Transplant Primer: Kidney Transplant

Section 1: Introduction to Transplantation	Section 4: Liver Transplant
Section 2: Heart Transplant	Section 5: Lung Transplant
Section 3: Kidney Transplant	Section 6: Pancreas Transplant

Kidney Transplant

Important! Nothing on this page is medical advice. If you need a transplant, please seek the advice and care of qualified transplant physicians. This is a general source of information and does not represent a medical opinion or recommendation.

Doctors may recommend a kidney transplant to treat kidney failure. Failure may be due to any number of diseases, with kidney complications of diabetes, glomerulonephritis, and hypertension leading the list. The person who needs a transplant is evaluated and, if they are found to be a suitable candidate, placed on a waitlist. When a donated cadaveric kidney becomes available, it is surgically removed from the donor (who is brain dead) and transplanted into the patient. Another option for the person in need of a transplant is a living donor. Living donor transplants, from biologically related (e.g., brothers, sisters, sons, daughters, etc.) or unrelated (spouses, friends, in-laws) individuals may be considered. Potential living donors go through an extensive evaluation to make sure that they are generally healthy and that they have two healthy normal kidneys. Living kidney donors can live a normal life after donating.

Kidney transplantation is the most successful treatment for kidney failure, and life expectancy is improved for patients when compared to dialysis treatments. There are also important quality of life improvements after successful kidney transplant surgery. Success of the transplant is expected in 93% to 97% of cases. A kidney transplant can last an average of 8 to 25 years. Although there is a greater short-term risk of death associated with the transplant surgery, this risk is outweighed by the long-term effects of continuous dialysis. Among 20,956 patients who underwent kidney transplants in 1997 and 1998, about 91% survived for at least three years afterwards.

Living donor results are even more successful. Studies show that less than 4 deaths occur out of 10,000 donors.

Step 1: Evaluating candidates for kidney transplantation
A team of specially trained staff evaluates the patient to establish whether he or she would be a good candidate for a kidney transplant. The staff includes people with special skills in a range of areas. The people who may be on the team include:

Nephrologists (medical kidney specialists)
Transplant surgeons
Social workers, psychologists, and/or psychiatrists
Nurses
Transplant coordinators

A kidney transplant is only offered to people who have irreversible, kidney failure. Other medical or surgical treatments for kidney problems have usually been tried before consideration of a kidney transplant. The kidney failure may have been caused by problems such as:

Diabetes
Glomerulonephritis, which is an inflammation of the filtering cells of the kidney
High blood pressure Pyelonephritis, an infection of the kidney
Pyelonephritis, an infection of the kidneys
Polycystic kidney disease (PKD), which is a condition that causes cysts throughout the kidney

Successful kidney transplants have been conducted on newborn infants, children and adults including people past the age of 70.

The evaluating team considers many factors to decide whether a person should be placed on the waitlist for transplantation. The person's general health and suitability for major surgery are taken into account. Risk factors are also considered carefully and may result in a recommendation against transplant surgery.

A kidney transplant would not be performed for people with certain conditions. These include:

Most cancers, unless successfully treated at least five years previously
Infections that cannot be completely treated or cured, such as tuberculosis
Severe lung, liver, or heart problems that would make the operation too risky

It is a normal reaction of the body to reject the donated organ. Anti-rejection drugs are prescribed to prevent this rejection. The candidate must be willing to take anti-rejection medicines indefinitely to keep the body from rejecting the donor kidney. The person will also need lifelong follow-up by health care professionals.

Step 2: Waiting
If a person is a suitable candidate for a kidney transplant, their name is put on a waiting list for an organ. Unfortunately, there are many more people on the waiting list than there are organs available each year. There are now more than 51,000 people in the U.S. waiting for a donor kidney. Waiting time may extend several years.

Kidneys are allocated based on a combination of the length of time a person has been on the wait list and how well-matched the kidney and the recipient are to each other.

The ideal donor is a living family member, or other unrelated individual who is emotionally close to the patient. This reduces the waiting time, the procedure can be planned in advance, and the results are better than transplantation using a kidney from a deceased donor.

Step 3: The transplant surgery
If the donor is living, they will receive general anesthesia and the transplant of the kidney into the recipient will occur immediately after the removal of the organ from the donor. Therefore, the patient receiving the transplant is prepared for surgery within the same time frame as the donor. They, too, will receive general anesthesia.

If the kidney is from a deceased donor, time is important. Unlike the living donor scenario, this surgery is typically not scheduled. It can occur at any hour of the day or night. A team of surgeons and anesthesiologists performs an operation to remove the kidneys from the donor. Additional surgical teams may be present to remove other organs. Although the donor is brain dead, this procedure is treated like any other operation using standard surgical practices and sterile techniques. . Organ procurement surgery respects the body and an open casket funeral is possible if desired. After the kidney is removed from the donor, it is preserved and packed for transport. Ideally, the kidney must be transplanted into the patient receiving the organ within 24 to 36 hours. After the transplant, the patient will begin recovery.

