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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.
- 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 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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