Kidney Transplant

Most people notice that they feel weak, lethargic, and become easily fatigued. Their appetite decreases and tongue has an unusual taste. However, there are other common signs of renal failure which include:

• Itching
• A reduction of urine or the need to urinate during the night
• Nausea, vomiting, pigmentation and easy bruising
• Reduced sexual function
• Abnormal build-up of fluid in the ankles and legs
• Breathlessness
• Chest pain
• Cramps and twisting

HAEMODIALYSIS: This entails removal of impurities of the blood through an artificial kidney machine, which works on the principle of osmosis and filters out the waste products of the blood.

PERITONEAL DIALYSIS: In peritoneal dialysis fluid is made to flow through the abdominal cavity and the waste products from the blood are removed by the dialysis fluid. Unlike haemodialysis, the blood of the patient need not leave the body to flow through a machine. Instead, a sterile washing fluid is flown in the abdominal cavity through a tube placed in the abdomen. During this process, impurities are washed out of the abdomen along with the dialysis fluid. Dialysis is definitely an inferior form of treatment when compared with the transplantation. During dialysis lack of sufficient blood (anaemia) or poor quality of blood causes shortness of breath and easy fatigability, leading to compromised quality of life. Dialysis is unable to take care of many more abnormalities, which are rectified following transplantation.

The main advantage of a successful transplant is freedom. There is release from repeated, unpleasant dialysis. Dialysis’ restriction on drinking water and fluids is not required. The diet is no longer restricted. It is possible to go on a holiday without any tension, to return to normal life and they become capable of conceiving children again. For men, potency returns and a normal sexual life is possible. After a successful transplant, a person feels healthy because anaemia, bone disease and chronic tiredness disappear. Full-time work may not be possible when on dialysis, but is possible after a transplant. After a successful transplant, a person feels healthy because anaemia, bone disease and chronic tiredness disappear. Full-time work may not be possible when on dialysis, but is possible after a transplant.

There are three sources:

LIVING RELATED DONORS: From a first degree relative such as brother, sister, parents and children. This is possible because most people have two kidneys and can live in good health with one. A close relative is preferred as the tissue is likely to have a good match. The spouse and grandparents have also been included recently in the list of close relative as per law.

LIVING UNRELATED DONORS: These include cousins, aunt, uncle, niece, nephew and other relatives which may be related to the patient through the maternal or paternal side.

DECEASED DONORS: From a person who is brain stem dead and does not have kidney diseases, infections and cancers. Most suitable donors are the victims of road accidents, brain haemorrhage, brain tumours, etc.

GENERAL ISSUES

Living donors are a valuable source of kidneys for patients with End-Stage Renal Disease (ESRD). The best long-term graft and patient survival occur with a living related donor organ. A donor is accepted if he understands the situation and is ready to donate for altruistic and emotional reasons.

The issue of a kidney donation from a family member is a difficult one for the patient as well as the family members, and they may find it delicate to refuse for a kidney particularly when someone dear is dangerously ill. They may be concerned about the risks involved in the operation for kidney donation, and it's likely after effects.

Questions often asked are: Would I be a suitable match? What will happen to my other kidney? What will the surgery be like? Would I have to take much time off from work and other activities? Would I be leading a compromised life, after the donation of one kidney?

The following information will deal with these concerns:

• Allows for specific planning of the operation, i.e. the best time for donor and recipient and early (pre-operative) immunosuppression. 
• Generally, recipient requires less immuno-suppressive drugs, therefore fewer side effects and less cost.
• It is more likely to be successful and has long graft survival due to good tissue match among family members. 
• The donor can also be screened for any communicable diseases.
• Reduces pre-transplant dependence on dialysis particularly important for people with diabetes and young children. This also significantly decreases overall cost.

Though allowed as per law, it's not commonly in practice due the following reasons:

• The donor may conceal his medical diseases fearing a financial loss if rejected. The disease may be transmitted to the recipient.
•  The likelihood of a good match will be as rare as one in four thousand, and hence the graft survival is less than optimal.
• The likelihood of donation for financial reasons can also be present.

