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Kidney Transplant


The kidneys

Kidneys are the master chemists of the body. They are two bean-shaped organs located on either side of the spine at the lower level of the rib cage. Each kidney contains up to one million functioning units called nephrons. Nephrons are the most important part of each kidney. A nephron consists of a filtering unit of tiny blood vessels called glomerulus capped by Bowman’s capsule attached to a tubule. The renal tubules are a series of tubes that begin after the Bowman capsule & end at collecting ducts. When blood enters the glomerulus, it is filtered and the remaining fluid then passes along the tubule. In the tubule, chemicals and water are either added to or removed from this filtered fluid according to the body's needs, the final product being urine that we excrete. They help the body pass out waste in the form of urine. They also help filter blood before sending it back to the heart.

Why are kidneys important?

Kidneys remove waste from the blood and excrete them into the urine. Your kidneys also regulate certain electrolytes such as:

• Potassium, which is vital for your hearts activity
• It produces active form of Vitamin-D which regulates calcium & phosphorous which are necessary for healthy bones and muscles.
• Produces hormones (erythropoietin) that assist in the production of red blood cells
• Release hormones that regulate blood pressure (renin angiotensin system).
• Many other organs depend on the kidneys in order to work properly.



Gross Anatomy of Kidney







Microscopic picture of functional unit of kidney (Nephron)





Collecting ducts

There’s a collecting duct at the end of each nephron in the renal medulla. This is where filtered fluids exit the nephrons. Once in the collecting duct, the fluid moves on to its final stops in the renal pelvis.

Renal pelvis

It’s a funnel-shaped space in the innermost part of the kidney. It functions as a pathway for fluid on its way to the bladder

Calyces

The first part of the renal pelvis contains the calyces. These are small cup-shaped spaces that collect fluid before it moves into the bladder.

Hilum

It’s a small opening located on the inner edge of the kidney where it curves inward to create a distinct bean like shape. The renal pelvis passes through it as well as the:

• Renal artery. This brings oxygenated blood from the heart to the kidney for filtration.
• Renal vein. This carries filtered blood from the kidneys back to the heart.

Ureter

The ureter is a tube of muscle that carries urine into the bladder, where it collects and exits the body.

Symptoms of a kidney problem:

• Reduced appetite
• Lack of sleep
• Fatigue
• Inability to concentrate
• Dry, itchy skin
• Increased or decreased urination
• Blood in urine
• Foamy urine
• Puffiness around the eyes
• Foot or ankle swelling
• Muscle cramps

If you notice any of these symptoms, contact your doctor. Depending on your symptoms, they may do some kidney function tests to make a diagnosis.

Tips for healthy kidneys

As kidneys affect many other parts of the body including the heart, follow these tips to keep them working efficiently:

Avoid extra salt

Eating a lot of salty food can disrupt the balance of minerals in your blood hence making it harder for the kidneys to work in the desired manner. Avoid eating processed & junk food in excess as they contain large amount of salt content. Eat healthy food such as:

• Fresh fruits and green vegetables
• Lean cut of meat
• Nuts & almond etc.

Exercise

High blood pressure is a known risk factor for chronic kidney disease. Regular exercise, even for just 20 minutes a day, can help reduce blood pressure.

Stay hydrated

Drinking plenty of water helps the kidneys perform one of their most important functions: removing toxins. Learn more about how much water you should really be drinking every day.

Stay hydrated

Use medications with caution

Regularly taking certain over-the-counter medications, such as nonsteroidal anti-inflammatory drugs like pain killers (diclofenac, ibuprofen, etc.) can cause kidney damage over time. Occasionally taking them is fine but work with your doctor to find alternatives if you have a condition that requires managing pain such as Arthritis.

Know the risk factors

Several things can increase the risk of developing a kidney condition. Make sure to regularly have your kidney function tested if you:

• have diabetes
• are obese
• have high blood pressure
• have a family history of kidney disease
• are on regular analgesics for arthritis



Introduction

Chronic Kidney Disease is a worldwide public health problem. It’s a social calamity and economic catastrophe. India with <3% of land mass of the globe, is the world’s largest democracy, hosts 17% of the Earth’s population (around 1.30 billion) and faces tremendous challenges to provide basic healthcare for its masses. At present, 80% of renal replacement therapy (RRT) is provided by the private healthcare system.