General anesthesia is administered to the transplant recipient prior to the operation. The transplant of the kidney begins with an incision in the lower part of one side of the abdomen. When the kidney is placed within the recipient, the blood vessels from the donor kidney must now be connected to the recipient's blood vessels. Next, the blood flow is restored. In addition, the ureter, which carries urine, is connected to the recipient's bladder. There is usually room for the donor kidney to be transplanted and connected without removing the original non-functioning kidneys. After the transplant is complete the incision is closed.

Step 4: After transplant surgery
Following kidney transplant surgery, the recipient will remain in the hospital for a few days to a week. Walking is encouraged as soon as the anesthesia wears off. Generally, he or she will also begin eating within 24 hours after surgery. A bladder catheter inserted during surgery can be removed in a few days.

Recovery for the living donor is usually speedy, and they may return home in 2 to 5 days. They too will awake with a bladder catheter, which is removed after the first day. As soon as the anesthesia wears off, the donor is usually up and around and can resume eating.

Because the organ will be identified as foreign by the recipient's immune system, rejection of the new kidney is always a possibility. Powerful drugs called immunosuppressants are given starting at the time of kidney transplantation surgery to try to prevent rejection. Observation during the first weeks following surgery is used to prescribe accurate immunosuppressant drug dosage.

Prior to discharge, the transplant team reviews information with the patient, gives instructions for follow-up care and medications, and answers the patient's questions. A prescribed rehabilitation program for the recipient will continue at home including exercise, nutrition, and the continuation of immunosuppression and other medications. The signs of rejection are also discussed with the transplant recipient and family.

Living donors do not have to take any specific medications or maintain a special diet as a result of kidney donation.

Step 5: Returning home
At-home rehabilitation for kidney transplantation depends on the individual. The transplant team will give specific instructions. In general, walking is recommended to restore strength, but heavy lifting should be avoided four to six weeks following transplant surgery. Other activities, such as driving may usually begin when the incision is free of pain. Sexual activity can resume when one is comfortable. A desire to become pregnant should be discussed ahead of time with the transplant team to determine if and when this is recommended.

At-home recovery is similar for the donor. The donor generally only needs to return for a postoperative check-up.

Continued follow-up visits are required for check-ups for the recipient. These begin soon after returning home. Initially, outpatient visits may occur weekly or even more often for the recipient, and as time progresses the frequency of follow-up visits usually decreases.

Possible post-operative complications may arise following kidney transplant surgery. They include:

Leaking or blocked ureter
Bleeding
Lymphocele (fluid collection around kidney requiring drainage)
Problems with blood vessels
Transplant renal artery stenosis

Leaking or blocked ureter - During transplant surgery, the ureter from the donor kidney is connected to the recipient's bladder. Sometimes the connection can leak. The treatment may involve inserting a very thin tube, called a stent. This provides the necessary scaffolding needed for the tissues to heal. Sometimes another operation is required.

Major bleeding - It is uncommon for a kidney transplant patient to experience bleeding after surgery. There may be leakage from the newly connected blood vessels and other operated surfaces. Patients may need a blood transfusion.

Problems with blood vessels - In general, complications can arise with blood vessel connections between the donor kidney and the recipient's blood vessels. A more serious complication is a clot in an artery or vein attached to the kidney. If a clot occurs and blood is unable to flow to and from the kidney, the kidney may cease to function.

Transplant renal artery stenosis - This is when the artery going to the kidney narrows, limiting blood flow to the kidney. This can also make it difficult to keep blood pressure under control. Treatment typically involves expanding the narrowed segment using a small balloon.

Other problems include the long-term risks of immnosuppression. These include complications related to too much or too little immunosuppression:

Rejection
Cancer
Infection

Rejection - It is fairly common for a transplant patient to experience rejection episodes. The body identifies the new organ as foreign and may try to reject it. The immunosuppressive medications prevent rejection in 50 to 75% of cases. Changes may be made in the medications including an increase in dosage or the use of additional drugs to stop the rejection. Some episodes can cause permanent damage to the new kidney. This may reduce longevity of the organ.

Cancer - Studies show that an estimated 6% to 8% of transplant patients will develop cancer over their lifetime with the transplant. This risk is higher than in the general population. Skin cancer is the most common, and is typically treated successfully. Some cancers result from the effects of the immunosuppressive medications and others are common cancers that occur at a higher rate in immunosuppressed individuals.

Infection - The immunosuppressant medications increase the risk of less serious and common infections such as urinary tract infection. In addition, they are associated with more serious infections like pneumonia. Finally, uncommon infections that do not affect non-immunosuppressed persons can occur.

Section 2: Heart Transplant

Section 4: Liver Transplant