Why Have A Kidney Transplant?
Where Are Kidneys For Transplantation Obtained
Kidney Transplantation Success Rates
Preparing For A Kidney Transplant
How You Can Prepare?
Medications Used In Kidney Transplantation
An Unsuccessful Transplant
Emotional Changes To Expect
Going Home With A Successful Transplant
Life With A New Kidney
The Renal Team
Living Donor Kidney Transplantation
New Developments in Live Donor Transplantation
Recipient, Donor and Family Concerns About Live Kidney Donation
Long Term Effects for Donor
Combined Renal And Pancreas Transplantation
Renal Resource Centre
A kidney transplant involves taking a kidney from the body of one person and implanting it surgically into the body of someone who has lost kidney function. The transplanted kidney can then perform the function of that personís own kidneys.
Whilst a transplant is not a cure for renal (kidney) failure, it does allow patients to live a more "normal" life than that experienced on dialysis. Patients with a well-functioning transplant have a greater sense of well being and are able to enjoy a lifestyle free of dialysis treatments, although they must continue with their transplant medications.
A transplant can mean improvement in anaemia, bone disease and in children, body growth. It also offers freedom from previous dietary and/or fluid restrictions and from restrictions on time and mobility.
Kidneys are donated by live donors and deceased donors.
For many years, most live donors were closely related to the potential recipient, such as a brother, sister or parent. Such close relatives were likely to be a close tissue match to the recipient, resulting in excellent outcomes. With the advent of improved immunosuppressive medications, it is now possible to achieve similar outcomes using live donors who are unrelated to the recipient. Spouses, more distant relatives and close friends are sometimes found to have a compatible blood group and tissue matches to the potential recipient. Many live donor transplants are performed using such unrelated donors. It is now also possible for altruistic members of the community to be assessed for their suitability as anonymous live kidney donors. These people are known as "non-directed kidney donors".
Kidneys from deceased donors are allocated to the best tissue matched patients on the transplant waiting list. Potential deceased donors are screened for cancer and transmissable viruses and their medical history is fully evaluated. Deceased donors can be heart-beating or non heart-beating.
The success rate of the transplanted kidney one year after kidney transplantation (one year graft survival) of live donor kidneys is 97% and for deceased donor kidneys, is 91% (ANZDATA 2007). Five year graft survival for live donor kidneys is 88% and for deceased donor kidneys, is 82%.
If the transplant works well for the first year, the chances are good that it will function for many years. If the transplant fails, a second transplant is possible and can be entirely successful. Many patients who received renal transplants 25 - 35 years ago remain well with those original grafts. The average transplant graft survival is 15 years.
The refinement and development of new immunosuppressive medications has consistently improved the success of kidney transplantation.
Many people with kidney failure requiring dialysis can be considered for transplantation. Apart from having kidney failure, these people must be in relatively good health and willing to undergo the procedures involved. For people with other major medical problems, such as severe heart and vascular disease, there may be increased problems for transplantation and dialysis may be a better treatment option. Some people are happy with their dialysis treatment and do not wish to undergo transplantation. Each patient should discuss their own medical suitability with their renal physician (kidney specialist).
Donor and recipient matching can be divided into three distinct areas: blood group matching, tissue type matching and cross matching. Each of these is an important aspect of donor and recipient matching and applies to living kidney donation and deceased kidney donation.
1. Blood Group
In the case of the deceased donor, the ordinary blood groups (A, B, AB, O) match the red blood cells of donor and recipient and must be compatible, as for blood transfusion. In the case of a live donor, some ABO incompatible transplants are possible.
2. Tissue Typing
This involves matching of a type of white blood cell called "lymphocytes". These cells (in fact, all body cells) have special markers called antigens on their surfaces. It is now known that a special group of these antigens, called HLA (Human Leukocyte Antigens) are important in transplantation. The closer the match of antigens between patient and donor, the better the chance of a successful transplant.
