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Renal Resource Centre 37 Darling Point Poad, Darling Point, NSW 2027 AUSTRALIA Telephone: 61 2 9362 3995 9362 3121 Facsimile: 61 2 9362 4354 Freecall: 1800 257 189 Click here for our location map |
Why A Kidney Transplant?
Where Are Kidneys For Transplantation Obtained
Kidney Transplantation Success Rates
Preparing For A Kidney Transplant
How You Can Prepare?
Kidney Transplantation
Post-Transplant Care
Drugs Used In Kidney Transplantation
An Unsuccessful Transplant
Emotional Changes To Expect
Going Home With A Successful Transplant
Life With A New Kidney
Living Donor Kidney Transplantation
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 person’s 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 dependence on dialysis treatments, although they must continue with their transplant drug treatment.
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.
There are two sources:
(a) Living Donors
For many years, most living donors were closely related to the potential recipient, e.g. 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 living 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 match to the potential recipient. There is an increasing number of transplants being performed using such unrelated donors. It is now also possible for members of the community, who wish to do so, to be assessed for their suitability as anonymous living kidney donors. These people are known as "altruistic living donors".
(b) Deceased Donors
Kidneys from deceased donors are allocated to the best tissue matched patients on the transplant waiting list. Potential deceased donors with a history of cancer or transmissable viruses such as hepatitis B and HIV are not considered for organ donation. Hepatitis C donors are now considered for donation to hepatitis C recipients.
Deceased Donor kidneys are drawn from two sources:
The success rate one year after kidney transplantation of living donor kidneys is 93 -97% (2002 statistics) and for deceased donor kidneys, 87 - 92% (2004 statistics).
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 refinement and development of new immunosuppressive medications has consistently improved the success of kidney transplantation.
Most people, who have irreversible kidney failure and are on dialysis, can be considered for transplantation. Except for their 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 his/her own medical suitability with his/her renal physician (kidney specialist).
As well as matching blood groups of donor and recipient in transplantation, it is necessary to also match white blood cells. This is called "tissue typing" and "cross matching". In both living donor and deceased donor transplants, it is important that blood and tissue types are compatible.
1. Blood Group
The ordinary blood groups (A, B, AB, O) match the red blood cells of donor and patient and must be compatible, as for blood transfusion.
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-Antigens (Histocompatibility Locus 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.
In deceased donor transplants, it is also important to have a good match on tissue typing.
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. The transplant will not proceed if there is a positive cross match.
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 check if any antibodies against an HLA antigen have formed (eg. due to blood transfusion), and to cross match against donor cells if a donor kidney becomes available. 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 patient’s 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.
Medical Investigations - are necessary to ensure fitness for transplantation. These may include physical examination, blood tests, xrays of heart, lungs and sometimes stomach and bladder. It is also important that any infections of the kidney and/or bladder are treated before transplantation.
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:
a) Stop Smoking
Smoking will greatly increase the risks associated with
transplantation, especially serious lung infections and heart disease, even
making the actual operation more hazardous.
b) Dental Care
Regular dental checks are essential, as risk of mouth infection
after transplantation is increased if teeth and gums are in poor condition.
c) Dialysis
As most people with kidney failure are on dialysis prior to
transplantation, maintaining the dialysis schedule is an important part
of the preparation.
d) Weight
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.
e) 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.
f) Blood Pressure Control
Good blood pressure control is the final arbiter of outcome for
dialysis and transplant. It is absolutely vital to ensure its control.
g) Exercise
Regular exercise under the supervision of your renal physician
is very important. It improves recovery time, blood pressure control,
mood and general well being.
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 – it may be necessary to attend the transplant clinic daily for 2-3 months to ensure any rejection is detected early and treated.
The renal unit social worker can advise about local short-term accommodation, if you live a very long distance from the transplant unit.
