisolone, Sirolimus and Mycophenylate. It is important you take these medications as directed to prevent the risk of graft rejection and failure. Unfortunately these important immunosuppressant medications are associated with a variety of side effects. Of particular importance is an increased risk of infection (because your immune system is being suppressed) which you should be wary of. You should therefore watch out for early signs of infection (such as fever or chills) and should seek early advice from your local GP or hospital if sany worrying symptoms develop.

In addition you will probably receive other drugs (special anti-virals) as prevention against the more common infections. Your team will also ensure your immunisations are up to date and consider any required vaccinations. It is recommended that patients on immunosuppressants receive their yearly flu-shot and appropriate vaccinations against Pneumococcus. Certain immunosuppressants cause steroidal side-effects such as weight gain, easy bruising and reduced bone density, while others may suppress your bone marrow or damage your kidneys. You will require long-term monitoring of your medications and their side-effects. In addition you will require regular monitoring of kidney and liver function with blood tests.

Due to suppression of your immune system you are also at increased risk of cancers, particualrly of the skin. As part of your long-term management you should therefore receive annual examinations by a dermatologist to identify any suspicious skin lesions. You should also attempt to avoid ultraviolet radiation as much as possible and regularly check your own skin. Skin cancers can be identified by irregularities in shape, border, colour and surface. Any new change in a lesion should alert you to have it checked out by a professional. The recommended cancer screening programs for breast, bowel and prostate cancer will also be integrated into your care.

Following kidney transplant you are also at increased risk of cardiovscular disease and increased lipids. It is therefore important that any of your cardiovscular risk factors are controlled aggressively. You may be required to change your diet and lifestyle (exercise) and/or commence on medications to lower your blood pressure or cholesterol.

References

  1. Arend S, Mallat M, Westendorp J, et al. Patient survival after renal transplantation; more than 25 years follow-up. Nephrol Dial Transplant 1997; 12:1672.
  2. Burkitt, Quick. Essential Surgery, 3rd Edition, Churchill Livingstone, 2002; pp. 37-42.
  3. Burra P, De Bona M, Germani G, Canova D, Masier A, Tomat S, Senzolo M. The concept of quality of life in organ transplantation. Transplantation Proceedings 2007; 39 (7): 2285-7.
  4. Danovitch G. Clinical Practice Guidelines for Management of the Transplant Recipient, Medscape, Conference Coverage, 2000. Available [online] at URL http://www.medscape.com/viewarticle/420535
  5. Ferrari P, Department of Health, Government of WA, WA Kidney Transplant Service, Suitability Criteria, Screening and Updates for Renal Transplant Patients, 2005 [cited 16th June 2007] Available from URL: http://wakts.qe2.health.wa.gov.au/home/wakts_education.asp
  6. Hall Y, Chertow G. End stage renal disease, BMJ Clinical Evidence [journal online] 2007 [cited 16th June 2007] Available from URL: http://www.clinicalevidence.com/ceweb/conditions/ knd/2002/2002_background.jsp
  7. Kidney Health Australia, Kidney Transplant – A Treatment Option [online] 2005 [cited 1st August 2007]. Available from URL: http://www.kidney.org.au
  8. Mathew T, Faull R, Snelling P. The shortage of kidneys for transplantation in Australia, MJA 2005; 182 (5):204-205
  9. Sahadevan, Kasiske. Long-Term Posttransplant Management and Complications (Chapter 9) in Danovitch G. Handbook of Kidney Transplantation, 4th Ed, Lippincott Williams and Wilkins, 2004.
  10. Shapiro R, Simmons R, Starzl T. Renal Transplantation, Appleton & Lange, Stamford, CT 1998.
  11. Sinert R, Erogul M. Transplants, Renal. E-medicine [serial online]. 2006 [cited 16th June 2007]. Available from URL: http://www.emedicine.com/emerg/topic607.htm
  12. Suthanthiran M, Strom T. Renal Transplantation. NEJM 1994; 331:365-376
  13. Thomas M. Lecture notes – End-Stage Renal Failure: Dialysis and Transplantation, Renal Consultant and UWA Lecturer, Royal Perth Hospital, 2007.
  14. Wu, C, Evans, I, Joseph, R, et al. Comorbid conditions in kidney transplantation: association with graft and patient survival. J Am Soc Nephrol 2005; 16:3437.