Kidney Transplants: Becoming an Organ Donor Recipient
What are kidney transplants?
A kidney transplant is an operation in which a healthy kidney from another person is surgically implanted into a patient who has kidney failure. It can take years to get a new kidney because many people are waiting for transplants and the supply falls far short of the demand. The donor’s kidney needs to be a good match for the recipient’s body. Tests are conducted on both the donor and the recipient to ensure that the organ will be compatible (a good match).
Unless there is a medical reason, a patient’s own (native) kidneys will remain in place. The operation takes three to five hours and the patient will remain in the hospital after the operation for an average of five to six days.
Who needs kidney transplants?
People with end-stage renal (kidney) disease (ESRD) or poorly functioning kidneys may be candidates for a kidney transplant. (Specifics about criteria for being a candidate are discussed below.) People with advanced chronic kidney disease (CKD) who are not yet on dialysis may also be considered for kidney transplantation. This is called preemptive kidney transplantation. Recent data suggest that patients receiving transplants do best if dialysis is avoided completely.
How does kidney transplantation help?
- Longer life expectancy after transplant when compared to dialysis.
- Relatively unrestricted diet
- Ability to become pregnant and bear children
- Lifestyle free of dialysis constraints allowing return to work, school, and travel activities
- Ability to train for athletic competition
Kidneys suitable for transplant can come from:
- Deceased donors
- Living donors related to the recipient
- Living donors not related to the recipient, such as a spouse, friend, coworker or neighbor
- Living donors whom you don’t know who want to help those in need—known as altruistic donors
Who is not a candidate to receive a kidney transplant?
People with the following health issues are not candidates for kidney transplantation:
- Active cancer (see below for clarification)
- Liver failure – unless liver transplant is planned
- Severe heart disease or decreased blood flow to the legs – unless due to potentially reversible cause, which should be corrected prior to transplant
- Active mental illness—if patient cannot give informed consent or comply with medications and follow-up
What conditions need to be treated prior to transplant?
- Active infection such as viral infection of the liver, diabetic foot infections and tuberculosis
- Stomach ulcers
- Heart disease—if irreversible
- Decreased blood flow to legs—if irreversible
- Predisposition to stroke
- Substance abuse
What about cancer?
Depending on the type of cancer, a person must be cancer-free (no recurrence or other cancer sites) for three to five years before receiving a transplant of any kind. Cancer in its earliest stages may only require up to a two-year wait. This measure is to reduce risk of cancer recurrence for the transplant recipient.
Immunosuppressive medications can enable tumors to grow more aggressively, thus adding significant risk for a transplant recipient.
For those with liver cancer, a kidney transplant is not recommended unless the person is selected for simultaneous liver transplant. For people with blood cancer such as multiple myeloma, kidney transplantation is usually not recommended due to the increased risk posed by anti-rejection medications.
How to start the transplant process
Evaluation for a kidney transplant can begin when there is twenty (20%) kidney function or less. Patients interested in being evaluated to receive a kidney transplant need to meet with the kidney transplant team. A person can be referred by a nephrologist or dialysis center, or can self-refer. The transplant center will gather all of the person’s medical records, studies such as x-rays and ultrasounds, laboratory reports (blood and urine) and insurance information, and schedule an appointment for a transplant evaluation.
The candidate will be asked about their family and social history. A complete assessment of the candidate’s health status must be conducted to determine preparedness for surgery and transplant. While transplant center requirements vary, the following studies are usually included:
- Blood studies: (A/B/O) and tissue type (antigens)/glomerular filtration rate (GFR)
- Viral testing e.g. hepatitis C and HIV
- Urine tests
- Complete physical exam
- EKG, xray
- Dental check up (to ensure there are no untreated dental caries or infection)
- Ultrasound to evaluate extent of kidney damage
- Colonoscopy
- Psycho-social evaluation (to check for compliance risk and mental-health state)
All key members of the transplant team meet with the transplant candidate.
For the best transplant outcomes, the recipient and donor should be blood-type compatible and non-reactive immunologically. Cross matching determines whether the recipient is sensitized to the tissue of the potential donor. Six different genes, or antigens, are responsible for ascertaining compatibility. A ‘negative’ cross match is desired, which means the recipient is not sensitized against that particular donor. The immune suppressive medications available today have improved the outcomes of kidneys with fewer antigen matches—and even no matches at all (zero-antigen match).
The transplant team then discusses the results of these studies and determines whether kidney transplants are the best therapy for that individual.
Informing the transplant candidate
The transplant coordinator will contact the patient to discuss whether kidney transplant is recommended. Once accepted into the program, the person is listed with the United Network for Organ Sharing (UNOS) database which handles the matching of donor organs throughout the United States. The average waiting time for a kidney is two to five years. Regional issues as well as blood type can affect the waiting time. Candidates may be called into the hospital several times for additional blood studies before receiving a transplant. Other factors must be considered before the final selection is made such as the current state of the recipient’s health and the quality of the match between recipient and donor. So people are sometimes called in several times with the possibility of receiving a kidney before the final decision to designate that kidney to him/her is made. This can be frustrating for people who have been awaiting that all-important call, so it’s best to understand from the beginning that delay may occur.
Possible changes in lifestyle
In addition to taking anti-rejection medicines and following the guidelines indicated above, a person who has been given a transplant should protect the new kidney from trauma. Accordingly, the transplant team may recommend that the recipient avoid contact and other ‘rough’ sports. He/she should also stay away from people who are ill with contagious diseases—good advice for anyone, but especially important for someone whose immune system is compromised. Being in moldy, musty environments is not healthy for a person whose immune system is compromised. Respiratory complications might become an issue.
What about outcomes?
Transplant teams quote average statistics for the time transplanted kidneys are expected to function well. Of course results vary with different individuals. Improved tissue-compatibility testing, surgical techniques and anti-rejection medications all help to improve outcomes. As discussed above, a key factor in transplanted-organ health is how well an individual complies with the orders of the transplant team. Taking medications, avoiding infection and other factors that can be controlled to some degree by the recipient greatly improve the chances of maintaining a healthy kidney.
What are the risks after transplant?
People undergoing kidney transplants face the same general risks of surgery as people undergoing different procedures. Anesthesia complications, bleeding and clotting of blood vessels and infection, though not common, are considered risks for any surgery.
Specific risks for kidney transplants include the following:
- Clotting of the blood vessels to the kidney transplant, causing damage to the kidney
- Blockage of urine flow
- Non-function of the kidney—the kidney either never ‘kicks in’ or it stops working
- Rejection of the ‘foreign’ kidney from the recipient’s body
- Infection—immune function is decreased because of the anti-rejection medication
- Cancer – especially skin cancer—requiring vigilance and frequent professional skin checks
Close monitoring before, during and after transplantation helps to minimize the impact of these complications and risks and improve outcomes.
