Kidneys are the essential organs of the body to maintain life. There are two kidneys located on either side of the spine, behind the abdominal organs and below the rib cage. They perform various important functions to keep the body healthy such as:
• Filtering the blood to remove waste products in the form of urine carried to the bladder which serves as a storehouse for the urine. When body senses that the bladder is full then the urine is excreted from the body through the urethra.
• Regulating the blood pressure by releasing hormones.
• Stimulating the red blood cells by releasing the erythropoietin hormone.
• Maintain body’s fluid and electrolyte balance.
Patient needs to undergo kidney transplant surgery when one or both the kidneys stop performing their functions properly or entirely and start building up a waste in the body causing a kidney failure. This is called end-stage renal disease (ESRD) also known as end-stage kidney disease (ESKD) which often requires dialysis. Dialysis is a mechanical process to remove wastes and other substances from the blood. There are some major causes of end stage kidney failure that includes:
• High blood pressure
• Glomerulonephritis (inflammation of kidney filtering units)
• Hemolytic uremic syndrome
• Immune system diseases such as lupus
• Kidney obstructions
• Urinary tract problems
• Congenital defects
Some patients with failed kidneys may require a kidney transplant, in which one or both kidneys are replaced with donor organs from a live or deceased person. A kidney transplant can free a patient from a lifelong dependence on a dialysis machine followed by the strict lifestyle which can allow patient to live a more active life. Doctor may suggest a kidney transplant after proper evaluation of the patient’s physical, psychological, and familial condition to ensure that the patient is eligible for it. If the patient is approved for the transplant, a family member including brother, sister, parents, children, spouse, close relative can donate the kidney. That process is known as live donor transplant. The live donor must have an excellent health and should not have any serious disease or infection. Patient can also get the kidney from the deceased person who has suffered brain death.
But in some cases, kidney transplants aren’t suitable and prove unsuccessful for people who have serious underlying medical conditions.These serious conditions may include:
• Recent history or ongoing cancer problem or chemotherapy.
• Serious active infection like tuberculosis, bone infections, or hepatitis
• Uncorrectable cardiovascular disease
• liver disease
• substance abuse
Before the transplant procedure, nephrologists, a kidney specialist will suggest some test such as blood tests that are required to find out what type of blood and tissue is present in the live or dead kidney donor which helps to match a donor kidney to the recipient:
Blood test typing –There are 4 blood groups: A, B, AB, and O. both the recipient and donor should have either the same blood type or compatible with each other, unless they are participating in a special program that allow donation across blood types.
The AB blood type is the easiest to match because that individual accepts all other blood types whereas blood type O is the hardest to match. They can only receive kidneys from the same blood type that is O, but can donate to all types. For example, body will not recognize the donor kidney and rejects it if a patient with blood type O received a kidney from a donor with blood type A.
Tissue typing is a kind of blood test for human leukocyte antigens (HLA). Antigens are markers which are inherited from the parents are found on many cells of the body that distinguish each individual as unique. Both recipients and any potential donors have tissue typing done during the evaluation process.
Most perfect match kidney transplants come from siblings where recipient’s markers and the donors’ markers are all same and they have the best chance of working for many years.
Although tissue typing is done despite partial or absent HLA match with some degree of "mismatch" between the recipient and donor.
Body makes substances called antibodies throughout the life that can destroy foreign materials in the body. Individuals may develop antibodies each time there is an infection, during pregnancy, have a blood transfusion, or kidney transplant. If there are antibodies to the donor kidney, the body may destroy the kidney. This is the reason when a donor kidney is available; a test called a crossmatch is done to ensure the recipient does not have pre-formed antibodies to the donor.
This test is done by mixing the recipient's blood with donor cells. Crossmatch will be positive if there are any antibodies against the donor. Special treatment will be done to reduce the antibody levels before giving the recipient this particular kidney. When the crossmatch test is negative, the recipient does not have antibodies to the donor and they are eligible to receive this kidney.
This test is performed many times during the preparation for a living donor transplant, and a final crossmatch is done within 48 hours before the transplant.
Serology is also performed to diagnose if there are any antibodies in the blood. This test is done for viruses, such as HIV (human immunodeficiency virus), hepatitis, and cytomegalovirus (CMV) to select the proper preventive medications after transplant. These viruses are also checked in any possible donor to help prevent spreading disease to the recipient.