Since these antigens are inherited from parents, each child inherits half of their antigens from each parent. Therefore, if a parent is the prospective donor for the child, they will share at least one half of the antigens. For siblings (brothers and sisters) of a recipient, the chances of a match are: 25% will have full match, 50% will have a half match, 25% will be completely mismatched.
3. Cross Match
Just prior to the transplant, blood is taken from donor and recipient and mixed to ensure no reaction, i.e. negative cross match. In the case of a deceased donor, the transplant will not proceed if there is a positive cross match. In the case of a living donor, new approaches may enable the transplant to proceed. see New Developments in Live Donor Transplantation
People waiting for a deceased donor kidney in Australia have their tissue typing recorded on a centralised computer list. Whilst tissue typing is done once, blood is taken monthly to cross match against donor blood if a donor kidney becomes available. This is because new antibodies can be formed e.g. after blood transfusion or after exposure to infection, which may lead to a positive cross match with the donor. When a kidney becomes available, the donor tissue typing is entered into the computer and matched with the most suitable recipient, who will then be offered a transplant. Because of the many possible tissue types, a patientís name may not come up for months or years. This is often frustrating and many people feel they may have been forgotten. However, it is important that the tissue type is as closely matched as possible, as this will help to reduce the possibility of the transplant being rejected. If two people have the same degree of tissue typing, the kidney is first offered to the person who has been on dialysis longer. It is important that patients' blood samples are sent to the tissue typing laboratory each month, so that they remain active on the waiting list.
Medical Investigations are necessary to ensure fitness for transplantation. These may include physical examination, blood tests, x-rays of heart, lungs and sometimes stomach and bladder. It is also important that any infections are treated before transplantation. Patients being considered for transplantation are reviewed by the transplant physician and the transplant surgeon.
Maintaining good health is vital preparation for a kidney transplant. As well as keeping generally fit, controlling weight and blood pressure, there are a number of important preparations:
Smoking, Drug and Alcohol Use
The use of tobacco and other addictive and mood altering drugs should cease so that your physical and mental health are in the best possible condition. Alcohol use must be moderate: two standard drinks per day (males) and one standard drink per day (females) with two alcohol free days per week.
Regular dental checks are essential, as risk of mouth infection after transplantation is increased if teeth and gums are in poor condition.
As most people with kidney failure are on dialysis prior to transplantation, maintaining the dialysis schedule is an important part of the preparation.
Controlling both body weight and fluid weight (i.e. not gaining too much weight between dialysis treatments) is important in order to be ready when a transplant becomes available.
Protection of Skin Against Sunlight
This is particularly important for people who do not have dark skin and will help prevent skin cancer after transplantation.
Good blood pressure management contributes to positive outcomes for dialysis and transplant patients. It is absolutely vital to ensure good blood pressure control.
Regular exercise under the supervision of your renal physician is very important. It improves recovery time, blood pressure control, mood and general well being. For example, 30 minutes walking 3-4 times per week.
Regular pap smears and mammograms are recommended for women every 2 years.
The phone call notifying the patient of an available deceased donor kidney can come anytime - day or night. It is important to be prepared for this, i.e. have arrangements made so that you are able to be contacted readily and can come straight to the hospital so that the transplant can be performed as soon as possible. This is necessary because of the time limitation in keeping the kidney healthy after it has been removed from the donor.
Once at the hospital, a thorough medical examination is carried out to determine fitness for surgery. This will include blood tests, x-rays an ECG and dialysis if necessary. Occasionally, it is necessary to cancel the surgery after arriving at the hospital. This may occur for unforseen reasons - such as the patient has an infection or the kidney shows signs of deterioration or is less well matched than expected. This usually only occurs in kidneys coming from far away, e.g. from interstate, where the final cross match on the monthly blood is only done when the kidney reaches your city.
Consider where you will stay after discharge from hospital Ė it may be necessary to attend the transplant clinic daily for 2-4 weeks to ensure any rejection is detected early and treated. Gradually, your visits will become less frequent as your kidney function stabilises.
The renal unit social worker can advise about local short-term accommodation, if you live a very long distance from the transplant unit. Travel and accommodation assistance are available to assist rural patients.
