What is Kidney Transplant

Am I a candidate for Kidney Transplant?
Rarely one may not be fit to undergo kidney transplant in situations as below: 

• Advanced age
• Severe heart, lungs or other health problems that make you unfit for kidney transplant surgery
• Active or recently treated Malignancy (Cancer) within the past two years
• Active or recurring infection that cannot be treated effectively
• Significant non-compliance with medical regimen or failure to follow the treatment plan
• Active drug abuse and uncontrolled psychiatric disease

There may be some specific medical condition where kidney transplant may not provide you the intended benefit. You need to discuss in detail about any concerns with your treating kidney transplant team before the procedure.

Are there any risks or complications associated with the Kidney Transplant?

The kidney transplantation can treat kidney disease with kidney failure, but this is not a permanent cure.
Risks associated with kidney transplant include:

• Surgical risk
• Rejection of the donor kidney
• Recurrence of native kidney disease may recur or happen de novo in the transplant kidney and may follow it’s own course.

Decision for undergoing a kidney transplant is a personal decision and deserves a careful thought and consideration of the all the risks and benefits. Discuss in detail about your decision with your family members, friends or other trusted advisers.

Complications can occur after kidney transplant. Some complications which may happen include:

• Bleeding
• Infection, most commonly being wound, urinary tract and lung infection
• New kidney may not function well due to many reasons most commonly being donor related factors, toxicity of anti rejection medicines and/ or infection
• Leakage of urine or blockage of urine in the ureter
• Kidney Rejection: Rejection is a normal response of body to a foreign object or tissue. When a new kidney is transplanted into a recipient’s body, immune system reacts to what it thinks is a threat to the body and attacks the new organ. For a transplanted kidney to survive, anti rejection medicines need to be taken. These have their their own side effects, most common being:
  • Uncontrolled Blood Sugar- Diabetes
  • High Blood Pressure- Hypertension
  • Excessive hair growth or hair loss
  • Bone Loss
  • High cholesterol
• Higher risk of developing cancer especially lymphoma and skin malignancy
• Facial puffiness and weight gain
• Heart attack and stroke
• Death

What all is needed or done to get ready for a kidney transplant?

Choosing a Kidney transplant Center
You can select a kidney transplant center based on many factors. Just gather some important information about the kidney transplant center as below:

• Number and type of kidney transplants the center performs in a year.
• Center specific kidney transplant survival rates.
• Vital infrastructure including well established urology, nephrology, critical care and radiology services, kidney transplant intensive care unit, dialysis, blood bank, laboratory and availability of latest transplant technology and techniques.
• Tentative cost estimate that will be incurred before, during and after the kidney transplant. Costs should include tests for donor and patient evaluation before kidney transplant, surgery, hospital stay, and post transplant follow-up appointments.
• Availability of insurance services and center’s listing on your insurance provider.
• Other services provided by the kidney transplant center, such as teleconsultation, travel and local housing during the recovery period.

Donor and Patient Evaluation
You need to undergo a basic followed by detailed evaluation before kidney transplant. The evaluation for kidney transplant is same for living related and deceased donor kidney transplant.

Deceased Donor Kidney Transplant:
To get a kidney from an organ donor who has died (deceased/cadaver), you have to be on a waiting list of the National Organ & Tissue Transplant Organization. Once you have been accepted as a kidney transplant candidate, you will be placed on the deceased donor kidney transplant waiting list. This is an online registration done by the organ transplant coordinator in a center where you are being regularly followed up for your kidney problem. The registration for kidney transplant is usually done after at least 3 months of starting on dialysis. You can register at any kidney transplant center of your choice, nearest one is usually preferred and registration is totally free of cost. Regular follow up is needed to keep your registration active. Till then you may continue your dialysis session at any other nearest center. When a donor kidney becomes available, you will be notified and told to come to the hospital right away. If you are to get a kidney from a living family member (living-related kidney transplant), the kidney transplant may be done at a planned time.

Basic evaluation before kidney transplant includes:

Kidney Transplant Team:
A kidney transplant team carries out the evaluation process for a kidney transplant and includes:

• Kidney transplant surgeon
• Transplant nephrologist (doctor specializing in the treatment of the kidney diseases)
• One or more kidney transplant nurses including kidney transplant coordinator and kidney transplant counselor
• Psychiatrist or psychologist
• Social worker
• Other team members include a cardiologist, an anesthesiologist
• Dietitian

Donor Screening and Matching: 

• Donor detailed history and physical examination
• Blood Group for both patient and donor to know the matching is the first step.
  Getting kidney from a donor whose blood type matches or is compatible with your own is preferred.  
  If blood groups are not matching or not compatible then:
  • A paired kidney exchange is possible between two to three pairs by matching blood groups between donors and recipients and this is called as Swap kidney transplant.
  • If this is also not working out then kidney transplants between donor and recipient with incompatible blood types are also possible but this needs additional medical treatment before and after transplant to reduce the risk of organ rejection. These are called as ABO incompatible kidney transplants.
• Screening tests are done for donor to know whether the donor is fit to donate kidney for kidney transplant including
  • Hemoglobin
  • Serum Creatinine
  • Fasting Blood sugar and HbA1C
  • Urine albumin Creatinine ratio
  • Ultrasonography of Whole Abdomen
  • DTPA Renal Scan to know the split functional status of the donor kidneys

