Kidney transplantation is the best modality of treatment for end-stage kidney failure. In this treatment, kidney of a healthy person is put inside the body of the patient. Generally kidney transplantation is done when the kidney failure is very severe (kidney functions comes down to less than 90 %). Most of the patients are treated with either on haemodialysis or peritoneal dialysis before transplantation is carried out. However, occasionally kidney transplantation is done before the patient develops features of severe kidney failure. This is called pre-emptive kidney transplantation. The advantage of this method is that patient does not need to go through the complications of severe kidney failure.
What are the advantages of kidney transplantation?
Transplantation is the only panacea (complete treatment) for kidney failure. Treatment modalities like haemodialysis or peritoneal dialysis will only take care of the excretory functions of the body, that too only up-to certain extent. These modalities do not take care of several other important functions of the kidney (refer to “section on functions of the kidney”), which are essential for a healthy life.
Any healthy individual above the age of 20 and below 60 (preferably 55) can be a kidney donor. However, success rate of transplantation is higher if the recipient and donor are genetically related. Brother, sister, parents and children (first degree relatives) are the preferred donors. If first-degree relatives are not available, second-degree relatives (uncle, aunt, nephew and niece) can be accepted as donors.
An unrelated person can donate kidney, however this has to be approved by the authorization committee of the state. Motive for such action by donor should not be financial gains. A true friend may be willing donate. Any financial transaction between the patient and the donor is illegal.
As safe and powerful immunosuppressive medicines have become available, survival figures up-to 5 years after transplantation are comparable to that of related kidney transplantation. However, results of live related kidney transplantation are superior in the long term.
1. Restriction of protein is considered as an essential part of treatment of kidney failure. This may delay the development of severe kidney failure (called end stage renal failure ESRF) by few months. However, if severe protein restriction is continued for a long time, it will cause malnutrition and poor health.
2. Once the patient develops significant kidney failure, dialysis (purification of blood) should be initiated. The frequency of dialysis should be thrice a week as 4 hourly sessions. Adequate dialysis will remove the toxins from the body and improve the health. Delay in starting dialysis and reduced frequency (less than thrice weekly) of dialysis may minimize the expenditure initially but this saving is insignificant as compared to the long-term complications, which can occur as a result of inadequate dialysis.
3. Anemia is a frequent complication of kidney failure. Most often blood transfusion is given to correct anemia. Though this is effective in reversing anemia quickly, blood transfusion may result in several undesirable complications. Several viral infections are transmitted through blood transfusion. Though blood is routinely screened for hepatitis viruses (B&C) it is still not absolutely safe. Another viral infection, which is transmitted through blood transfusion is cytomegalovirus (CMV). Infections with these viruses can result in multiple complications in transplant patients. Use of erythropoetin will reduce the requirement for blood transfusion. All patients with renal failure should be vaccinated against hepatitis B.
4. If the patient has an infection with a hepatitis virus (B or C) it is safer to treat this infection before transplantation. However, in certain situations treatment may not be possible. This is particularly true about certain types hepatitis C virus strains, in which case it is advisable to proceed with transplantation as renal transplantation is a superior modality of treatment than dialysis even for patients who are infected with hepatitis C. Treatment of hepatitis after transplantation is risky and it could damage the kidney.
5. Donor of the kidney should be young, healthy and related. However, most often such ideal donors do not exist. If the choice is between an elderly parent and a young distant relative it is better to choose the younger donor. Recent studies have shown that with good immunosuppression, kidneys from not so related donors also can function for a long time.
Although spouses genetically dissimilar by and large they are accepted as donors. However, results are similar to other types of unrelated kidney transplantation.
Donor needs to be evaluated in detail before kidney donation. Blood counts, blood sugar, liver functions, heart function and lung functions should be checked. Chest X-ray, electrocardiogram and ultrasonography of the abdomen should be done. Finally to know the blood supply pattern of the kidney, a test called angiogram is done. Angiogram gives precise information about the length, position and of blood vessels supplying the kidney. Such knowledge is essential before operation is performed. Recently investigations like spiral CT, MR angiogram have become available which also give equal information about vascular pattern.
It is essential that donor and the recipient have compatible blood groups. The guidelines are similar to that of blood transfusion. A person with AB blood group can receive a kidney from any person with any blood group and a person with O group can donate a kidney to anybody. However, unlike blood transfusion Rh typing does not have much relevance with respect to kidney transplantation. An Rh negative person can receive a kidney from an Rh positive person.