Simple blood group test is done to determine if the donor and recipient are likely a suitable match. If blood and tissues are matching and the donor is willing to undergo the operation, further detailed medical screening is necessary. This involves X- rays and kidney function tests to determine whether the donor's kidneys and urinary system are in good shape. If the donor is found to have any health problems, the transplant will not proceed.

Donor and recipient should have similar blood group, or donor should have O+ve blood group. AB+ve recipient may get a kidney from any donor. In case donor and recipients don't have matching blood groups ABOi Incompatible transplant can be considered. Swap transplant or paired donation can also solve incompatible blood group.

When and if a family member decides to donate a kidney, it must be a voluntary decision free from any coercion or feelings of being pressurised. Free and confidential discussion between the prospective donors, doctors and transplant coordinator is likely to allay apprehensiveness of the donor and infuse more confidence in him. Every prospective donor has the right to discuss facts about donation and make his decision about kidney donation.

The donor who decides to go ahead with the surgery can enquire about the risk to his/her health during and after the operation. Donors should stop smoking and use oral contraceptives, three months before the operation to avoid post-operative complications.

When all the detailed tests are completed, and both the donor and patient are found fit, a date is decided for the surgery. It is necessary for the family to understand that by performing transplant the transplant team is undertaking a tremendous responsibility and are extra careful. In case they are not satisfied with any of the reports they may have to postpone the transplant, and this is done in the larger interest of the patient. Both donor and patient go to the theatre at the same time for the kidney transplant operation. Removal of a kidney for a transplant is a major surgery, and the donor will feel some pain and discomfort after the operation. He/she are usually kept for five days in the hospital after the operation. The donor's remaining kidney smoothly takes over the function of the two kidneys, enlarging in size to handle increased workload. Because the incision is made close to the ribs and chest, breathing exercises are recommended before and after the operation to prevent any chest complications.

After the operation, donor and recipient are not kept in the same area, as the recipient needs to be nursed in a special infection-free isolated area (Transplant ICU).

OPEN DONOR NEPHRECTOMY: Here kidney is removed by 9 to 12 cm incision in the flank and rib may be excised for the better access. It is time tested old operation but is associated with significant morbidity like- pain, pseudo hernia and prolonged convalescence. It is rarely done now. We at our hospital don’t do this operation. This operation is more morbid, painful and associated with an ugly scan.

LAPAROSCOPIC DONOR NEPHRECTOMY: Here kidney is dissected with the help of laparoscopic instruments (Keyhole surgery), and finally, the kidney is removed by a 6 cm non-muscle cutting incision just above the pubic bones. This incision is not visible and is associated with good cosmetics. There is minimal morbidity and pain. The donor can go home after 3-4 days and can resume his work within two weeks. This form of kidney removal is becoming very popular, and now in the west, 95% of all kidneys are removed by this method. We have done over 2000 such operations in last 16 years and remove all kidneys by this approach only. In female patients, the kidney can be removed through vaginal route to avoid any incision in the abdomen to make it a very cosmetic operation.

Usually, a 12-15 cm incision in given in right iliac fossa and kidney is placed retroperitoneally. Renal artery is joined with internal or external iliac artery, and vein is joined with the external iliac vein.

The ureter is joined with the bladder over the stent. It usually takes 3-4 hours to do this surgery.

A) Eligibility

Most people who have irreversible renal failure and are on dialysis can be considered for transplantation. For people with other major medical problems, such as severe heart and vascular diseases, there may be increased risk for transplantation, and dialysis may be a better treatment options. Some people are happy with their dialysis treatment and don’t wish to undergo transplantation. Each patient should discuss his/her own medical suitability with their doctor and the transplant coordinator before arriving at a decision.

B) Compatibility

Apart from matching blood groups of donor and recipient, it is also necessary to match blood cells like T and B cells. This is called 'tissue typing' and 'cross matching'. In both live-donor and deceased donor transplants, it is important that blood and tissue types are compatible.

• Blood typing: It matches red blood cells of donor and patient and must be consistent, as for blood transfusion. Like B blood group patient must have a kidney from the same i.e. B blood group or O group (universal donor). 
• Tissue Typing: This involves matching of a type of white blood cell called ‘lymphocyte’. These cells have special markers called antigens. It is now known that a special group of these antigens, called HLA Antigens (Histocompatibility Locus Antigens) are important for the success of transplantation. The closer the match of antigens between patient and donor, the better will be the chance of a successful transplant.
• Cross-match: Just before the transplant, blood is taken from donor and recipient, and mixed to ensure no reaction, i.e. negative cross match. 
• We also check for presence of donor-specific antibodies in the patient. If they are present in high titre, it is not a good thing for the patients and may need special treatment.