Detailed Evaluation

• After basic evaluation donor and patient evaluation is done from cardiology, pulmonology and anesthesia to know the fitness to undergo kidney donation and kidney transplant surgery.
• If these are normal, then further testing is done to know good donor match to avoid rejection after kidney transplant. This includes:
  • Cross match: This test involves mixing a sample of your blood with the donor’s blood in the lab and determines whether antibodies in your blood will react against specific antigens in the donor’s blood. The chances if rejecting donor kidney is very less in case of negative cross match report.
  • Tissue (HLA) typing: If your blood type is compatible and cross match is negative, the next step is a tissue typing test called human leukocyte antigen (HLA) typing. This test compares genetic markers and gives an idea about the likelihood the transplanted kidney survive long. A good match means that it’s less likely that your body will reject the organ.
• Tests to look for active infection and immunity towards viral infections, routine preoperative blood and urine tests are done. Also ultrasound, chest X Ray and CT scan or MRI are done before kidney transplant.
• Psychological and social issues involved in an organ transplant, such as stress, financial issues, and support by family and significant others are assessed before kidney transplant.
• Dental Examination, women may get a Pap test, gynecology evaluation, and a mammogram before kidney transplant.

The treating kidney transplant team will assess all the facts from clinical and social history, physical examination, all the tests and other specialty consultations in total to determine your eligibility for a kidney transplant.

What steps are taken before kidney transplant process?

• Your kidney transplant team will explain the procedure in detail to you and your kidney donor and both can ask any question.
• You and your kidney donor will be asked to sign an informed consent form that gives permission to do the kidney transplant surgery after understanding all the risks and benefits.
• If you have been on routine dialysis before the procedure, you will get dialysis before the kidney transplant procedure.
• For a planned living kidney transplant, you would be asked to fast for 6 to 8 hours before the kidney transplant operation, generally after midnight. In the case of a cadaver organ transplant, you should be asked to fast once you are told a kidney has become available.
• Based on your medical condition, your transplant team including surgeon, nephrologist and anesthetist may ask for other specific medicines or preparations before the kidney transplant surgery.

What all happens during kidney transplant Surgery?
The kidney transplant requires an average hospital stay of around 7 to 10 days for kidney recipient and 2 to 5 days for kidney donor. Procedure can be done either with traditional open method or in a minimal invasive manner with robotic assistance and hospital stay may vary depending on your condition and your treating team practices.

Generally, a kidney transplant follows the following process:

• After preoperative review, informed consent, 8 to 6 hours of fast and soap water bath you are asked remove your clothing and put on a hospital gown before shifting to preoperative room.
• An IV (intravenous) line will be started in your arm, hand or neck to monitor the status of your heart and blood pressure, and to take blood samples and give few injections including immunosupressive medicines.
• Hair at the surgical site may be shaved off, if needed.
• You will be positioned supine on the operating table, lying on your back.
• The kidney transplant surgery will be done under general anesthesia. The tube inserted via mouth to lungs will be attached to a ventilator that will take care of your breathing during the procedure.
• The anesthesiologist or nurse anesthetist will closely watch your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
• The surgical site skin will be prepared with antiseptic solution and per urethral catheter will be inserted into your bladder to monitor urine output during surgery.
• The surgeon will make a long incision into the lower abdomen on one side and prepare the bed for placing the kidney. The surgeon will prepare the donor kidney on the bench before implanting it. In case of robotic kidney transplant small incision is given around umbilicus and camera is inserted and then other ports are placed for different instruments and position is changed to head down position. After this robot is docked and bed is prepared for implanting donor kidney.
• After bench surgery on donor kidney it will be placed into the patient’s abdomen.
• The renal artery and vein of the donor kidney will be anastomosed to the iliac vessels.
• After the artery and vein are attached, the blood flow through these vessels into kidney and urine starts coming through the ureter. Surgeon inspects for any bleeding, vascularity of the kidney and after satisfactory findings ureter (the tube that drains urine from the kidney) will be connected to your bladder. Surgeon may put double J stent into ureter to support healing.
• The incision will be closed layer by layer with stitches or surgical staples. Usually absorbable stitches are used to close skin.
• A drain may be placed in the incision site to reduce chances of collection.
• Incision site is covered with a sterile bandage.
• After this you would be taken out from anesthesia and shifted to kidney transplant unit.
• Tubes like urine catheter, drain and double J stent are removed gradually.
• Treating team regularly takes care of vitals, intake – output, medicines including immunosuppression, tests, feeding, ambulation and physiotherapy.
• Often new kidney starts making urine immediately. Sometimes it may take several days more commonly in deceased donor kidney transplant, and may need temporary dialysis until your new kidney begin to function properly.
• You are discharged after satisfactory recovery and asked to regularly follow up in out patient department.

What all happens after kidney transplant Surgery?

• If you are from a far place you are asked to spend few weeks near the hospital in a lodging facility.
• After discharge from hospital you are kept under close surveillance to check how well your transplant kidney is working and also to look for any sign of rejection. Blood and urine tests are done twice a week and your medications adjusted according to the reports.
• Some soreness or pain around the incision site is expected while its getting healed. You are asked to take daily bath and prevent infection.
• You are asked to avoid lifting heavy objects or exercising other than walking until the wound has healed (usually about six weeks after surgery).
• You are prescribed many medicines after kidney transplant. These include immunosuppressant drugs that help keep your immune system from attacking and rejecting your new kidney. Additional drugs help reduce the risk of other complications, such as infection, keep blood pressure and blood sugars under control after kidney transplant.
• Regular follow up is needed with test reports and medicines are to taken regularly at fixed time intervals.
• Most kidney transplant recipients can return to work and other normal activities within eight weeks after kidney transplant.