TRANSPLANT

Overview

Once a patient has reached the stage of kidney failure, the options available to them are:
• Dialysis
• Transplantation

Kidney failure can be managed for many years with dialysis, but there is a general agreement, supported by recent studies in both adults and children, that patients who receive transplants enjoy a better quality of life than those who remain on dialysis.

Unfortunately, transplantation isn’t the best option for everyone and transplantation also has its advantages and disadvantages:

Advantages

• Freedom from dialysis
• Less fluid and dietary restrictions
• Increased energy and well-being
• A less restricted life-style
• A possible return to work
• Improved fertility in women
• Increased life expectancy

Disadvantages

• Initially lots of hospital visits
• Outcomes are less predictable
• Taking drugs for life
• Risk of long-term complications
• Loss of some social welfare benefits

The final decision to be on the transplant waiting lists is yours.

A major undertaking

A transplant is a major undertaking – one that involves a considerable amount of clinical evaluation. Before the search for a suitable kidney begins, your doctors will determine if you are a suitable recipient. Not all dialysis patients are suitable for transplant.

The standard review procedures for major operations apply to transplant candidates – for example, your heart and lung function must be sufficient that you will survive the operation. Clinical conditions such as obesity and cancer may affect your suitability for a transplant, as would non-clinical conditions such as current drug abuse.

If you are having treatment for an infection or other serious medical condition, you may temporarily be taken off the transplant list until your body has recovered sufficiently to undergo such a major operation.

Waiting List

If you decide to opt for a kidney transplant you may be lucky enough to have a living donor offer you a kidney.

However, if you need to wait for a cadaveric (deceased) donor, you will be put on to the waiting list. Your details, including blood group and tissue type, will be put into the national computer at UK Transplant (UKT).

When kidneys become available, the UKT searches for the most suitable candidate for transplantation. The waiting list is not a 'queue' but operates by finding the right kidney for the right patient.

The average waiting time for an adult kidney transplant is 506 days.
For children, the average wait is 203 days.
 

For the latest statistics on transplants in the UK visit:

www.uktransplant.org.uk

Assessment

When you have decided that you want to have a transplant, and before you are put on the list as a suitable candidate, you will be seen by the transplant surgeon, after which you will find yourself taking many tests.

These will help the transplant team to find any potential problems before they occur, and determine if a transplant is the best option for you.

These tests are often called the “pre-transplant workup”.

One of the most important set of tests for a transplant candidate is the blood and tissue type, [see finding a suitable donor] but there are many other tests that you might have pre-transplantation depending on your clinical needs.

Finding a donor

There are 3 possible sources for your new kidney:
• a kidney donated by a living blood relative
• a kidney donated by a living non-relative
• a kidney from a deceased donor (a cadaveric donor)

The living donor

Living donors are usually your immediate family – your mother, father, sisters, brothers or children may offer to donate a kidney. Cousins, aunts and uncles are also possible blood-related donors. However, if tests prove that their kidney is compatible, an unrelated person such as a friend or spouse can become a donor. Regardless of whether the donor is a blood relation or not, as long as they are healthy, the procedure is relatively safe and recovery can be rapid (a few weeks).

Evidence shows that by having only one kidney the donor can lead a normal life, but all parties involved must consider the psychological effects associated with this procedure. Discussion with prospective donors at the beginning of the process is important to ensure that they are fully aware of all the implications.

Tests will be carried out to check for compatibility between you and the donor’s kidney. These include:

Blood typing

This is important in transplantation because your donor needs to be of a blood group that you can accept.

You can be one of four blood types; O, A, B, AB.
The table below shows how blood typing works:

Tissue typing

Each of us carries a set of 6 inherited markers (Human Leukocyte Antigens or HLAs) on the surface of our cells. They play a vital role in the recognition of cells by the immune system and this test is used to determine the match between the kidney donor and recipient.

The deceased donor

More than half of all kidney recipients receive organs from deceased (cadaveric) donors. Kidneys suitable for transplantation tend to come from people who have had strokes or a car crash and are transferred to a hospital intensive care unit and die whilst attached to a ventilator. The kidney will only be removed from the body when the donor has been declared brain dead after a series of tests.

When a kidney becomes available, it is logged onto the national computer at the UK Transplant (UKT) which searches for the most suitable candidate for transplant.