When the patient is on deceased donor waiting list before going for a kidney transplant, that period is called pre-transplant period. During this period the recipient undergoes several evaluation tests to ensure the safety of the operation and to check if the body can tolerate the anti rejection medications that are required post transplantation. Some of the tests may include general health (CBC, colonoscopy, pap smear, mammogram for women, prostrate for men), cardiovascular tests (electrocardiogram, stress test, echocardiogram, cardiac catheterization) and pulmonary evaluation (chest x-ray, spirometry). These tests may vary by age, gender, cause of renal disease, and other medical conditions.
The kidney transplant is performed under general anesthesia and surgery usually takes 2 to 4 hours. This type of transplant is known as heterotopic transplant surgery in which the patient’s own kidneys will be left in place unless they are causing severe problems such as uncontrollable hypertension, enlarged kidneys or frequent infections in kidneys. The donor kidney is placed in the lower abdomen, in the pelvis and can be put on either side. The arteries that carry blood to the kidney and the vein that carries blood away are surgically connected to the artery and vein already existing in the pelvis of the patient. The tube that carries urine from the kidney is connected to the bladder and sometimes a stent (plastic tube) is placed through this join. This will be removed in 4-5 weeks later in a minor operation. A drainage tube may be placed near the kidney to drain out any blood or other fluid from the operation area.
Post kidney transplant
Patient requires a proper monitoring of the kidney functions, early symptoms of rejection, medications and immunosuppression related effects like infections and cancer. Rejection can occur when the body fights off the transplanted kidney just as it fights off bacteria and viruses that cause illness.
In most of the cases, rejections can occur within six months after the transplantation but it can also occur at any time, even years later. Immediate treatment can reverse the rejection in most of the cases.
It is important to take anti – rejection medications also known as immunosuppressive agents that help in preventing and treating rejection. These medications are necessary for the transplant patient throughout the life. Rejection may happen and kidneys can fail if the medications are stopped.
Some of the medications and combination of drugs that might be used after a kidney transplant will be prescribed depending on the specific transplant may include anti-inflammatory drugs, anti-proliferative medicines, cytokine inhibitors, antilymocyte globulin. These medicines can also have some side effects respectively.
Live donor transplant are best options for many patients because they give better long-term results, no transplant waiting list for a kidney from the deceased donor, surgery can be planned at convenience of both the donor and the recipient, lower rejection risk and better functioning of the transplanted kidney.
Kidney donors have the same life expectancy, general health, and kidney function as most other people and they do not need any special medication or diets after they recover from the surgery. Woman can still have children even after donating the kidney.
There can be some complications and risks related to the transplant surgery.
1. As the surgery involves joining blood vessels together and the ureter (tube) to the bladder there are risks of leaking or blocking. Leaking of blood vessels can cause bleeding which may require a blood transfusion or a further operation. When the blood vessels get block, kidney loses its blood supply and usually have to be removed which is a more serious problem. Fortunately it happens in rare cases and will usually happen in the first week.
2. Patient will be more prone to infection after the transplant as anti-rejection immunosuppressive drugs given to the patient suppress the immune system partially that fights infection in the body. Repeated urinary infection can damage the kidney so the patients needs to for regular urine tests.
3. Virus infections such as flu or the common cold may take more time to get normal. Uncommon virus cytomegalovirus (CMV) can remain in the body. Blood tests will detect whether the patient have or had the virus infection or not. And If the patient does not have and receive a kidney from someone who has had the infection, then there is a chance that the virus may be passed to the patient through the kidney. The virus can cause some medical issues. If the virus transmission detected early then doctor can give effective drug treatment to prevent serious disease. Doctors may also prefer to give patient anti-viral drugs for three to six months.
4. The immunosuppressive drugs can also increase the risk of developing certain cancers, most commonly the skin cancer. Cancer of the immune system (lymphoma) being the more serious risk.
Post transplant, patient may be asked to monitor his or her temperature and weight after getting discharged from the hospital and should be responsible for taking the medications that have been prescribed by the doctor. Patient should avoid outside food and should eat clean and hygienic homemade food. He or she should follow a proper balanced diet chart that can be customized by the dietician keeping in mind the needs and requirement of the patient’s body. The recipient should do adequate amount of exercise after renal transplantation. It will help the recipient to prevent excessive weight gain but should also avoid any physical exertion and heavy exercise like wrestling, football or water sports like swimming. Patient should completely give up smoking and drinking before and post surgery as it may increase the chances of cancer, liver and heart disease in immune-suppressed persons. Proper care should be taken to avoid infection by keeping away from people with colds or any other infections, keeping hands away from face and mouth, avoid contacting stray animals, pets such as fish, cats.