The transplant operation takes around 3-4 hours. The transplanted kidney is placed on the right or left side of the lower abdomen, below the navel (see Diag. 1). The new kidneyís artery and vein are joined to an artery and vein in the pelvic area. The ureter (urine drainage tube) from the kidney is attached to the bladder. Many patients are surprised to learn that their failed kidneys are not removed but left to continue whatever small amount of function they may still have. However, if the failed kidneys must be removed, a separate operation is necessary prior to transplantation. This is only rarely required e.g. in the case of chronic infection or very large kidneys.
After surgery, there is usually some pain around the operation site, which will be relieved by medication. A bladder catheter and drainage tubes from the wound are needed for about a week to assist healing. The amount of urine produced by the new kidney is very closely monitored and measured. Recovery from the transplant operation is usually fairly rapid; patients are out of bed on the day after the operation and are able to move around in a few days. A nuclear medicine scan and/or ultrasound test may be done early and repeated to assess kidney function.
In many hospitals, new transplant patients are cared for in a separate area or ward from other patients. It is sometimes necessary for transplant patients to be nursed in this area since the medications taken to prevent rejection of the new kidney also make patients susceptible to infection. For this reason, the number of visitors may be restricted. In some transplant areas flowers and fruit are not permitted, as they may harbour bacteria.
It is not unusual for kidney function to be slow in starting, especially for deceased donor kidneys. This delay in function is usually caused by temporary damage to the kidney cells and the kidney may take 3 weeks or even longer to recover. Sometimes, the kidney may function briefly, then stop again due to temporary damage. If the kidney does not function well immediately following transplant, it does not mean it will not function satisfactorily in time. Dialysis may be necessary for days or weeks until kidney function is sufficient to keep the body in good chemical balance.
The length of stay in hospital depends on how well the kidney works and the occurrence of any complications. Average stay is about 1-2 weeks but may be up to 4 weeks.
After discharge from hospital, it may be necessary to return daily as an out-patient for some weeks. These visits decrease in frequency as kidney function stabilises.
The body resists the presence of foreign cells or tissue of a donor kidney in much the same way that it fights off bacteria and viruses which cause illness. The rejection process occurs when the patientís white blood cells reduce or stop the function of the transplanted kidney. Some patients experience a rejection episode in the first few weeks after their operation. Symptoms of rejection may include fever, decreased urine output, fluid retention and increase in weight, tenderness over the kidney and elevated blood pressure. Most rejection episodes can be reversed with drug treatment.
There are three types of rejection:
a) Hyperacute Rejection - can occur minutes or hours after the transplant. This type of rejection is very rare. It is untreatable and the kidney is removed immediately
b) Acute Rejection - can occur at any time from a week to a year after transplant. Occasionally, it can occur some years after transplant. This form of rejection is experienced by most transplant patients and is usually treatable. It is certainly likely to occur if the drug treatments prescribed are not taken regularly.
c) Chronic Rejection - occurs slowly over a long period of time and there may be no obvious symptoms. Chronic rejection is also difficult to treat. If the transplanted kidney eventually stops working, the patient will require dialysis. Another transplant is possible and your renal physician will discuss this option.
Because the drugs used to prevent and control rejection also weaken the bodyís defences, patients are more prone to infection after transplant. Risk of infection commonly in the wound site, mouth, urinary tract and lungs is highest in the first few months after transplant because drug dosage is highest. This is the reason for strict infection control in the transplant ward. Whilst some infections can be very serious, most are controlled by antibiotics and/or reducing doses of anti-rejection drugs.
Most units prescribe medications to prevent particular high risk infections after transplantation.
Slow wound healing can be caused by some medications, diabetes and obesity. Those at risk are closely monitored.
In order to control rejection, a combination of medications is given which suppress or reduce the effectiveness of the bodyís immune system. These medications are called immunosuppressives and must be taken throughout the life of the transplanted kidney.