Certain patients will receive priority:

•children
•those who have the highest level of compatibility with the donor
•those who have been waiting the longest

Donor Issues

Issues and background information about donors

Donation is the key to all transplant activities.

In the UK there are far more recipients than donors, and this section of the website explores some of the types of donation available, and some of the issues surrounding the different types of donation possible.

One of the most common misconceptions about donation is that you have to have died to be able to donate!

The vast majority of donors are cadaveric (from deceased individuals) but there are other options. Techniques have been discovered that allow kidneys and lungs to be donated from living donors, normally close relatives. For more information, see our live donor section.

Each day about 8 people receive an organ transplant.

Anyone, regardless of age, can express a wish to be a donor.

Medical suitability for donation is determined at the time of death.

Keep in touch

The time you may have to wait for your organ transplant can vary from a few days to several years.

During this time, it is important to keep in touch with the transplant centre. Make sure you keep them up to date with:

• Your ‘round the clock’ contact details for home, work, school and holidays
• Phone numbers of your friends and family
• Your medical history. Let them know if you have any infections or if any of your medication is changed.

You may have a mobile/pager that you can carry with you at all times. Make sure that you have it turned on, and charged up!

Be prepared

Your call may come at any time, day or night, so it’s best to be prepared. Make a list and pack ahead of time, so that you’re ready to go straight to the transplant centre.
• Pack your hospital bag: clothing, toiletries, books, etc
• Prepare a list of people who should be contacted when you get ‘the call’
• Give the list to a family member or friend so that they can make phone calls for you and bring any forgotten items to the hospital
• DON'T forget to bring your medicines with you

Get informed

You are about to undergo major surgery, and enter a new phase of your life. Fear of the unknown is always a stressful situation, but it is important that you manage your stress and keep concerns to a minimum whilst you are waiting for your transplant.

• Learn as much as you can about your operation and what to expect from your transplant.

• Find out as much as you can about the lifestyle changes you will have to make to get the most out of your new organ. (see lifestyle section)

• Visit the transplant centre and familiarise yourself with the surroundings

• Information groups and patient education sessions are run by many centres and can provide you with further written information

• Your transplant team will be happy to answer any questions you may have, and will have some useful leaflets for you to read.

• They may also put you in touch with patients who have already had a similar operation to the one you are about to undergo.

The Operation

The Operation

A kidney transplant operation is the second most common form of all transplants, and the most common solid organ transplant in the UK.

It requires a general anaesthetic and will usually last between 2 - 3 hours. You will be able to discuss the operation in detail with your transplant team, but some general details are given here.

Arriving at the hospital

When a suitable kidney becomes available, you will be called into the hospital. If you have not already been advised to do so, you must immediately stop eating or drinking as you are about to undergo an operation. Further details on preparing for this moment can be found in Pre-transplant section.

You will be taken to your ward and soon afterwards you will undergo a physical examination to check that it is safe to proceed with the operation. If the doctor considers that the risk of the operation is too high, for example, if you have an infection, then unfortunately you will be sent home and put back onto the waiting list.

You will also undergo what is called a cross-match with the donor kidney. This is the final test to check that your body does not contain antibodies that would react with the donor kidney. High levels of these antibodies indicate a high risk that your body will reject the new kidney even if it seems a good match. Although this may be very upsetting, it will also mean that the operation will not go ahead. However, depending on the centre, it is likely that this test will be performed before you are informed about the transplant.

The potassium levels in your blood will also be checked to make sure they are low enough for an anaesthetic.

Pre-op prep

You may need to be dialysed or, if on CAPD, you will continue with your exchanges and then drain out and cap off just before the operation.
Prior to the operation you will be given immunosuppressive or anti-rejection drugs and a general anaesthetic. An intravenous (IV) tube will be put in place to keep you from getting dehydrated and to increase your urine flow.

Your Operation

Whether the donor is live or deceased, an operation to transplant a kidney lasts about two to three hours.

Once you are asleep, the surgeon will make a diagonal cut about 8-10” in length into your abdomen, on the right or left just below your navel.

The blood supply of the donor kidney will be attached to your own blood supply and the new kidney’s ureter (the tube that takes urine to the bladder) will be attached to your bladder.

