Kidney Transplantation

A successful kidney transplant invovles transferring a kidney from a healthy donor to a patient with non-functioning kidneys. Healthy kidneys clean the blood by removing excess fluid, minerals, and wastes. They also make hormones that keep the bones strong and the blood healthy. When loss of function occurs in the kidneys, harmful wastes build up in the body, the blood pressure may rise, and the body may retain excess fluid and not make enough red blood cells. When this happens, the patient needs treatment to replace the work of the kidneys.

Types

Deceased Donor

Most transplanted kidneys come from people who have died. However, the number of people waiting for kidneys has increased in recent years, while the number of kidneys available from deceased donors has remained constant. The result is a shortage of kidneys and a longer waiting time for people with kidney failure.

Many suitable kidneys go unused because family members of potential donors don’t know their loved one’s wishes. People who wish to donate their organs should talk about this issue with their families. Several organizations, including UNOS and the National Kidney Foundation (see the "[#resources Resources]" section), provide organ donor cards for people who wish to make this life-preserving gift when they die. A properly completed organ donor card notifies medical officials that the person has decided to donate your organs. In most states, a person can indicate their desire to be an organ donor on their driver’s license.

Living Donor

A growing number of transplanted kidneys are donated by living family members or friends. Potential donors need to be tested to make sure that donating a kidney won’t endanger their health, as well as for matching factors. Most people, however, can donate a kidney with little risk.

A kidney from a living donor often has advantages over a deceased donor kidney:

• People who receive a kidney from a family member or friend don’t have to wait until a kidney becomes available. Living donation allows for greater preparation and for the operation to be scheduled at a convenient time.
• Kidneys from family members are more likely to be good matches, although there’s no guarantee.
• Kidneys from living donors don’t need to be transported from one site to another, so the kidney is in better condition when it’s transplanted.
• Living donation helps people waiting for kidneys from deceased donors by lowering the number of people on the waiting list.
• The number of Altruistic donors is increasing in the United States

Minority Donation

Diseases of the kidney are found more frequently in racial and ethnic minority populations in the United States than in the general population. African Americans, Asian Americans, Hispanics/Latinos, and Pacific Islander Americans are three times more likely to suffer from kidney failure than Americans of European descent. Successful transplantation is often enhanced if organs are matched between members of the same ethnic and racial group. A shortage of organs donated by minorities can contribute to longer waiting periods for transplants for minorities.

The National Minority Organ/Tissue Transplant Education Program (MOTTEP), with the support of the National Institutes of Health’s (NIH’s) Office of Research on Minority Health and the NIDDK, is the first national program to empower minority communities to promote minority donation and transplantation, as well as good health habits. In turn, this effort should improve the chances for a well-matched organ among all those waiting for a transplant.

How Kidney Transplantation Is Done

Kidney transplantation is a procedure that places a healthy kidney from another person into the patient's body. This new kidney will take over the work of the two nonfunctioning kidneys.

A surgeon places the new kidney inside the lower abdomen and connects the artery and vein of the new kidney to the patient's artery and vein. The blood flows through the new kidney, which makes urine, just like the patient's own kidneys did when they were healthy. Unless they are causing infection or high blood pressure, the patient's own kidneys are left in place.

The transplantation process begins when a patient learns that his or her kidneys have failed or or no longer functioning, and they must start to consider treatment options. Whether transplantation is to be among the options will depend on the specific situation. Transplantation is not for everyone. The doctor may tell the patient that they have a condition that would make transplantation dangerous or unlikely to succeed.

Medical Evaluation at a Transplant Center

If the doctor sees transplantation as an option, the next step is a thorough medical evaluation at a transplant hospital. The pretransplant evaluation may require several visits over the course of several weeks or even months. The patient will need to have blood drawn and x-rays taken. The patient will be tested for blood type and other matching factors that determine whether the patient's body will accept an available kidney.

The medical team will want to see whether the patient is healthy enough for surgery. Cancer, a serious infection, or significant cardiovascular disease would make transplantation unlikely to succeed. In addition, the medical team will want to make sure that the patient can understand and follow the schedule for taking medicines.

If a family member or friend wants to donate a kidney, he or she will need to be evaluated for general health and to see whether the kidney is a good match.

Placement on the Waiting List

If the medical evaluation shows that the patient is a good candidate for a transplant but does not have a family member or friend who can donate a kidney, the patient will be put on the transplant program waiting list to receive a kidney from a deceased donor someone who has just died.

Every person waiting for a deceased donor organ is registered with the Organ Procurement and Transplantation Network (OPTN), which maintains a centralized computer network linking all regional organ gathering organizations (known as organ procurement organizations, or OPOs) and transplant centers. The United Network for Organ Sharing (UNOS), a private nonprofit organization, administers OPTN under a contract with the Federal Government. (See the "[#resources Resources]" section.)

UNOS rules allow patients to register with multiple transplant centers. Each transplant center will probably require a separate medical evaluation, even if a patient is already registered at another center.