The crude and age-adjusted incidence rates of end-stage renal disease (ESRD) are estimated to be 151 and 232 per million population respectively, in India [1,2]. Even today, over 90% of patients requiring RRT in India die within months of diagnosis because of inability to afford treatment [3], and even in those who do start RRT, 60% stop for financial reasons.

In western countries, diabetes and hypertension account for over 2/3rd of the cases of CKD.[4] In India too, diabetes and hypertension today account for 40–60% cases of CKD.[5] With rising prevalence of these diseases in India, prevalence of CKD is expected to rise, and obviously this is the key target population to address.

Diabetic kidney disease is the commonest cause of ESRD (end stage renal disease) in India. By 2030, India is expected to have the world’s largest population of patients with diabetes. Diabetes and hypertension are two major cause for CKD.

Kidney Transplantation is the pioneer discipline in solid organ transplantation and the relationship between transplant surgeon & nephrologist has served as a model for multidisciplinary team care.

The purpose of Renal Replacement Therapy (RRT) is to prolong and to maintain the quality of life



Frequently Asked Questions about Kidney Transplant Evaluation

If both your kidneys have stopped working properly or may stop working soon, you have what is called End-stage Kidney Disease. There are only two treatments available, either dialysis or kidney transplant. You will need to decide what medical treatment is best for. Your doctor, patient support groups and other people who have been treated for kidney disease can give you more information to help you. The more you learn, the better you may feel about your decision. Kidney transplant is currently the best modality of treatment for most patients with end-stage renal disease.

Types of Kidney Transplant:

1. Pre-emptive kidney transplant
2. Living-donor kidney transplant
3. Deceased-donor kidney transplant

Advantages of Kidney Transplant

Kidney transplant is the treatment of choice for kidney failure compared to a lifetime on dialysis. A kidney transplant can treat chronic kidney disease with glomerular filtration rate (GFR, a measure of kidney function) less than or equal to 20 ml/min & end-stage renal disease to help you feel better and live longer. Compared to dialysis, kidney transplant is associated with:

• Better quality of life
• Lower treatment cost
• Return to job
• Lower risk of death
• Fewer dietary restrictions


Advantages of Kidney Transplant

Pre-emptive kidney transplant

A pre-emptive kidney transplant takes place before your kidney function deteriorates to the point of needing dialysis. Pre-emptive kidney transplant is considered the preferred treatment for end-stage kidney disease. In India, there is no accurate data but only about 20 percent of kidney transplants are performed pre-emptively in the U.S. Several factors have been linked to the lower than expected rate of pre-emptive kidney transplants, such as:

• Shortage of donor kidneys
• Lack of access to transplant centres
• Low rates of physician referrals for the procedure among candidates of lower socio-economic status
• Lack of physician awareness of current guidelines

Advantages of Pre-emptive Kidney Transplant

• Lower risk of rejection of the donor kidney
• Improved survival rates
• Improved quality of life
• Lower treatment costs
• Avoidance of dialysis and its related dietary restrictions and health complications
• These benefits of pre-emptive kidney transplant are especially significant among children and adolescents with end-stage kidney disease.

Living-donor kidney transplant



Living-donor kidney transplant procedure

A living-donor kidney transplant is the removal of a kidney from a living donor and placement into a recipient whose kidneys no longer function properly.



The Transplant Operation:

You should plan to spend about a week in the hospital after your kidney Transplant. Both the surgeon and the anaesthetist will meet you before the surgery and explain again about the surgical procedure and anaesthesia respectively.

The kidney transplant surgery usually takes 3 - 4 hours under general anaesthesia. A catheter will be placed into your bladder in order to accurately measure your urine output. This catheter will stay in for 5-6 days after your surgery.

The new kidney is placed on the right or left side (in case of second transplant) of your lower abdomen. Graft (new kidney) renal artery and renal vein are joined (anastomosed) to the internal/external iliac artery and external iliac vein respectively.

The ureter of the new kidney is connected to your bladder. Wound is closed in anatomical layers after placing a tube drain which helps to remove collected blood, lymph or urine in case of urine leak from the site of ureterovesical anastomosis. After surgery, you will be shifted to the transplant ICU where your vitals and blood parameters will be monitored by dedicated nurses and doctors very closely.

You will be encouraged to get out of bed as soon as your doctor feels this is safe, usually within 24 hours of transplant. Once you pass flatus, you will be allowed to drink and eat gradually. Usually the serum creatinine reaches to normal level in 4-5 days.