The transplant operation takes around 3-4 hours. The transplanted kidney is placed on the right or left side of the abdomen, below the navel (see Diag. 1). The new kidney’s artery and vein are joined to an artery and vein in the pelvic area. The ureter (urine 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. 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 if the kidney is slow to 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 2-4 weeks but may be up to 2-3 months.
Some patients are discharged early because of risk of infection in hospital. They may need to return daily as an out-patient for 2-3 months.
1) Rejection.
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 patient’s
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 kidney stops working, the patient can return
to dialysis and await another transplant.
2. Infection
Because the drugs used to prevent and control rejection also
weaken the body’s defences, patients after transplant are more prone
to infection. 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.
3. Prophylactic Antibiotics
Most units have some drugs to prevent particular high risk
infections after transplantation, based on experience of HIV/AIDS
patients where some protocols have been shown to be lifesaving and
effective.
In order to control rejection, a combination of drugs is given which suppress or reduce the effectiveness of the body’s immune system. These drugs are called immunosuppressives and must be taken throughout the life of the transplanted kidney.
There are several drugs used and the renal physician will determine which drugs 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 drugs have a number of side effects, which usually subside as drug dosages are lowered. Each patient’s experience of side effects is individual.
If the kidney does not work in spite of all the drugs 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 about 6 months after the kidney is removed.
Just as transplantation involves many physical changes to the body, it can cause many emotional changes. It is a tense time for both patient and family, as they wait to see if the kidney will work and then face possible rejection episodes. Patients must also cope with isolation in the early stages from usual contact with family and friends. The drugs given, as previously discussed, produce physical side effects, which can be distressing to patients as body image may change and mood swings are experienced. Feelings of irritability, depression and elation 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 can feel overwhelmed. It is important during this time to share these feelings with someone close and discuss your fears and concerns with the doctor and /or other staff.
Leaving hospital with a new kidney is an exciting time but is not the end of contact with the renal unit. In the first few months it is necessary to make frequent visits to the renal physician. This may mean daily visits for several weeks. At the clinic, blood is taken and a medical check made, since rejection or infection may still occur suddenly. It is therefore necessary for country patients to stay close to the renal unit for some time after the transplant. For country patients follow-up is also maintained through a competent local doctor and reliable laboratory service. Clinic visits become less frequent as kidney function stabilises and general health improves.
There are a number of important precautions that every transplant patient must observe when returning home:
1. Drug Management
A very important part of treatment is taking the drugs in the
dosages prescribed by the doctor daily and for the life of the
transplant.
2. Avoid Sources of Infection
This includes crowded places and people with colds or viruses
(especially small children). It is also advisable to avoid contact with
animals (especially family pets) as they can also carry infections. This
is important in the early stages of the transplant because drug dosages are
high and the body’s defences are lowered. Chicken Pox is particularly
contagious and dangerous. Close contact with it requires protection
with immune globulin - see your doctor the same day.
3. Skin Care
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..
4. Reporting any Illness
This is particularly important in the first year. Prompt treatment
of any problems can prevent further complications.
5. Diet
Whilst the diet is relatively free of restrictions, the drugs taken
increase the appetite, making it difficult to control weight gain. The
renal dietitian is available to advise on a healthy and satisfying diet.
6. Risks
There is a 1 % per annum risk for each patient of a non-skin tumour.
A kidney transplant can offer a "new lease of life" but patients and their families have to make many adjustments in the first year after transplant, particularly in learning to live with disruption to one’s life and the "uncertainty" about how long the kidney will function.
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. There are considerably increased risks of pregnancy complications, such as premature births and hypertension in women who have kidney transplants and 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. Both men and women should have annual cancer screening.
It should now be clear that deciding to have a kidney transplant is a major decision the patient and family should discuss and prepare 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.
In the 1960’s, most renal transplants performed in the USA were from living donors. Until recently, emphasis in Australia has been on deceased donors. However, the increasing gap between the number of potential recipients and donated kidneys has led to a steady increase in living donors in Australia. Around 40% of all transplants performed in Australia now use living 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. Reduces time dependent on dialysis - particularly important for
people with diabetes and young children.