Your own kidneys are usually left in place, with the new kidney placed in the pelvic region

When you wake up, you may feel some pain and discomfort and may feel nausea from the anaesthetic. This is completely normal, and the nurses will help you to feel more comfortable. You will be given pain relief and anti-sickness drugs.

The first few days after the operation are critical and your blood pressure, fluid intake and urine output will be closely monitored to see how your body is responding to the transplant.

For more information see the post-transplant section.

Living donor operation

Living donor transplants in the UK now represent about one in five of all kidney transplants, and between 2000 and 2001 increased by 3% (from 347 in 2000 to 358 in 2001 : source transplant UK).

What is the process for a live donation?
The donor will discuss with the transplant team the options available to him/her in surgery. The donor may be given the choice of the traditional ‘open nephrectomy’ (surgical removal of the kidney) or the newer ‘laparoscopic’ (keyhole) techniques.

For the donor, the procedure requires a hospital stay of approximately one week and then another two to three months away from work. Recovery time for the donor is very dependent on their health and lifestyle.

Whichever option is chosen, after removal, the donor's kidney is taken directly to the recipient. Following transplantation to the recipient, the kidney usually begins to function immediately after transplant, even before the donor has left the operating theatre to start their recovery.

Waking Up

When you wake up, you may feel some pain and discomfort and may feel nausea from the anaesthetic. This is completely normal, and the nurses will help you to feel more comfortable. You will be given pain relief and anti-sickness drugs.

The first few days after the operation are critical and your blood pressure, fluid intake and urine output will be closely monitored to see how your body is responding to the operation.

Possible complications

About 10% of live donors will develop an infection following their operation. These infections are usually treated with a course of antibiotics.

Because a donor operation is major surgical procedure, there is a small risk of death (about 1 in 3000). These deaths are most often associated with heart attacks or blood clots on the lungs.

Pain Relief

Having an open procedure is potentially painful, however transplant centres are very attentive to pain relief post-op. You may be hooked up to an I.V. or receive an epidural for the first couple of days before moving on to regular painkillers for as long as required.

Life after donation

The only physical reminder to the donor of the operation will be a scar, as life with one healthy kidney should be no different from life with two.

· Open nephrectomy
· Laparoscopy

Open nephrectomy

This is the traditional operation to remove the kidney, which usually takes two to three hours, followed by a period in the recovery area.

An incision is made into the side, and sometimes the smallest rib is removed to gain access to the kidney.

This is a major operation, and the donor is usually in hospital for about 10 days, although the scar may remain sensitive for several weeks.

The donor will need to attend a check-up four to six weeks after discharge, and annual check-ups to monitor long-term health.

The risks to both the donor and the function of the kidney after the operation are well established with this procedure.

Laparoscopy ("Keyhole" surgery)

Laparoscopy is a technique where three or four small incisions are made, through which the surgeon does most of the operation, and the kidney is then removed through a larger incision in the navel.

There are several advantages of this procedure to the donor. There is a reduction in the length of the hospital stay and recovery is more rapid.

However, there are still some concerns over the function of the kidney through this procedure, although there is no difference in function between kidneys from this procedure or open nephrectomy.

The transplant team should discuss both of the procedures with the donor and recipient so that they can make an agreed choice of operation.

Post-transplant

Overview

After the transplant operation, you are likely to stay in hospital for up to 10 days, depending on how well your new kidney functions.

You will already have started to take drugs to prevent rejection and there will be many daily blood tests and urine measuring to closely monitor your new kidney.

Immediately after your transplant

When you wake up, you may feel some pain and discomfort and also may feel nausea from the anaesthetic. This is completely normal, and the nurses will help you to feel more comfortable. You will be given pain relief and anti sickness drugs.

Central Line

You will also be given fluids via a 'central line' which is a tube inserted in one side of the neck during your operation. This line is also used to give you drugs that help kidney function and prevent infection.

Urinary Catheter

A urinary catheter is a tube that passes the urine from your bladder into a bag. This allows the medical staff to accurately measure the amount of urine you pass. The tube usually stays in for approximately 5 days after the transplant. Once the catheter has been removed you should measure your urine and record it on your chart.

Drinking

The hospital staff will tell you when you may start drinking and how much to drink each day. You should record everything you drink on your chart.

How will the new kidney function

Some kidneys function immediately after the operation, others don't. If this is the case it doesn't mean it will never work - just that it needs time to recover.