Many factors influence when a new kidney begins to work. Do not be disappointed if the new kidney does not make urine immediately. Sometimes a new kidney needs a few days or weeks to regain complete function.

We call this delay in regaining the kidney function “Delayed Graft Function”. Usually catheter is removed on fifth postop day and drain is removed on sixth postop day when the drain output is minimal. Patient is discharged with advice how to take medicines for immunosuppression and called for follow up in the OPD regularly.



PRECAUTIONS

You will be instructed to wear a mask for the first 6-12 weeks post-transplant, whenever you are somewhere you may be exposed to sick people for example, any doctor’s office, getting your blood drawn, anytime you are in the hospital corridors or waiting rooms.

• Good hygiene should always be maintained in order to avoid infections. Frequent hand washing and hand sanitizers should be used frequently by you and your family.
• Anyone entering your hospital room (including your care team members) should use hand sanitizer or wash hands thoroughly as they enter.
• Raw or undercooked fish, seafood, meat, and poultry are strongly discouraged.
• You should not have loose ice in your beverages.
• Avoid crowds. In the first month or so after your transplant, while you are taking high doses of immunosuppressive medications, you are more likely to get an infection. Stay away from people who have measles, mumps, chickenpox, shingles, or the flu.

Possible Complications:


Early:

• Bleeding
• Infection
• Rejection of the donated kidney
• Leaking from or blockage of the tube (ureter) that connects the kidney to the bladder


Late:

• Failure of the donated kidney
• Heart attack and stroke (rare).



*Acute rejection:

*Acute rejection is the most common. You are at the greatest risk in the first three months after surgery. This type of rejection can be treated successfully.

The following are possible signs of acute rejection:

• Fever > 100 degrees F
• Sudden weight gain of three or more pounds overnight
• Decreased urine output
• Pain or tenderness over the kidney transplant site.



*Chronic rejection:

*Chronic rejection occurs gradually over a period of years and may be difficult to treat. The most important thing you can do to prevent rejection is to take your anti-rejection medications exactly as they are prescribed. You will need to take these medications for as long as you have your new kidney. Missing anti-rejection medications will put you at risk for rejection.

Anti-rejection medication side effects:

After a kidney transplant, you'll take medications to help prevent your body from rejecting the donor kidney. These medications can cause a variety of side effects, including:

• Acne
• Bone thinning (osteoporosis)
• Diabetes
• Excessive hair growth
• High blood pressure
• Infection
• Puffiness (edema)
• Weight gain
• High cholesterol
• Increased risk of cancer, particularly skin cancer and lymphoma



Who can donate a kidney?

Any healthy person who is a near-relative (siblings, parents, spouse, grandparents) between 18 to 65 years of age. The pre-transplant tests performed are blood grouping, tissue typing and cross matching. Blood group testing between the donor & recipient must be compatible before tissue typing and cross matching is performed.

But now a days ABO incompatible transplants are being performed on a regular basis with comparable results. Statistics show that kidney transplant from live donor functions longer and the success rate for live donor kidneys is about 98 % for the first year and 90% at 5 years.

The average life of a kidney donated from a perfectly matched (tissue typing identical) sibling is 25 to 30 years and the average life of a kidney donated from a half matched or unrelated donor is 15 - 20 years. No live donor candidate is allowed to donate a kidney unless the transplant team is certain to the best of their ability that the donor will live a normal & healthy life with one kidney.



Deceased kidney transplant procedure:

Deceased-donor kidney transplant is when a kidney from someone who has been declared brain dead is removed with consent of the family or from a donor card and placed in a recipient whose kidneys have failed & no longer function properly and is in need of kidney transplantation.



Choosing a transplant centre:

You are also free to select a transplant centre on your own. When you are considering transplant centres, you may want to:

• Know about the number of transplants the centre performs each year
• Ask about the transplant centre’s patient and kidney survival rates
• Know about the transplant surgeon’s training and experience, because surgical outcome is better with surgeon trained from reputed centre.


After you have selected a transplant centre, you will need an evaluation to determine whether you meet the centre’s eligibility requirements for a kidney transplant.

The team at the transplant centre will assess whether you:

• Are healthy enough to undergo surgery and tolerate lifelong post-transplant medications
• Have any medical conditions that would decrease transplant success
• Are willing and able to take medications as directed and follow the suggestions of the transplant team



How does a kidney transplant differ from dialysis?