The renal physician will determine which medications and dosages are needed. Dosages are very large at first to prevent rejection and are gradually reduced as the kidney begins to function well. These medications have a number of side effects, which usually subside as drug dosages are lowered. Each patientís experience of side effects is individual and each patient is monitored very closely in the post-operative period.
If the kidney does not work in spite of all the medications given, it will be removed and dialysis treatment resumed. If one kidney is rejected, a second transplant will not necessarily also be rejected. Patients are usually able to go back on the transplant list once they have recovered.
Just as transplantation involves many physical changes to the body, emotional changes are not unusual. It is an extremely exciting but it can also be a time of great anxiety as the patient and family and more commonly live donor, wait for the kidney to start functioning and for blood results and overall health to improve. Anxiety about possible rejection and infection is normal and patients may find the isolation from family and friends difficult. The anti-rejection medications may initially cause some physical changes and mood swings. Alternating feelings of elation, depression and irritability are common.
Some of these feelings may be offset by an increased sense of well-being as the transplant begins to function. However, with so many changes occurring so quickly, the patient and family may sometimes feel overwhelmed with anxiety and fear. It is important during this time to share these feelings with someone close and discuss your concerns with your physician and other staff. They understand this can sometimes be an extremely tense time and will always try to anticipate your fears and disappointment, especially if the kidney is slow to function and dialysis is still necessary, even if only for a short time.
Leaving hospital with a new kidney is an exciting time but contact with the transplant unit does not end upon discharge from hospital. In the first few months after discharge from hospital, frequent visits to the transplant renal physician are required. Daily visits for the first few weeks are common. This is so the physician can closely monitor the transplanted kidney's function and any signs of infection or rejection. It is therefore necessary for patients from rural and remote areas to stay in accommodation close to the hospital for some time after the transplant surgery. Clinic visits become less frequent as kidney function stabilises and general health improves. Follow-up for rural patients can also be maintained through the local doctor and renal physician.
There are a number of important precautions that every transplant patient must observe when returning home:
A very important part of treatment is taking the medications in the dosages prescribed by the doctor daily and for the life of the transplant.
Avoid Sources of Infection
For a short period immediately after the transplant, it is suggested that patients avoid crowded places and people with colds or viruses (especially small children). Good hand washing and treatment of scratches helps prevent infections. Chicken Pox is very contagious and dangerous. Vaccination prior to transplantation is recommended.
The drugs given will make the skin very sensitive to the sun. The incidence of skin cancer is very high in transplant patients, so it is essential to wear protective clothing and SPF 30+ sunscreen when outdoors. Reapply the cream regularly.
Reporting any Illness
This is particularly important in the first year. Prompt treatment of any problems can prevent further complications.
Whilst the diet is relatively free of restrictions, transplant medications increase the appetite, making it difficult to control weight gain. Food hygiene and avoiding foods that contain large amounts of bacteria (eg: pate, soft cheeses, salami, raw seafood) is important. The renal dietitian is available to advise on a healthy and satisfying diet.
There is a 1 % per annum risk for each patient of a non-skin tumour. Regular cancer screening is advised.
A kidney transplant can offer a "new lease of life" for patients and their families. There are some readjustments in the first year after transplant, and maybe a degree of anxiety about how long the kidney will function. As time goes on, these feelings usually decrease.
Most people are able to get back to normal activities and work within 3 to 6 months after transplant. Exercise (gentle at first) is also an important part of toning muscles and maintaining good health.
For many people, sexual function improves after transplant. Sexual activity will not harm the transplanted kidney nor increase risk of infection. However, as is the case for any major surgery, it is advisable to wait about four weeks before having sexual intercourse.
Having a baby after receiving a kidney transplant is possible but not usually advised until at least 1-2 years of good kidney function. The need for contraception should be discussed with your doctor. There are considerably increased risks of pregnancy complications, such as premature births and hypertension in women who have kidney transplants. Careful monitoring of the pregnancy is needed. Couples considering pregnancy should seek advice from their doctor, as x-rays and other tests might be necessary and preferably done before the pregnancy.
