The kidneys are adaptable organs that can function with only 15% capacity. However, complete kidney failure leads to an accumulation of waste products in the bloodstream, causing illness. Kidney failure can be acute, occurring suddenly due to trauma, and may partially or fully recover. Chronic renal failure is a progressive and irreversible condition that develops over years due to infection, diabetes, hypertension, or genetic factors. End-stage renal disease is the final stage of chronic renal failure, where the kidneys lose their ability to function.
Common signs of renal failure include weakness, fatigue, decreased appetite, unusual taste in the mouth, itching, reduced urine, nighttime urination, nausea, vomiting, pigmentation, easy bruising, reduced sexual function, fluid build-up in the legs, breathlessness, chest pain, and cramps. Haemodialysis and peritoneal dialysis can filter waste products from the body, but a kidney transplant is necessary to stimulate red blood cell production.
When planning a diet for a patient with chronic renal failure, it is important to consider five main constituents: fluid (water), protein, sodium, potassium (salts), and phosphorus. These elements need to be carefully balanced to ensure that the patient is receiving the necessary nutrients while also avoiding further damage to their kidneys.
When a patient reaches end-stage kidney failure, their only options for survival are dialysis or transplantation. Dialysis is necessary to sustain the patient's body functions, but it does not replace kidney function. Even if the patient decides to have a kidney transplant, they will need to undergo dialysis until the transplant can be performed. Although dialysis can prolong a patient's life, it is associated with certain complications that are not seen after transplantation. Patients who receive a kidney transplant generally live longer than those who remain on dialysis in the long run.
The primary advantage of a successful kidney transplant is the freedom it provides. Patients no longer have to undergo unpleasant and restrictive dialysis, which includes limitations on fluid intake and dietary restrictions. They can enjoy a normal diet and even go on holiday without the worry of needing dialysis. The return to a normal life includes the ability to conceive children for women and restored potency and sexual function for men.
In addition to the physical benefits, a successful transplant can improve a patient's overall quality of life. Anaemia, bone disease, and chronic tiredness typically associated with kidney failure disappear, and patients can often return to full-time work. Conversely, these improvements are not typically seen in patients who continue on dialysis.
There are three types of kidney donors: living related donors, living unrelated donors, and deceased donors. Living related donors include first degree relatives such as siblings, parents, and children, as they can live with one kidney. Close relatives are preferred as they are more likely to have a good tissue match. Spouses and grandparents have also been added to the list of close relatives who can donate as per the law. Living unrelated donors include cousins, aunts, uncles, nieces, nephews, and other relatives who may be related through the maternal or paternal side. Deceased donors are individuals who are brain stem dead and do not have kidney diseases, infections, or cancers. The most suitable donors are those who have died from causes such as road accidents, brain haemorrhage, or brain tumours.
Living donation can be a sensitive and complex issue for both the patient and their family members. The best chance for long-term success after a kidney transplant comes from a living related donor. However, it can be difficult for family members to refuse to donate a kidney, especially when a loved one is seriously ill. Donors need to understand the situation fully and make the decision to donate based on altruistic and emotional reasons. Concerns about the risks and potential after-effects of kidney donation may also arise.
The advantages of a living related kidney donation are numerous. Specific planning of the operation can be done, including the timing and pre-operative immunosuppression. The recipient may require fewer immuno-suppressive drugs, leading to fewer side effects and reduced costs. Additionally, the long-term success of the transplant is more likely due to the good tissue match among family members. Donors can be screened for communicable diseases, and pre-transplant dependence on dialysis can be reduced, which is especially important for people with diabetes and young children. This approach can also significantly decrease overall costs.
An ideal donor for kidney transplant is a close blood relative, such as a parent, sibling, or child. Other family members like grandparents, cousins, in-laws, and nieces are also considered eligible for donation. In addition, the donor must be an adult between 18 and 70 years of age and in good health. Spouses are also included in this category.