Medical investigations are necessary to ensure fitness for transplant. These may include physical examination, blood tests, X-rays of heart, lungs and sometimes stomach or bladder. Nowadays, Erythropoietin is given preoperatively to cure anaemia associated with renal failure. Some people do develop antibodies after a transfusion, and these are carefully watched. There is almost no risk of developing AIDS and hepatitis from a blood transfusion (or a transplant), as all blood and donors are screened beforehand. It is also important that the infections of the kidneys and bladder are treated before transplant.

Maintaining good health is a vital preparation for a transplant. Apart from keeping fit, the following are important:

• STOP SMOKING: Smoking increases the risks associated with transplantation, especially of severe lung infections and heart disease, even making the actual operation more hazardous. 
• DENTAL CARE: Regular dental checks are essential, as risk of mouth infection after transplant is increased if teeth and gums are in poor condition. 
• GOOD HYGIENE: Daily bath with soap will decrease chances of wound infection. 
• DIALYSIS: Maintaining the dialysis schedule for any patient with kidney failure, particularly those awaiting transplant is an important part of the preparation. 
• WEIGHT: Controlling both body weight and fluid weight (i.e. not gaining too much weight between dialysis) is important in order to be ready when a transplant is done.

• INTENSIVE CARE: After your transplant operation, you will stay in Transplant ICU (KTU). It is a specialized unit in which you are closely monitored. The visiting hours may be limited, so your visitors will need to check with the nurses before coming to the hospital. 
• VITAL SIGNS: The nurses will take your vital signs (blood pressure, pulse, temperature, respiratory) enabling them to assess your condition. 
• INTAKE AND OUTPUT: Measurement of the amount of liquid you drink and get intravenously (intake) is compared to the amount you urinate and drain through your various tubes (output). These totals, along with your weight, give the team valuable information about your fluid balance and how well your kidneys are functioning.

A) Special Ward:

The transplant patients are cared for in a ward separate from other patients. It is sometimes necessary for transplant patients to be nursed in this area since medications taken to prevent rejection of the new kidney also makes patients more susceptible to infection. For this reason, the number of visitors is restricted. In transplant ICU, flowers and food from outside are not permitted, as they may transmit infection to the patient.

The patient is allowed to take liquid diet on day 1 and allowed to do breathing exercise. He is mobilised on day 2.

The Foleys catheter and drains are removed on the 5th post-operative day. The patient is usually discharged on the 7th day.

The stent which is placed during surgery is removed around 10th day as an outdoor procedure with the help of flexible cystoscopy. Stitches are also removed around same times. If patient has permacath, it is also removed at the same time.

B) Hospitalization:

The length of stay in hospital depends on how well the kidney works and occurrence of any complications. The average stay is about 5 days for the donor and a week for the recipient but may vary in case of complications.

2. ACUTE REJECTION: It occurs from a week to a year after the transplant. It can occur years after transplantation, very rarely. This form of rejection is experienced by most transplant patients and is usually treatable. One important preventable cause of this of rejection is failure to take the prescribed drug treatment regularly.

3. CHRONIC REJECTION: Occurs slowly over a long period and may be asymptomatic. It 's hard to treat. Ultimately transplanted kidney fails and the patient has to return to dialysis awaiting another transplant.

• Sudden weight gain in two days 
• Temperature more than 100 degrees F 
• Decrease in urine output 
• Pain or swelling in the region of transplantation 
• Swelling over ankles and hands 
• Increase in blood pressure 
• Rise in serum creatinine and blood urea

If you notice one or more of these signs, do not ignore it, notify your doctor or call the kidney transplant unit.

However, rejection is diagnosed with kidney biopsy and often treated successfully with steroids, ATG, plasmapharesis and Immunoglobulins. Milder rejection is treated successfully in 98% of the cases, However severe rejection or antibody mediated rejections have poor outcome.