You will already have started to take drugs to prevent rejection, but about 20 - 30% of patients will experience some form of rejection in the first few weeks after a transplant. Fortunately, in most cases this can be overcome with extra drugs. You may find it difficult coming to grips with the (sometimes) constant change of drug regime. Some patients report feeling a loss of control. Unfortunately there may be many changes to regimes on an on-going basis.

· Immediate function
· Primary non-function
· Hyper-acute rejection

Immediate function

In this case, the transplanted kidney starts to work immediately, making urine and filtering out waste materials from your blood. This is measured by a decrease in the levels of the chemical creatinine in your blood.

Immediate function after transplant occurs in approximately 70% of patients who receive a kidney from a deceased donor, and 95% of those who receive a kidney from a living donor.

Primary non-function (delayed)

In about 20-40% of those who receive a kidney from a deceased donor, and 5-10% of those who receive a kidney from a living donor, the kidney takes some time to start working properly.

This may be because of the time the donated kidney is outside of a body without blood flow. The kidney is, however, kept on ice and perfused with special fluid to preserve it until it can be transplanted. Shock to the kidney due to being removed could offer another explanation for delayed function.

You will need to continue dialysis until the kidney starts to function properly, which may take several weeks.

Hyper-acute rejection

In less than 5% of kidney transplants, the kidney does not work immediately, and your body immediately rejects it. This rejection is because your body’s immune system recognises the transplanted kidney is ‘foreign’ and tries to remove it.

Hyper-acute rejection is very difficult to treat, and unfortunately usually results in a loss of the kidney, and a return to dialysis and the waiting list.

What complications might there be?

The majority of complications can be split into the five main categories below. Before your operation, your transplant team will discuss with you the likelihood that you will suffer from any of these or other complications following transplant.

· Problems with the transplanted kidney
· Infections
· High blood pressure and high cholesterol
· Diabetes
· Nephrotoxicity
· Hospital infection

Problems with the transplanted kidney

Your immune system fights foreign bodies or invaders such as bacteria or germs. There are two kinds of natural defences used by the body: white blood cells and antibodies.

Before you undergo the transplant operation, a cross-match with the donor kidney is carried out to see that you do not have a high level of antibodies that would react with the donor kidney. However, some antibodies remain undetected and your body is able to recognise that the transplanted kidney is ‘foreign’.

The rejection process then starts – the severity varies from patient to patient – and may be acute or chronic. [link to acute and link to chronic]

Infections

The drugs that you take to prevent rejection make it more likely that you will be affected by bacterial, viral and fungal infections.

Although you are surrounded by germs it is not necessary to become a recluse.
Follow these few simple points and you will reduce the risk of infection:

• Eat a healthy diet and get enough sleep
• Exercise regulary and maintain a normal weight
• Wash your hands thoroughly after using the toilet and before meals
• Wear gloves when gardening or handling rubbish
• Avoid contact with people with viral infections

In your physical review pre-transplant, your doctors will assess the likelihood that you could suffer from viral infections such as hepatitis B and C or cytomegalovirus (CMV). The donor kidney will also be checked for any bacterial or viral infection before transplant. You may be given medications to prevent any suspected infections.

• Bacterial infections tend to occur within one month after the operation and urinary tract infections are the most common. The majority of these can be prevented by the use of antibiotics after the transplant.

• Viral infections usually occur between the first and sixth month after transplantation. The most common viral problem is called cytomegalovirus (CMV), but there is a very effective treatment for this, given orally or as an intravenous infusion.

High blood pressure and high cholesterol

Circulation problems are important complications after transplantation, and these can be caused by high blood pressure (hypertension) or high levels of fats in the blood (hyperlipidaemia)

• Hypertension is common in people with kidney disease, but after transplant can be increased as a side effect of some of the immunosuppressant drugs. At least half of kidney transplant patients have high blood pressure.

• Hyperlipidaemia is high levels of certain fats (cholesterol and triglycerides) in the blood. Again, high cholesterol levels are a side effect of some of the immunosuppressant drugs.

Both conditions can be treated effectively with lifestyle changes, such as giving up smoking and taking up exercise, dietary changes and drugs. [link to lifestyle section]

Diabetes

There are several reasons why diabetes can be a problem after a transplant. Diabetes is a disease that affects blood sugar levels.