Observers of OPTN operations have raised the concern that people in certain regions of the country have to wait longer than others because allocation policies for some organs give preference to patients within the donor’s region. Kidneys, however, are assigned to the best match regardless of geographic region. The Federal Government continues to monitor policies and regulations to ensure that every person waiting for an organ has a fair chance. The key to making waiting times shorter is to increase the number of donated organs.

Waiting Period

The lengh of time the patient will have to wait depends on many things but is primarily determined by the degree of matching between the patient and the donor. Some people wait several years for a good match, while others get matched within a few months.

While on the waiting list, the patient should notify the transplant center of changes in health. Also, he or she shoudl let the transplant center know if they move or change telephone numbers. The center will need to find the patient immediately when a kidney becomes available.

OPOs are responsible for identifying potential organs for transplant and coordinating with the national network. The 69 regional OPOs are all UNOS members. When a deceased donor kidney becomes available, the OPO notifies UNOS, and a computer-generated list of suitable recipients is created. Suitability is initially based on two factors:

• Blood type. The patient's blood type (A, B, AB, or O) must be compatible with the donor’s blood type.
• HLA factors. HLA stands for human leukocyte antigen, a genetic marker located on the surface of your white blood cells. A person inherits a set of three antigens from the mother and three from the father. A higher number of matching antigens increases the chance that the kidney will last for a long time.

If the patient is selected on the basis of the first two factors, a third is evaluated:

• Antibodies. The immune system may produce antibodies that act specifically against something in the donor’s tissues. To see whether this is the case, a small sample of the patient's blood will be mixed with a small sample of the donor’s blood in a tube. If no reaction occurs, the patient should be able to accept the kidney. The transplant team might use the term negative cross-match to describe this lack of reaction.

Transplant Operation

If a living donor is available, the patient will schedule the operation in advance. The patient and the donor will be operated on at the same time, usually in side-by-side rooms. One team of surgeons will perform the nephrectomy—that is, the removal of the kidney from the donor—while another prepares the recipient for placement of the donated kidney.

If the patient is on a waiting list for a deceased donor kidney, he or she must be ready to hurry to the hospital as soon as a kidney becomes available. Once there, the patient will be tested for the antibody cross-match test. A negative cross-match means that the patient's antibodies do not react and the transplantation can proceed.

The patient is given a general anesthetic to make him or her sleep during the operation, which usually takes 3 or 4 hours. The surgeon will make a small cut in the lower abdomen. The artery and vein from the new kidney will be attached to the artery and vein. The ureter from the new kidney will be connected to the bladder.

Often, the new kidney will start making urine as soon as your blood starts flowing through it, but sometimes a few weeks pass before it starts working.

Risks

Rejection

The patient can help prevent rejection by taking the medicines and following a diet, but watching for signs of rejection—like fever or soreness in the area of the new kidney or a change in the amount of urine you make—is important. The patient should report any such changes to the health care team.

The body may still reject the new kidney and the patient may need to go back on dialysis. Unless the health care team determines that the patient is no longer a good candidate for transplantation, he or she can go back on the waiting list for another kidney.

Side Effects of Immunosuppressants

Immunosuppressants can weaken the immune system, which can lead to infections. Some drugs may also change the patient's appearance. The patient's face may get fuller; he or she may gain weight or develop acne or facial hair. Not all patients have these problems, though, and diet and makeup can help.

Immunosuppressants work by diminishing the ability of immune cells to function. In some patients, over long periods of time, this diminished immunity can increase the risk of developing cancer. Some immunosuppressants cause cataracts, diabetes, extra stomach acid, high blood pressure, and bone disease. When used over time, these drugs may also cause liver or kidney damage in a few patients.

Most centers in the word use a steroid based immunosuppression protocols( i.e: steroids and two other immunosuppression drugs. Some centers in the US have been very successful in using a steroid sparing protocol, with good outcomes.

Financial Issues

Treatment for kidney failure is expensive, but Federal health insurance plans pay much of the cost, usually up to 80 percent. Often, private insurance or state programs pay the rest. A social worker can help the patient locate resources for financial assistance.

Recovery Time

As after any major surgery, the patient will probably feel sore and groggy when he or she wakes up. However, many transplant recipients report feeling much better immediately after surgery. Even if a patient wake up feeling great, he or she will need to stay in the hospital for about a week to recover from surgery, and longer if he or she has any complications.

Posttransplant Care

The body's immune system is designed to keep the patient healthy by sensing foreign invaders, such as bacteria, and rejecting them. But the immune system will also sense that the new kidney is foreign. To keep the body from rejecting it, the patient will need to take drugs that turn off, or suppress, the immune response. The patient may have to take two or more of these immunosuppressant medicines, as well as medications to treat other health problems. The health care team will help the patient learn what each pill is for and when to take it. The patient should make sure to understand the instructions for taking the medicines before he or she leaves the hospital.