• Feeling of run down 
• Temperature greater than 101F, swelling or discharge from site of operation or any cut or abrasion 
• Burning or pain on urination 
• Foul smelling or cloudy urine 
• A persistent cough or change in the colour of sputum 
• Shortness of breath 
• Diarrhea

If you develop any of these problems, please contact your doctor immediately.

• Avoid people with colds or flu
• Stay away from crowded places like cinema, concerts, and sporting events at least for the   first 6 months. In case you have to be there, wear clean new mask 
• Bathe daily and keep your hair clean 
• Take good care of your teeth and visit your dentist regularly after the second or third months 
• Wash and cover all cuts and scrapes no matter how small they are. Check them daily for signs of infection 
• Take your temperature at least once a day 
• Eat clean and fresh food
• Always wash your hands before eating 
• Drink clean or boiled water

Upon discharge from the hospital, you will need to take your blood pressure at least daily, or more if indicated by your nephrologists/Transplant surgeon. Many of your medications can cause hypertension (high blood pressure) and might even lead to strokes, so it is essential that you take anti-hypertensive medication if required and monitor your blood pressure carefully. These numbers are recorded as 120(s)/80(d). You will also need to check your temperature daily.

After you leave the hospital, you will be required to weigh yourself daily to determine your body fluid status. If indicated, you may be required to monitor your blood sugar.

Your body’s immune system is responsible for recognising foreign objects like splinter, bacteria and your new kidney. You will be taking medications that suppress your immune system. These drugs help prevent your body from rejecting the new kidney. Medications are an essential part of your care for the rest of your life. You must become familiar with all of your new medications and take them regularly at the same time, every day. Skipping even one dose can lead to the rejection of your new kidney.

The drugs and their possible side effects are:

Prednisone is a steroid preparation that decreases inflammation, the swelling and pain that occurs when the body recognises something foreign. It blocks one of the responses in the chain of responses that leads to rejection of the kidney. You will be going home on a dose sufficient to prevent rejection of your kidney. This dose is called a maintenance dose. Prednisone is a vital drug in the prevention of rejection. It does have side effects. However, the severity of these side effects varies from person to person and diminishes as the dose is lowered.

SIDE EFFECTS WHICH MAY OCCURS WITH THE USE OF PREDNISONE PREDNISONE 

• Moon face: A roundness of the face that develops two to four weeks after the drug is started. The roundness decreases as the dose is lowered. You can minimise the roundness by avoiding turtlenecks and using makeup. 
• Acne: This occurs in some patients. Good hygiene is essential. Do not prick the pimples, since this may lead to infection. Ask your doctor for a medicated soap or cream. 
• Increased appetite: It is very easy to gain weight while taking prednisone. It is important to control your caloric intake since large weight gains put extra strain on your kidney and other organs. It is easier to keep control overweight rather than losing it later. 
• Muscle wasting: This effect of prednisone can be minimised through an exercise programme.
•  Mood Swings: On high doses of prednisone you may find your mood changes from being very happy to very sad in a short period and for little apparent reason. Your family should be informed of this so that they can better support you during these mood swings. 
• Increased blood sugar 
• Increased susceptibility to infection

Imuran destroys white blood cells (WBCs), the part of the immune system that recognises and attacks foreign bodies like bacteria. The white blood cells also recognise your new kidney as foreign and try to get rid of it. The dose of Imuran must be carefully regulated because the reduction in the number of WBCs below normal will make you very susceptible to infection. Therefore you may not receive Imuran every day.

After discharge, your WBC count will be checked twice a week until you are on a stable dose of Imuran.

Never stop taking your Imuran unless your doctor tells you to do so.

IMURAN has several possible side effects: 

• Risk of infection: Maintaining good health habits and avoids people with infections. 
• Mouth sores: If you develop any mouth sores, please tell your doctor so that an antibiotic mouthwash can be ordered. Gently brushing your teeth after each meal may prevent the sores. 
• Thinning hair: Some people may notice more hair than usual on their pillow. You will not become bald, and your hair will probably grow back. 
• Liver abnormalities: This is periodically checked by simple blood tests. If it were to occur the Imuran would be stopped, and another drug started in its place.