HLA (Human Leukocyte Antigens) are major targets of immune response. Each individual inherits one set of HLA antigens from each parent. HLA compatibility among relatives will be as follows.
Parents and children- 50 %
( brother & sister)- 100 % – in one fourth of the cases
(sister & sister)- 50 % in half the cases
(brother & sister)- Nil in one fourth of the cases
Between husband & wife – Nil as they are genetically dissimilar (if there is a relation between husband and wife compatibility depends on the relationship)
There is a direct correlation between survival after renal transplantation and HLA typing. The best results are seen with complete HLA matching. With lesser degree of matching survival comes down even further.
There are two types of cross match; RBC crossmatch and WBC cross match. The former is done before blood transfusion and the latter before kidney transplantation. The purpose of WBC cross match is to find out whether the recipient (patient) has preformed antibodies in his or her blood against the donor tissue. WBC cross match is done by incubating the serum of the recipient and lymphocytes (a type of WBC) together. If the cross match is positive it means that patient has preformed antibodies against the tissue and transplantation should not be carried out.
Two surgical teams will be operating in adjacent operation theatres. One team will operate on the recipient (patient or the person who is receiving the kidney). Abdomen is opened and the place where the new kidney (called renal allograft) has to be put is prepared. Usually kidney is placed in the right or left ileac fossa (above the groin within the abdominal cavity). The second team will operate on the donor (the person who is donating the kidney). One of the kidneys will be dissected (usually the left) and removed along with renal artery, renal vein and ureter.
The removed kidney is subsequently flushed with cold fluids to remove blood clots and to cool the kidney. Once the kidney is cooled it is put in the abdominal cavity of the recipient. Renal artery of the donor kidney will be connected to internal ileac artery of the patient and renal vein to the internal ileac vein and ureter to the urinary bladder. Once the blood vessels and ureter are connected, urine flow will resume immediately.
Normally the transplant kidney starts functioning immediately. However, urea and creatinine levels may take few more days to settle down to normal levels. Anemia is corrected within few weeks and original health is regained within a period of 1-2 months.
Usually, kidney functions become normal or near normal after transplantation. Hence, the dietary practice, which was followed during the period of renal failure need not be continued. However, it is important to restrict salt as majority of patients continue to have high blood pressure after transplantation. Dietary fat needs to restricted as transplant patients are at a higher risk of developing hyperlipidemia and related complications. Total calorie intake needs to be restricted to avoid excess weight gain. Generally, there is no need to restrict high potassium diet. However, some patients have a tendency for developing high potassium level in the blood after transplantation and they need to restrict the food items containing lot of potassium.
A person in normal health can drink up-to approximately 14- 15 litres of water without developing any complications. Intake higher than this will result in a condition called water intoxication, a life threatening condition associated with swelling of brain.
Transplant patients often have a tendency to drink huge quantities of water as a result of the false assumption that higher water intake will improve the kidney function. I have seen patients drinking 7-8 litres daily, sometimes getting up in the middle of the night to dink and they use the same opportunity to pass urine also. As long as kidney functions are well within normal range this does not cause any problem, but it is unnecessary.
In patients with deranged kidney function (not all patients regain absolutely normal kidney functions after transplantation) consuming excess water can result in water intoxication. This condition is characterized by swelling of brain, low salt level in the blood (hyponatremia) as a result of dilution of blood and can be associated with loss of consciousness. In conclusion, there is no reason to drink enormous quantities of water; often it can be harmful. Fluid intake depending on thirst, approximately 2- 3 litres daily is more than sufficient.
The most important medication after transplantation is immunosuppressive medication. These medicines are used to suppress the patient’s immune system from rejecting the transplant kidney, which is a foreign tissue. The following are the important immunosuppressive medications.
First 1-2 days after transplantation steroids are given as injections. After that these medicines are given orally. Prednisolone is the most frequently used steroid. It is usually started at a dose of 20- 30 mg daily and the dose is gradually reduced. At 6 months after transplantation the dose of prednisolone will be 5 mg daily. Further reduction is usually not done. Although prednisolone is an effective drug it is associated with several side effects. Development of diabetes, weakness of bones, obesity and pimple formation are some of the side effects. However, other steroids like dexamethazone and betamethazone have more side effects and should not be used on a regular basis.