Although legally permitted, the practice of living unrelated organ donation is not common due to several reasons. Donors may hide their medical conditions to avoid financial loss if their offer is rejected, potentially transmitting diseases to the recipient. Additionally, finding a good tissue match among unrelated donors is rare, with a likelihood of only one in four thousand, leading to less than optimal graft survival rates. Furthermore, the possibility of financial motivations for donation cannot be overlooked.
To determine if a potential donor is a suitable match for a recipient, a simple blood group test is done. If the blood and tissues match and the donor is willing to proceed, further medical screening is necessary, including X-rays and kidney function tests to ensure that the donor's kidneys and urinary system are in good condition. If the donor has any health issues, the transplant will not proceed.
It's important for the donor and recipient to have similar blood groups, or for the donor to have O+ve blood group. However, an AB+ve recipient may receive a kidney from any donor. In cases where the donor and recipient don't have matching blood groups, ABOi Incompatible transplant can be considered. Swap transplant or paired donation can also be used to solve incompatible blood groups.
It is crucial that a family member who decides to donate a kidney does so voluntarily, without any coercion or pressure. To facilitate this, open and confidential discussions between the prospective donors, doctors, and transplant coordinator are essential. Such conversations can help to allay any concerns the donor may have and give them more confidence in their decision. Prospective donors have the right to be informed about the donation process and make their own decision.
If a donor decides to proceed with the surgery, they may ask questions about the risks to their health during and after the operation. To avoid post-operative complications, donors should stop smoking and using oral contraceptives three months before the operation.
Once all the necessary tests are done, and both the donor and recipient are deemed suitable for the surgery, a surgery date is scheduled. It is important for the family to understand that the transplant team takes on a significant responsibility, and they are extremely cautious. If any of the reports are unsatisfactory, they may have to postpone the transplant for the patient's well-being. Both the donor and recipient undergo the kidney transplant surgery simultaneously. The removal of a kidney for transplant is a major surgery, and the donor may experience some pain and discomfort after the procedure. Typically, the donor is kept in the hospital for about five days after the operation. The remaining kidney of the donor gradually adjusts to the increased workload and takes over the function of the two kidneys. Breathing exercises are suggested before and after the operation to avoid any chest-related complications as the incision is made near the ribs and chest.
After the operation, the donor and recipient are not kept in the same area as the recipient requires specialized nursing care in an isolated and infection-free area, such as a Transplant ICU.
There are two methods for removing a kidney from a donor: open donor nephrectomy and laparoscopic donor nephrectomy. Open donor nephrectomy involves a 9-12 cm incision in the flank, and may require excision of a rib to access the kidney. This method is associated with significant morbidity, such as pain, pseudo hernia, and prolonged recovery time, and is rarely performed nowadays.
In contrast, laparoscopic donor nephrectomy is performed using laparoscopic instruments, which allows for keyhole surgery and a smaller incision of only 6 cm above the pubic bone. This method is associated with good cosmetic results and minimal morbidity and pain. Donors can typically go home within 3-4 days and return to work within two weeks. In fact, this method has become very popular in the West, with 95% of all kidneys being removed by this method. At the hospital where the author works, they have performed over 2000 laparoscopic donor nephrectomies in the last 16 years, and remove all kidneys by this approach. In female patients, the kidney can even be removed through the vaginal route to avoid any incision in the abdomen, making it a highly cosmetic operation.
During the surgery, a 12-15 cm incision is made in the right iliac fossa and the kidney is placed retroperitoneally. The renal artery is connected to either the internal or external iliac artery, and the vein is connected to the external iliac vein. The ureter is attached to the bladder over a stent, and the surgery typically takes 3-4 hours.
Kidney transplants can now be done using a robotic system, where a small incision of 5-6 cm is made in the abdomen, and the rest of the operation is performed using a robot. This approach offers several benefits, such as less pain, faster recovery, no wound infections, and no lymphocele. This technique is particularly helpful for obese and young female patients. However, it can be costly due to the high expense of robotic instruments.