If the patient has been on hemodialysis, he or she will find that your posttransplant diet is much less restrictive. The patient can drink more fluids and eat many of the fruits and vegetables that he or she was previously told to avoid. The patient may even need to gain a little weight, but must be careful not to gain weight too quickly (by avoiding salty foods that can lead to high blood pressure).

Experts on Kidney Transplantation

This process takes a coordinated effort from the whole health care team, including the nephrologist with extra training in transplantation, transplant surgeon, transplant coordinator, pharmacist, dietitian, and social worker. Lot of times, the transplant nephrologist acts as a primary care physician for most of these patients given their need of management of the drugs and to watch out for interactions and complications.

Research

The NIDDK, through its Division of Kidney, Urologic, and Hematologic Diseases, supports several programs and studies devoted to improving treatment for patients with progressive kidney disease and permanent kidney failure, including patients who receive a transplanted kidney.

• The End-Stage Renal Disease Program promotes research to reduce medical problems from bone, blood, nervous system, metabolic, gastrointestinal, cardiovascular, and endocrine abnormalities in kidney failure and to improve the effectiveness of dialysis and transplantation. The program seeks to increase kidney graft and patient survival and to maximize quality of life.
• The NIH Organ/Tissue Transplant Center, located at the NIH Clinical Center in Bethesda, MD, is a collaborative project of NIH, the Walter Reed Army Medical Center, the Naval Medical Research Center, and the Diabetes Research Institute at the University of Miami. The site includes a state-of-the-art clinical transplant ward, operating facility, and outpatient clinic designed for the study of new drugs or techniques that may improve the success of organ and tissue transplants.
• The U.S. Renal Data System (USRDS) collects, analyzes, and distributes information about the use of dialysis and transplantation to treat kidney failure in the United States. The USRDS is funded directly by NIDDK in conjunction with the Centers for Medicare & Medicaid Services. The USRDS publishes an Annual Data Report, which characterizes the total population of people being treated for kidney failure; reports on incidence, prevalence, mortality rates, and trends over time; and develops data on the effects of various treatment modalities. The report also helps identify problems and opportunities for more focused special studies of renal research issues.

Other Resources

UNOS maintains a website called Transplant Living to help patients learn about their treatment and find resources. The website includes a page that lists organizations that provide financial assistance—available at www.transplantliving.org/beforethetransplant/finance/funding.aspx.

Patient Assistance Programs
From Prescription Drug Companies

The immunosuppressants and other drugs the patient must take after their transplant will be a large part of that patient's medical expenses. Most drug manufacturers have patient assistance programs giving discounts to patients who can show that they can't afford the cost of their prescribed medications. The Pharmaceutical Research and Manufacturers of America publishes the Directory of Prescription Drug Patient Assistance Programs, available at www.pparx.org. To request a directory through the mail, write to

Pharmaceutical Research and Manufacturers of America
1100 Fifteenth Street NW
Washington, DC 20005

An organization called the Medicine Program offers help in finding and applying for free medicines supplied by pharmaceutical companies. To request assistance, obtain an application form, available on the website or through the mail, and list the medicines needed. Send the application back with a $5 processing fee for each medicine requested. If the Medicine Program fails to qualify the person to receive the medicine, then the processing fee will be returned.

The Medicine Program
P.O. Box 1089
Poplar Bluff, MO 63902
Phone: 1–866–694–3893
Internet: www.themedicineprogram.com

Government Agencies

The U.S. Department of Health and Human Services coordinates organ procurement and allocation activities through its www.organdonor.gov Health Resources and Services Administration (HRSA).

HRSA’s Division of Transplantation administers the OPTN through a contract with UNOS, whose website can be found at www.transplantliving.org.

Nongovernment Organizations

Coalition on Donation

TransWeb: All About Transplantation and Donation is a nonprofit educational website featuring answers to frequently asked questions, donor memorials, patient experiences, and a reference section.

American Association of Kidney Patients

American Kidney Fund

American Society of Transplantation

Life Options Rehabilitation Program

National Kidney Foundation, Inc.

Additional Reading

To following literature provides fruther informtaion about kidney failure and its treatment:

AAKP Patient Plan
This is a series of booklets and newsletters that cover the different phases of learning about kidney failure, choosing a treatment, and adjusting to changes. American Association of Kidney Patients

Getting a New Kidney: Facts About Kidney Transplants
and
Keeping Your New Kidney Healthy: Facts About Transplant Medications www.a-s-t.org/index2.cfm?Section=patients&Sub1Section=patient_education_brochures&Sub2Section=
english&content=available_brochures.html| American Society of Transplantation

Kidney Transplantation Diabetes Association

Medicare Coverage of Kidney Dialysis and Kidney Transplant Services PDF

What Every Patient Needs to Know, 2004; Network for Organ Sharing

Newsletters and Magazines

Family Focus Newsletter (published quarterly); National Kidney Foundation Inc.

Renalife (published quarterly); Association of Kidney Patients