Transplantation has many advantages like, it improves your health and longevity, provides a lifestyle free from dialysis, you start leading near normal & healthy life, you stop/reduce taking medicines for high blood pressure, low haemoglobin & low calcium. Usually you will have no/fewer fluid and diet restrictions after getting a “new kidney.” Most people even feel well enough to return to work.

Dialysis only filters the blood during a treatment session, not in the constant way a kidney does. For this reason, dialysis patients usually have diet and fluid restrictions. Dialysis also requires a vascular access in the form of A-V fistula or AV graft where the blood can be collected and filtered in the dialysis machine outside the body.

A transplanted kidney performs all the functions of a kidney a person has from birth. It constantly filters blood for waste and excess fluid



What is the success rate of kidney transplant?

Christian Medical College Hospital, Vellore performed the first successful renal transplant in 1971 in India. The actuarial survival data have significantly improved in the past five decades. In 2000– 07, the 5-year survival was 85%; in the 1990s, the 10-year survival was 70%; in the 1980s, the 20-year survival was 55%; and in the 1970s, the 30-year survival was 20%. Now the actuarial survival rate is 98% at 1 year and 90% at five years. A living donor kidney functions, on average, for 15 to 20 years, and a deceased donor kidney for 8 to 12 years.

What medical conditions might rule me out for a transplant listing?

Following medical conditions might rule out a transplant:

• Advanced age
• Severe heart disease
• Active or recently treated cancer
• Poorly controlled mental illness
• Dementia
• Alcohol or drug abuse
• Any other factor that could affect their ability to safely undergo the procedure and take the medications needed to prevent organ rejection.



What is kidney paired donation?

If you have a potential donor who is not a biological match with you (such as having an incompatible blood group) but may match with someone else, kidney paired donation may be an option

. Hence the person who wanted to donate to you can donate to a different patient, and that patient’s intended donor can donate a kidney to you. Kidney paired donation may often help transplant candidates who are very hard to match.



How would I be matched for a kidney from a deceased donor?

ZTCC (zonal transplant co-ordination centre) maintains the computerized waiting list of recipients of each organ. And it has all the medical information on all transplant candidates who are actively listed on the waiting list with medical information on deceased donors. On confirmation of availability of the organ, the ZTCC co-ordinators will contact hospital co-ordinators about the availability of the organ. The hospital transplant co-ordinators will then connect with the patients. The team will then decide whether to accept the offer for their candidate depending upon patient’s clinical condition and cross match status. If the offer is turned down for one candidate, it goes to the next person on the list.



How long is the wait for a deceased donor transplant?

Unfortunately, there are not enough organs available for everyone who needs a kidney transplant. Waiting times for a deceased donor kidney transplant can vary greatly in different parts of the country, but waiting times of 4 to 5 years are common.



What must I do after a transplant?

After a transplant, you will need an ongoing treatment to stay healthy & maintain your kidney functions for the best possible result. Your immune system will recognize the transplanted kidney as being “different”, hence it may try to attack (reject) the organ. To lower the chance of organ rejection, you will need to take medicine every day (immunosuppression).

As long as you have a functioning transplant, you will need to have regular medical tests and check up with your doctors. These tests & check-ups are more frequent for first 3 months. Afterwards if you do well, you do not need to have these tests very frequently but at certain interval as suggested by your doctors.



Will my sex life be affected?

People who have not had satisfactory sexual relations due to the complications of kidney disease may notice an improvement as they begin to feel better after a transplant. In addition, fertility (the ability to conceive) tends to increase. Men who have had a kidney transplant have fathered healthy children. Women who have had a kidney transplant have had successful pregnancies. Women should avoid becoming pregnant too soon after a transplant. It's best to talk to your doctor when considering having a child. Family planning & Birth control counselling may be helpful at this time. It is important to protect yourself against sexually transmitted diseases (STDs). Be sure to use protection during sexual activity.



References

1. Agarwal SK. Chronic Kidney disease and its prevention in India. Kidney Int Suppl 2005; S41–S45

2. Modi GK, Jha V. The incidence of end-stage renal disease in India: a population-based study. Kidney Int 2006; 70: 2131–2133. Epub 2006 Oct 254

3. Abraham G. The challenges of renal replacement therapy in Asia. Nat Clin Pract Nephrol 2008 Dec; 4: 643

4. Snyder S, Pendergraph B. Detection and evaluation of chronic kidney disease. Am Fam Physician 2005;72:1723-32.

5. Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al. What do we know about chronic kidney disease in India: First report of the Indian CKD registry. BMC Nephrol 2012;13:10.

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