KIDNEY TRANSPLANTATION

Kidney transplantation

A kidney transplant is the transfer of a healthy kidney from one person into the body of a person who has little or no kidney function.

The main role of the kidneys is to filter waste products from the blood and convert them to urine. If the kidneys lose this ability, waste products accumulate in the blood, which is potentially life-threatening.

This loss of kidney function, known as end-stage Chronic Kidney Disease or kidney failure

is the most common cause for needing a kidney transplant. It’s possible to partially replace the functions of the kidney using a blood purification procedure known as dialysis. However, this can be inconvenient and time-consuming, so a kidney transplant is the treatment of choice for kidney failure whenever possible.

Kidney patients of all ages — from children to seniors — can get a transplant. Every person being considered suitable for transplant will get a full medical and psychosocial evaluation to make sure they are a good candidate for transplant. The evaluation may reveal potential problems, that can be corrected before transplant. Medical professionals provide with a complete physical exam, review health records, and order a series of tests and X-rays in order to evaluate how well a candidate for a transplant can handle treatment and decide if a transplant is suitable for him. Every patient with Chronic Kidney Disease can get a transplant, as long as:

they are well enough to withstand the effects of surgery
the transplant has a relatively good chance of success
the person is willing to comply with the recommended treatments required after the transplant – such as taking immunosuppressant medication and attending regular follow-up appointments

Reasons why it may not be safe or effective to perform a transplant include having an ongoing infection (which has to be treated first), severe heart disease, obesity and cancer that has spread to several places in your body. If you have diabetes, you may also be able to have a pancreas transplant.Getting a transplant before you need to start dialysis is called a preemptive transplantation. It allows you to avoid dialysis altogether. Getting a transplant not long after kidneys fail (but with some time on dialysis) is referred to as an early transplant. Both have benefits. Evidence indicate that a pre-emptive or early transplant, with little or no time spent on dialysis, can lead to better long-term health outcomes. It may also allow you to keep working, save time and money, and have a better quality of life.

Kidney donations are possible from people who have recently died. This is known as deceased kidney donation. However, this type of kidney donation has a slightly lower chance of long-term success. Unlike many other types of organ donation, it's possible to donate a kidney while you're alive because you only need one kidney to survive. This is known as a living donation. A kidney from a living donor may last longer than one from a deceased donor. To get a deceased donor kidney, you will be placed on a waiting list once you have been cleared for a transplant.

From the time you go on the list until a kidney is found, you may have to be on some form of dialysis. Ideally, a kidney transplant should be performed when tests show that the extent of damage to your kidneys is so extended that you’ll need dialysis within the next 6 months. However, because of the lack of available kidneys, it’s unlikely you’ll receive a kidney donation at this time with the exception of a living one. On average, the waiting time for a deceased donor kidney transplant is 2 and a half to 3 years.

During the surgical procedure, the native kidneys generally aren’t extracted when you get a transplant. The surgeon leaves them where they are unless there is a medical reason to remove them. Nephrectomy is recommended in case of polycystic kidney disease due to the large size of the kidney or due to chronic infection or bleeding of a cyst within the kidney. The donated kidney is placed into your lower abdomen, where it’s easiest to connect it to your important blood vessels and bladder. If the kidney came from a living donor, it should start to work very quickly. A kidney from a deceased donor can take longer to start working—two to four weeks or more. If that happens, you may need dialysis until the kidney begins to work. How soon you can return to work depends on your recovery, the kind of work you do, and your other medical conditions. People who have not had satisfactory sexual life due to kidney disease may notice an improvement as they begin to feel better. In addition, fertility (the ability to conceive children) tends to increase. All pregnancies must be planned. Certain medications that can harm the fetus must be stopped six weeks before trying to conceive.

After surgery, certain medicines are considered to be necessary, because they tend to keep the immune system less active (called anti-rejection medicines or immunosuppressant medicines), in order to stop your body from attacking or rejecting the donated kidney. Patients need to take them as long as the new kidney is working. Without them, the immune system would recognize the donated kidney as “foreign,” and would attack and destroy it. Widely used immunosuppressants include tacrolimus, tacrolimus, ciclosporin, azathioprine, mycophenolate, prednisolone and everolimus. Additionally, vaccinations should be up to date, although any vaccines that contain live viruses, such as the measles, mumps and rubella (MMR) vaccine should be avoided. In addition, there are certain recommendations in order to avoid contact with people having recently being infected with chickenpox or flu. Moreover, living with a kidney transplant includes:

smoking if you smoke
follow a healthy diet
lose weight
comply with the special medication and inform for any side effects or new drugs you will need to take

There are also certain risks of a kidney transplant that include:

risks related to the procedure itself
risks related to the use of immunosuppressant medications (which reduce the activity of your immune system)
risks related to something going wrong with the transplanted kidney

Complications that occur in the first few months after surgery are known as short – term complications, such as infection, blood clots, narrowing of an artery, blocked ureter, urine leakage and acute rejection. Long – term complications usually develop after many years and are associated with the immunosuppressant medication. The most significant long – term complications are:

an increased risk of infections
an increased risk of diabetes
high blood pressure
weight gain
abdominal pain
diarrhea
extra hair growth or hair loss
swollen gums
bruising or bleeding more easily
decreased bone density
mood swings
an increased risk of certain types of cancer, particularly skin cancer

Chronic rejection develops within months to years after transplantation and is the major cause of long-term graft loss. It is the result of a gradual decrease of the kidney function. Hypertension, proteinuria and increase of serum creatinine levels are features of this progressive loss of kidney function and may lead to chronic allograft nephropathy. A rejection episode does not always have clear signs or symptoms and that is why regular physical examination by the transplant team and blood tests are so important.

Bibliography

National Kidney Foundation, January 26, 2017
Kasiske BL et al. “The evaluation of renal transplant candidates: Clinical practice guidelines”, J Am Transplant. 2001;1.
“Evaluation, selection and preparation of the potential transplant recipient”, Neprology Dialysis Transplantation. 2000;15 (suppl 7):3-38.
Malgorzata Kloc and Rafik M. Ghobrial. “Chronic allograft rejection: A significant hurdle to transplant success”, Burns Trauma. 2014; 2(1): 3–10

Leivaditis Konstantinos MD, PhD
Demirtzi Paraskevi MD

Nephrologists, “NEPHROXENIA” Chalkidiki Dialysis Centre