Cyclosporine soft gelatin capsules are supplied in two strengths: 100/25mg. Your dose will be calculated as per your body weight and to be taken twice a day. If for instance, your physician prescribes 125mg to be taken twice daily, you simply remove one 100mg and one 25mg capsule from the blister packs. Your next dose will then be taken 12 hours later in the same way. Capsules should be left in the blister pack until required for use. Swallow the capsules whole with a glass of water.

Cyclosporine solution is taken twice along with milk. The exact amount is measured with the help of given pipette. The solution should be kept at room temperature.

SEVERAL SIDE EFFECTS ARE ASSOCIATED WITH CYCLOSPORINE THEY INCLUDE 

• Temporary kidney damage (reversed when the dose is lowered) 
• Increased in facial and body hair 
• Hand tremors 
• Swelling of gums 
• Increased risk of certain types of cancer

It is similar to cyclosporine but is more potent. Its complications are also similar, but it does not cause excessive hair growth and gum hyperplasia. It is a preferable agent in children and young females. It is available in 1, 2 and0.5 mg capsules. It is also available in once a day preparation (ADVAGRAF) which helps in reducing the number of drug patients has to take and also related to higher compliance.

Side Effects:

• Diabetes 
• Tremors in hands 
• Rise in serum creatinine 
• Rise in BP

It is a new drug and is used for failing kidneys. It is not associated with kidney damage. It is a useful drug for those have marginal kidney and need to take small doses of tacrolimus. It helps in preserving kidney function.

Side Effects: 

• High lipid levels 
• Wound healing problems 
• Losing protein in urine 
• Pneumonia 
• Mouth ulcer

Induction agents

Simmulect: It is an IL-2 inhibitor which reduces acute rejection rate. It is given on day 0 and day 4 by the intravenous route. It has significant benefit in Cyclosporin era, but its efficiency has decreased in Tacrolimus era. It is still used in many centres as a safe induction agent.

ATG( Antithymocytic Globulin): It is a more potent induction agent to reduce acute rejection rate. It is now a day given in low doses in the first week of the transplant, starting 2 hours before the transplant. It is more popular in zero matched transplants like spousal, second-degree relatives and cadaveric transplant. Since it is more potent, sometimes it may invite some viral and bacterial infections after few months.

Transplantation involves not only physical changes in the body but also many emotional changes. It is a tense time for both patient and the family as they wait to see if the kidney will work and then what happens when rejection episodes occur. Patients must also cope with isolation in the early stages from usual contact with family and friends. The drugs given produce physical side effects, which can be distressing to the patients’ mood changes such as irritability, depression and feelings of elation may occur.

Some of these feelings may be offset by an increased sense of well-being as the transplant begins to function. However, with so many changes happening so quickly, the patient and family can feel overwhelmed. It is important during this time to share these feelings with someone close and to discuss your fears and concerns with the doctor and/or other staff.

Most people have to follow a special diet before their transplant. Due to kidney failure, you were probably told to follow a low potassium, low phosphorus and low sodium diet. Now, following transplant, you are allowed to eat a variety of foods, including those high in potassium and phosphorus. Some patients may experience low Serum Phosphorus levels following transplant. With your new kidney, you now can eat and drink milk products, meat, whole grain bread, crackers and cereals- all good sources of phosphorus.

Even so, you may need to modify some of your food selections because of side effects from your anti-rejection medications, such as fluid retention, high blood pressure and increased serum cholesterol levels.

High Serum Cholesterol and High Low-Density Lipoprotein (LDL) levels are common following transplant. High serum cholesterol levels are associated with heart disease. To reduce your risk of heart disease, you should follow a heart-healthy diet: 

• Eat smaller portions of beef, lamb(red meat) 
• Egg without yellow yolk and fish are good 
• Remove visible animal fat and poultry skins from meat home. 
• Limit egg yolk consumption 
• Select non-fat/low-fat dairy products

If you are on Prednisone, may also give you false hunger sensation causing you to feel hungry despite having eaten within an hour, and eating, again and again, might lead to excessive weight gain.