It should now be clear that deciding to have a kidney transplant is a major decision. The patient and family are advised to discuss all the practical and emotional issues together. The renal team, consisting of physician, surgeons, nursing staff, dietitian and social worker are available to talk over all aspects of transplantation. Many units also offer regular transplantation information workshops, which can complement the discussions with members of the renal team.
In the 1960ís, most renal transplants performed in the USA were from live donors. For many years, the majority of transplants performed in Australia were from deceased donors. However, the increasing gap between the number of potential recipients and donated kidneys has led to a steady increase in live donors in Australia. Around 50% of all transplants performed in Australia now use live donors.
The issue of donating a kidney is a difficult one for patient and family. Both are likely to have mixed feelings. Most patients are hesitant about asking a family member to donate a kidney and family members may be concerned about the risks involved for them. Questions often asked are: Would I be a suitable match? What will happen to my other kidney? What will the surgery be like? Would I have to take much time off work and other activities? The following information attempts to address their concerns.
1. Transplantation may sometimes be possible before dialysis is commenced (preemptive transplantation).
2. Time dependent on dialysis is reduced. This is particularly important for people with diabetes and young children.
3. Transplant surgery can be planned to suit the donor and recipient.
4. In the case of well matched donors, the recipient may require less immunosuppressive medication.
Live donors can be related or unrelated to the recipient and can be of a different sex. Prospective donors must be an adult (over the age of 18 years) and be in good health.
A close blood relative, such as a brother, sister, parent or child may be a suitable donor as well as less immediate blood relatives, such as cousins, uncles, aunts, nephews and nieces. Brothers and sisters may be a half or perfect match and parents can be a half match. Unrelated donors include spouses, friends, in-laws, distant relatives and altruistic members of the community, known as non-directed donors. It is also possible to match perfectly with an unrelated donor, although a perfect match is not necessary for a succussful transplant.
Blood tests are performed to determine if a donor and patient are a suitable match. If recipient and donor are compatible, further extensive medical screening is necessary. This includes x-rays and renal function tests to determine whether the donorís kidneys and urinary system are healthy. Potential donors are assessed by their own , independent renal physician. If other health problems such as diabetes, heart or lung disease present, the transplant will not proceed.
Prospective donors will be advised to minimise health risks by not smoking, achieving a healthy weight and ceasing oral contraceptives three months prior to surgery.
Both ABO blood group incompatibility and positive cross matching had previously precluded transplantion, with a high risk of very rapid severe rejection and destruction of the kidney within hours or days, in a process known as acute rejection. Over 30% of patients with a potential live donor have blood group incompatibility or a positive cross-match with their intended donor. Over 35% of potential live donors have been unable to donate because of blood group incompatibility with the intended recipient.
Recent advances now make ABO blood group incompatible and positive cross-match transplants possible for suitable patients. The key elements to success appear to be combining techniques before and after the transplant that remove naturally occurring and blood group antibodies, while also preventing new antibodies being formed by the recipient. Recent studies reveal similar short and long-term patient and graft survival as observed in blood group compatible transplantation.
Several transplant units in Australia have started performing such operations. In the event that you have an incompatible or positive cross-matched donor, your renal physician will advise if this procedure is suitable for you.
The Australian Paired Kidney Exchange Program (AKX) is a nationwide live kidney donor program, established by the National Organ Donation and Transplantation Authority to increase available organs from live donors. The goal of AKX is to increase live kidney donor transplants by identifying matches for incompatible donor-recipient pairs. Approximately 30% of potential donors fail to fulfil their wish to donate a kidney to a relative or friend due to incompatible blood group or tissue matches.
Paired kidney exchange involves pairs who are either incompatible or mismatched by blood group or tissue type to be exchanged or swapped. The potential recipient and their kidney-donating but incompatible partner are matched with another pair in the same situation. The donors in each pair donate to the matching recipient in the other pair. In a four-way operation, a kidney would be removed from each donor and given to the other person's partner.
Should you wish to register with AKX and participate in this program, contact your renal physician.
