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Renal transplantation

In advanced and permanent kidney failure, kidney transplantation may be the treatment option of choice leading to increased survival after renal failure. Since the 1950s, when the first kidney transplants were performed, we've learned much about how to prevent rejection and minimize the side effects of medicines.

But transplantation is not a cure; it's an ongoing treatment that requires lifetime intake of medicines. And the wait for a donated kidney can be years long.

A successful transplant takes a coordinated effort from the whole health care team, including the nephrologist, transplant surgeon, transplant coordinator, pharmacist, dietitian, and social worker.

How Transplantation Works

Kidney transplantation is a procedure that places a healthy kidney from another person into the patient's body. This one new kidney takes over the work of the two failed 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. 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 Transplant Process

The pretransplant evaluation may require several visits over the course of several weeks or even months. Blood tests and x rays are taken. Blood type and other matching factors that determine whether the patient's body will accept an available kidney are done.

Criteria for inoperability include:

  • Presence of cancer
  • Serious infection
  • Significant cardiovascular disease
  • Patient must be able to understand and comply with 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. (See the "Organ Donation" section.)

Patients whose medical evaluation shows that they are good candidates for renal transplantation but do not have a donor, are put on the waiting list for a cadaveric organ transplant.

Every person waiting for a cadaveric 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" 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.

The waiting period 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.

  1. Blood type (A, B, AB, or O) must be compatible with the donor's blood type.
  2. HLA factors. HLA stands for human leukocyte antigen, a genetic marker located on the surface of the white blood cells. These markers are inherited as a set of three antigens from the mother and three from the father. A higher number of matching antigens increases the chances that the new kidney will last for a long time.

If 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 recipient's blood will be mixed with a small sample of the donor's blood in a tube. If no reaction occurs, it should be safe to transplant the kidney.
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Transplant Operation

If the transplant will take place with a living donor, both recipient and 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 on a waiting list for a cadaveric kidney, the recipient must be ready to hurry to the hospital as soon as a kidney becomes available. Once there, a blood sample is taken for the antibody cross-match test. If the result is a negative cross-match, it means that antibodies don't react and the transplantation can proceed.

The procedure is done under general anesthesia. The operation usually takes 3 or 4 hours. The surgeon will make a small cut in your lower abdomen. The artery and vein from the new kidney will be attached to the recipient's artery and vein. The ureter from the new kidney will be connected to the recipient 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.

Post-transplant Care

The immune system will sense that the new kidney is foreign. To keep the body from rejecting it, the patient will have to take drugs that turn off, or suppress, the immune response.

Rejection

Signs of rejection

  • Fever or
  • Soreness in the area of the new kidney or
  • A change in the amount of urine

If the new kidney is rejected then unless the patient is no longer a good candidate for transplantation, s/he can go back on the waiting list for another kidney.

Side Effects of Immunosuppressants

  • Weakening the immune system, which can lead to infections
  • Face may get fuller
  • Weight gain
  • Acne
  • Increased facial hair

Not all patients have these problems, though, and diet and makeup can help.

Some immunosuppressants may increase the risk of developing:

  • Cancer
  • 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.

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. Your social worker can help you locate resources for financial assistance. For more information, see the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) fact sheet Financial Help for Treatment of Kidney Failure.

Patient Assistance Programs From Prescription Drug Companies

The immunosuppressants and other drugs you must take after your transplant will be a large part of your 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, which is available at www.phrma.org/pap on the Internet.

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