High blood sugar (hyperglycaemia)

• When the blood sugar level is too high, it passes into the urine. This high level of sugar makes your kidney produce more and more urine, dehydrating the rest of the body. After a transplant, this dehydration caused by high blood sugars can sometimes result in kidney failure.

• High blood sugar prevents your body’s defences from working properly, so you may get an infection

• A major problem with continued high blood sugar levels in diabetes is a narrowing of the arteries. This may cause heart attacks and strokes.

Low blood sugar (hypoglycaemia)

• If the level of sugar in your blood is too low, your brain does not receive enough to function effectively and you may suffer from a hypoglycaemic attack, which may lead to a coma.

Managing diabetes

Some of the most important drugs used after a transplant – a steroid and some of the immunosuppressive drugs – can cause diabetes. However, there is currently no alternative to these – so even if they cause diabetes, you may have to keep using them to prevent kidney rejection.
The management of diabetes is very clearly understood and you may receive medications to control the levels of sugar in your blood.
Diet, exercise and lifestyle changes such as giving up smoking are also effective in the management of diabetes. [link to lifestyle]

Nephrotoxicity

This is when your kidney cells are destroyed by a toxin or antibody. Unfortunately a side effect of some of the important immunosuppressive drugs is nephrotoxicity. Nephrotoxicity can be acute or chronic.

• Acute nephrotoxicity is reversible by lowering the dose of the drug.

• Chronic nephrotoxicity can only be diagnosed once tissue scarring is already present (by a kidney biopsy). Once scarring exists, the disease is usually irreversible, but the kidney can continue to work successfully for several more years .

Hospital infection

Hospital aquired infections (such as MRSA), are a hazard to a newly transplanted patient. Hospitals are alert to this potential problem, however, and will take every precaution to prevent such a thing from happening.

Follow-up clinics

During the first few months after a transplant, you may feel your life dominated by all the medicines you have to take, and the frequent visits you need to make to the hospital. You will get used to taking the drugs and the hospital visits will become less frequent. Above all, it is important to return to the transplant unit every week for your follow up visits.

During these visits your kidney will be checked to make sure everything is working well, and you will be checked for signs of rejection or infection.

Biopsy

If your kidney function changes or is not as good as it should be, you may be required to have a biopsy. The biopsy will show up any signs of rejection. Most kidney transplant patients will have a biopsy at some stage during their recovery.

Ultrasound scan

An ultrasound scan is sometimes used to check the kidney, the bladder and the blood supply to the kidney.

Medication

The main drugs that you will have to take for the rest of your life are the immunosuppressant drugs.

These are also called anti-rejection drugs, as they help your body to accept the new kidney and prevent it from trying to destroy it.

One of the biggest causes of transplant failure is not taking the immunosuppressant drugs. This is called non-compliance.

You must take the correct amount of your immunosuppressive drugs at the right time without missing a single dose

• If you are unable to do this or forget at any time, call your transplant coordinator or doctor straight away to ask what to do.

• Do not stop taking your drugs if you experience any side effects, but call your transplant coordinator or doctor straight away. They will decide the best course of action

For more information on drugs go to the Medication section.

Long term

The majority of long term problems after transplantation result from the anti-rejection drugs and not from the transplant itself.
Being healthy will help you to reduce the risks.

Infection

Transplant patients are vulnerable to viral infections, chicken pox, cold sores and shingles in particular. If you suspect you have these, or have come into contact with them, you should contact your transplant unit immediately.

Rejection

Rejection of a new kidney is a common complication. Rejection is usually treated easily with anti-rejection drugs and should not be a cause for great anxiety.

Skin Cancer

The risk of kidney transplant patients developing skin cancer is increased to 70% because of the immunosuppressive drugs. You must therefore take great care to protect your skin from the sun.

• Use a Factor 30 sun block in the summer
• Wear clothing that covers the skin when outside
• Avoid the midday sun

Other Cancers

The risk of other cancers is only slightly increased after transplantation with the exception of:
• Skin Cancer - see above
• Cervical cancer - have annual cervical screening
• Lymph glands - These abnormal cells caused by the glandular fever virus effect approx 1 in 100 patients and can usually be treated with a reduction in the immunosuppressive drugs.