Cyclosporine is an important constituent of the immunosuppressive armamentarium currently used to prevent transplant rejection. It is a powerful drug and its introduction in 1990’s has improved the results of transplantation. Cyclosporine is expensive and many patients find it difficult to afford this drug. These patients will benefit from the simultaneous use of ketoconazole along with cyclopsorine. Ketoconazole reduces the rate of breakdown of cyclosporine in the liver making it possible to reduce the dose. Ketoconazole has been reported to cause liver damage in some people and this risk can be minimized by using a smaller dose. I have used low dose Ketoconazole (50 mg daily or one fourth of a tablet) in nearly 200 patients and found that dose of cyclosporine could be reduced to nearly one third to one fourth of the usual dose. No significant side effects were encountered. This has been presented in several international conferences.
Cyclosporine is like a double-edged sword. It can be associated with several side effects. It is important to check the blood level of cyclosporine frequently and maintain it within the therapeutic range. Low blood levels may precipitate a rejection episode and high levels can be harmful to the kidney. Other important side effects of cyclosporine include excessive growth of hair, thickening and swelling of the gums, high cholesterol levels.
Some centers had earlier advocated withdrawal of cyclosporine at one year if everything is going fine. However, there is a significant risk associated with this. Approximately 10-15 % of patients develop rejection episodes once cyclosporine is withdrawn and some of them may suffer from loss of the graft also. The current recommendation is to continue cyclosporine as long as it is possible.
Azathioprine is another important immunosuppressive medication. It is a relatively safe drug. Blood counts should be regularly monitored while patient is receiving this drug. Drugs like Zyloric (allopurinol) for reducing uric acid levels in the blood should not be used while patient is receiving azathioprine.
This is a relatively new entrant. It is a very effective drug in preventing rejection episodes with relatively frequency of side effects. However, some patients may experience burning sensation in the stomach and diarrhea. Splitting the dose and taking the drug at multiple intervals can minimize side effects. Blood counts need to be monitored at regular intervals.
These are powerful medicines (monoclonal antibodies), which are given before and at the time of transplantation. These medicines reduce the risk of rejections. However, they are costly.
These medicines are generally administered when the match between the kidney donor and patient is poor. But if the patient can afford these drugs are recommended even for well matched donor recipient pairs.
Majority of patients do well after transplantation. However, complications do occur. It is important realize that treatment does not finish with transplantation. Regular monitoring is important after transplantation. Complications should be treated as they arise.
A major problem after transplantation is infection. Medicines, which are given to protect the kidney, weaken the body resistance and make the patient prone to develop infections. Type of infection may vary from the usual infections, which affects the general population to uncommon infections, which affect only people with a weak immune system. Risk of developing these infections can be reduced by avoiding crowded and unhygienic places, eating relatively clean food. It is also important to avoid work sites where buildings are constructed and destroyed, close contact with animals and pets as these can predispose to the development of certain life-threatening infections. The following is a list of infections, which can occur after transplantation.
Skin and soft tissue infection
Diabetes can occur after transplantation. Mostly medicines such as steroids and cyclosporine are responsible for this. People with a family history of diabetes are at a higher risk.
c. High blood pressure
d. High lipid levels: Elevated cholesterol levels can occur after transplantation.
e. Coronary heart disease
f. Cerebrovascular accidents
1. Kidney functions should be checked frequently. This will pick up a rejection episode early and can be treated.
2. Personal hygiene must be maintained. This will reduce the rate of infection. Construction and destruction of buildings can result in dissemination of fungal infections. It is also important to avoid lose contact with animals and pets as these can transmit certain microorganisms usually confined to these animals.
3. As time passes, risk of the patients’ body rejecting the kidney comes down. However risk of developing other complications like ischaemic heart disease, stroke and malignancy increases. Blood pressure needs to be well controlled. Diet has to be planned and daily exercise is recommended. Excessive intake of carbohydrates, fat and salt should be avoided.
4. Painkiller medicines belonging to the class of nonsteroidal anti-inflammatory drugs (Brufen, Voveran etc) should be avoided as this can cause sudden deterioration of kidney functions.
Dr Abi Abraham M recognized nationally as well as internationally as an expert in the field of nephrology and kidney transplantation. He has more than 23 years of experience both as a clinician and academician. He has a wide range of experience in renal transplantation, critical care nephrology, vasculitis, lupus and electrolyte disorders. He has been awarded three prestigious fellowships, has widely cited publications in peer-reviewed journals, memberships in many renal societies and held administrative positions in organizations..