When and if a family member decides to donate a kidney, the decision to donate must be voluntary and free of feelings of being "pressured". It is important for the donor to discuss their intention with their immediate family and the potential recipient.
Sometimes, for a variety of reasons, family members and/or the patient may be opposed to the donation. The process is often complex and so it is essential to work through these issues with staff who can assist. Feelings and concerns about the donation should be discussed in confidence with the renal physician, social worker or psychiatrist caring for the donor. The patient should have similar discussions with their renal team. Every prospective donor has the right, after consideration of all the facts to withdraw the donation, just as every recipient has the right to refuse the donation.
When all tests have been completed, a date for the transplant surgery is scheduled. Both donor and recipient go to the operating theatre at the same time. Following the surgery, the donor will be cared for in a surgical ward.The recipient will be cared for in a separate transplant ward, to minimise the possibility of infection.
Donor surgery can be performed as either an open procedure, involving a large incision under the ribs or increasingly, as laparoscopic (keyhole) surgery, involving much smaller incisions in the abdomen. A camera is used to guide the removal of the kidney through a much smaller incision. The transplant surgeon will advise if this procedure is possible.
Laparoscopic surgery provides the donor with a faster, easier and less painful recovery from surgery. Donors can be discharged from hospital 2-4 days after the surgery. They can usually return to work within 4 weeks of surgery but should avoid any heavy lifting during those first 4 weeks. Open surgery requires a hospital stay of about one week. Heavy lifting must be avoided for about 12 weeks.
Most kidney donors recover quickly after the surgery and are able to resume work and other activities in 4-6 weeks. Resuming active sports will take longer.
Living with one kidney does not interfere with a womanís ability to have children and does not change life expectancy or increase the risk of acquiring kidney disease. Long term follow up with annual blood pressure, blood and urine testing is recommended.
Giving a kidney can be a very rewarding and satisfying experience for both donor and recipient, providing considerable forethought is given. Renal unit staff will provide you with all the information and counselling needed to make this decision.
More detailed information on the process of living kidney donation is available in "Kidney Donation by Live Donors", produced by NSW Health and available from transplant units or the Renal Resource Centre.
In people with renal failure due to the complications of diabetes (diabetic nephropathy) and for whom renal transplantation is being considered, a combined renal and pancreas transplant is a possibility.
Combined renal/pancreas transplantation in Australia has been possible since 1987 and several hundred have been performed since then. The group of patients considered suitable for the combined procedure are those:
a) with diabetes mellitus who are insulin dependent (Type 1 Diabetes)
b) with impending renal failure or on dialysis, requiring a renal transplant
c) aged less than 50 years with no heart disease
In conjunction with the above requirements, individual suitability is determined through a number of medical, surgical and nursing assessments. The transplant work-up involves an assessment of the diabetic changes within the blood vessels, eyes, nerves and kidneys. This work-up is required both to exclude life threatening contra-indications to the operation and to assess the value of any benefits that may be gained through the addition of a renal/pancreas transplant. There are a number of potential benefits that may be gained from this procedure. However they are quite variable from person to person and should be discussed on an individual basis.
Combined transplants are performed in Australia at the National Pancreas Transplant Unit at Westmead Hospital in New South Wales and at Monash Medical Centre in Victoria. Further information on this procedure and eligibilty requirements can be obtained from your renal physician.
The Renal Resource Centre is a national unit established to provide information and educational materials on kidney disease for patients and health professionals.
The primary objective of the Centre is to ensure that patients have easy access to such information, are well informed and can actively participate in their own health care.
The Renal Resource Centre is committed to providing education and service to the renal community.
Renal Resource Centre
RNS Community Health Centre
2C Herbert St,
St Leonards NSW 2065
Telephone: 61 2 9462 9455
Facsimile: 61 2 9462 9080
Freecall: 1800 257 189
RENAL RESOURCE CENTRE
2C Herbert St, St Leonards NSW 2065
Telephone: (02) 9462 9455 or (02) 9462 9400
Facsimile: (02) 9462 9080
Toll Free: 1800 257 189
Supported by the Australian Kidney Foundation