To prevent you from gaining too much weight follow these suggestions: •

• Buy low-fat/non-fat dairy foods such as milk, cheese, cottage cheese, yoghurt, on fat or light sour cream and cream cheese. 
• Select plain, whole-grain bread (versus high-fat sweet bread, doughnuts, croissants) and low-fat, low-sodium crackers. 
• Avoid or drink very little juice, as it is full of calories. 
• Avoid drinking regular sodas. Drink any diet beverage. 
• Do not eat any fried foods. One tablespoon of any oil has 120 calories. 
• Make sure you never skip meals and try to have some healthy snacks between your meals if necessary. This will prevent you from getting too hungry between meals and will give you extra energy throughout the day.

Food Safety is critical since food poisoning can make you very sick when you are  immunosuppressed. To prevent food poisoning, follow these tips:

• After handling raw meat or poultry, use soap and water to wash your hands, utensils, bowls, cutting boards, and faucet handles if you touched them during food preparation. Juices from meat and poultry can be wiped up by using one-part bleach and nine parts water. 
• Keep poultry and meat refrigerated. 
• Do not use cracked eggs or eat foods containing raw or poached eggs. 
• Do not allow raw meat or poultry to come in contact with food that will not be cooked such as fresh fruit and vegetables. 
• Never leave perishable foods out for more than two hours. 
• Wash fruits and vegetables thoroughly under running water before peeling and cutting. Also, cut away any bruised areas.

These are the general guidelines regarding diet modifications for kidney transplant patients, which can be individualised with the help of your dietitian. Dietitian is available to provide you with nutrition information and answer any questions about your new diet. Depending upon your medical history and condition following transplant, you may need to be on a special diet. Before you go home, the dietitian is available to provide you with written nutrition information and counselling so you can transition from hospital to home.

During your hospitalisation, diagnostic procedures are used to determine the status of your kidney/pancreas transplant and general physical condition. Some of the tests you may need to have performed during your post-operative period include:

CHEST X-RAY: A chest X-ray is obtained prior to the surgery to gain a baseline picture of your lung status. X-rays may also be ordered postoperatively at your physicians’ discretion to check any change in your pulmonary status.

RENAL NUCLEAR SCAN: A renal scan is relatively simple and requires no patient preparation. The purpose of the scan is to assess the renal transplant blood flow and function using a radiopharmaceutical dye injected directly into your vein or vascular access.

KIDNEY TRANSPLANT ULTRASOUND WITH DOPPLER: An ultrasound uses sound waves to locate and outline internal organs and note any abnormalities. During the procedure, the ultrasonologist can visualise your kidney and its blood vessels, noting any abnormalities.

KIDNEY BIOPSY: A kidney biopsy helps show what is occurring in your kidney/ pancreas and can help make precise diagnosis of rejection in a transplanted kidney. This procedure is usually performed in the radiology department with ultrasound guidance. During the procedure, a specially designed needle is inserted through the abdomen to obtain a sample of kidney tissue. Once the needle is removed, firm pressure is applied to stop any bleeding that may occur. After the biopsy, you will be sent back to your room, and your vital signs and the puncture site is checked regularly for signs of bleeding into the urinary tract.

COMPUTED TOMOGRAPHY (CT) SCAN/ MAGNETIC RESONANCE IMAGING (MRI): CT scans and MRI are special X-ray techniques that enable visualisation of a particular tissue layer. It is possible to view organs and surrounding areas, layer by layer allowing a more precise picture of abnormalities that may exist. For full assistance and timely help regarding your queries and worries, please feel free to contact the transplant team on the phone numbers given below or meet in person at the following address.

BLOOD GROUP (ABO) INCOMPATIBLE KIDNEY TRANSPLANTATION: About 30% of potential live donors for kidney transplantation are found to be blood group incompatible. This means that antibodies in the patient with kidney disease will reject the kidney of the donor because of different blood group types. Previously, if this transplant had been performed, the kidney would have immediate rejection. The table below shows blood group incompatibilities.

Since the 1980s, techniques have been developed to overcome this barrier by reducing antibodies before transplantation safely. This has enabled many more patients to receive kidney transplants around the world. The results of blood group incompatible kidney transplants are comparable to those of live donor blood group compatible, and at one year about 90-95% of transplanted live donor kidney transplants would be expected to be functioning. These types of transplants have been performed throughout the world.