2. Allows for specific planning of operation, i.e. the best time for
donor and recipient and early (pre-operative) immunosuppression.
3. Generally, the recipient requires less immunosuppressive drugs,
therefore fewer side effects.
4. It is more likely to be successful if the donor is related to the
recipient.
5. It may sometimes be possible before dialysis is commenced (preemptive
transplantation).
Living donors can be related or unrelated to the recipient. A close blood relative, that is, a brother, sister, parent or child may be a suitable related donor. Because of inherited genes, brothers and sisters may be a perfect match (see section on tissue typing). Parents and children have at least half match and so are better matched than a deceased donor kidney. It is necessary for donor and patient to have compatible blood and tissue type. However, sexes of the donor and patient do not have to match. The prospective donor must be an adult (over 18 years of age) and be in good health.
This is happening at an increased rate in Australia. Results appear to be similar to those for deceased donor transplants. It is increasingly likely to be considered as the waiting list for kidneys grows. Spouses, friends and even altruistic members of the general public are being considered as living kidney donors.
Blood tests are performed to determine if a donor and patient are a suitable match. If blood and tissue are compatible and the donor is willing to go ahead with the transplant, further extensive medical screening is necessary. This includes x-rays and renal function tests to determine whether the donor’s kidneys and urinary system are in good working order. If this is not the case or there are other health problems (heart or lung disease), the transplant will not proceed.
When and if a family member decides to donate a kidney, it must be a voluntary decision free from feelings of being "pressured". It is important to discuss the decision with family, particularly the patient. However, it is also essential to discuss feelings and concerns confidentially with the renal physician and social worker or psychiatrist. Every prospective donor has the right, after discussing and considering the facts, to decide against kidney donation.
The donor who decides to go ahead with the surgery can ensure risks to his/her health are minimised by not smoking and ceasing oral contraceptives three months prior to the operation.
When all tests are completed a date is set for the transplant surgery. Both donor and recipient go to 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 or isolation area to reduce the possibility of infection.
Donor surgery can be performed as either an open procedure, involving a large incision under the ribs or as laparoscopic (keyhole) surgery, involving much smaller incisions in the abdomen and the use of a camera to guide the removal of the kidney. The transplant surgeon will advise if keyhole surgery is possible.
Keyhole surgery is becoming more widely available and makes the removal of a kidney from the donor a much less traumatic procedure. It makes the recovery from donor surgery faster, easier and less painful. Donors can be discharged from hospital 2-4 days after keyhole surgery and can usually return to work within a month after surgery. Heavy lifting must be avoided for about 4 weeks.
Open procedure surgery requires a hospital stay of about 1 week. In this case, heavy lifting must be avoided for about 3 months.
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 woman’s ability to have children and does not change life expectancy or increase the risk of acquiring kidney disease.
Giving a kidney can be a very rewarding and satisfying experience for both donor and recipient, providing considerable forethought is given. The renal unit staff are available to provide you with all the information needed to make this decision.
A detailed guide, "Kidney Donation by Live Donors" is available from 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 contraindications 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.
Information concerning renal disease, its treatment and community services is available from the Centre. Fact sheets and booklets can be ordered direct or downloaded from the Centre’s web site.
The Centre is available to all renal patients, their families and renal unit staff throughout Australia.
Renal Resource Centre
Sydney Dialysis Centre
37 Darling Point Road
Darling Point NSW 2027
AUSTRALIA
Tel: 02 9362 2995; 9362 3121; 1800 257 189
Fax: 02 9362 4354
Web: www.renalresource.com
RENAL RESOURCE CENTRE
37 Darling Point Road,
Darling Point NSW 2027
AUSTRALIA
Telephone: (02) 9362 3995 or (02) 9362 3121
Facsimile: (02) 9362 4354
Toll Free: 1800 257 189
Web: www.renalresource.com
Supported by the Australian Kidney Foundation
Renal Resource Centre