The success rate of living-donor related kidney transplant is high, with a 90-95% success rate after one year. If the transplant functions well in the first year, there is a good chance it will continue to function for many years. Patients who received a renal transplant 15-20 years ago can still have functioning grafts and live normal lives. After five years, 80% of patients still have good kidney functioning, with 40-50% still functioning after 10 years. About 20% of patients still have a functioning graft after 20 years. In the event of transplant failure, a second transplant is possible and can also be successful, as can a third or fourth transplant.
A- Qualification Individuals with irreversible renal failure who are undergoing dialysis are generally eligible for transplantation. However, those with significant medical conditions, such as severe heart or vascular diseases, may have an increased risk of complications from transplantation and may be better suited for dialysis. Ultimately, the decision to pursue transplantation should be made after consultation with a physician and transplant coordinator.
B- Compatibility To ensure a successful transplant, blood and tissue types must match between the donor and recipient. Blood typing determines compatibility based on the red blood cells of the donor and patient, while tissue typing involves the matching of a specific type of white blood cell called lymphocytes, which have unique antigens, including HLA antigens that are crucial for transplantation success. A cross-match is also performed just prior to transplantation to ensure no reaction occurs. Fitness for transplantation is determined through medical investigations, including physical exams and various tests, such as X-rays and blood tests. Before transplantation, infections of the kidneys and bladder must be treated. In addition, preoperative Erythropoietin is administered to correct anemia associated with renal failure. If a transplant fails, subsequent transplants may be considered.
Maintaining good health is crucial before undergoing a kidney transplant. In addition to staying physically fit, there are several other factors to consider- Quitting smoking is essential as it can increase the risk of severe lung infections and heart disease, making the transplant procedure more hazardous. Regular dental check-ups are necessary as poor dental health can increase the risk of mouth infections after the transplant. Maintaining good hygiene is important to reduce the chances of wound infections, and daily baths with soap can be helpful. For patients with kidney failure, adhering to the dialysis schedule is crucial, especially for those waiting for a transplant. Controlling body weight and fluid weight is also important to be prepared for a kidney transplant.
After your transplant surgery, you will be admitted to the Transplant ICU (KTU), a specialized unit where you will receive close monitoring. Visiting hours may be limited, so visitors should check with the nurses before coming to the hospital. The nurses will take your vital signs, including blood pressure, pulse, temperature, and respiratory rate, to assess your condition. Additionally, the amount of liquid you consume and receive intravenously (intake) will be compared to the amount you excrete and drain through various tubes (output) in order to measure your fluid balance and how well your kidneys are functioning. These measurements, along with your weight, provide the medical team with important information.
Following your transplant surgery, your medical team may recommend that you see a physiotherapist. The main objectives of physiotherapy for organ transplant recipients are to reduce the risk of pulmonary complications after surgery, counteract the negative effects of prolonged bed rest on the body, improve overall strength, endurance, and flexibility, and establish a regular exercise routine.
The transplant patients receive care in a dedicated ward to prevent infection, as medications used to prevent rejection of the new organ can make patients more susceptible to infections. The number of visitors may be limited, and outside food and flowers are not allowed in the transplant ICU to avoid infection transmission. On the first day after the surgery, the patient can have a liquid diet and perform breathing exercises. By the second day, the patient is mobilized. The Foley's catheter and drains are usually removed on the fifth post-operative day, and the patient is typically discharged on the seventh day. The stent, if placed during the surgery, is removed around the 10th day, along with stitches and permacath if present. The length of stay in the hospital varies depending on the function of the transplanted organ and any complications that may arise, but the average stay is approximately five days for the donor and a week for the recipient.
Diagnostic procedures are used during hospitalization to check the status of kidney/pancreas transplant and general physical condition. Tests may include chest X-ray, renal nuclear scan, kidney transplant ultrasound with Doppler, kidney biopsy, and CT/MRI scans. In cases of blood group (ABO) incompatible kidney transplantation, techniques have been developed to safely reduce antibodies before transplantation, enabling more patients to receive kidney transplants. Results of blood group incompatible kidney transplants are comparable to those of live donor blood group compatible transplants, with a 90-95% expected functioning rate at one year post-transplant.