About Kidney Transplant

We have got two kidneys. They are bean-shaped organs located on each side of our vertebral column below the diaphragm in the back of the upper part of the abdomen. They maintain our health by removing waste products, excess water, and salt (sodium and potassium). They also keep blood pressure, bone health, and hemoglobin. When the kidney is not able to perform these functions efficiently, we call it kidney failure. When the kidney stops functioning completely, we call it end-stage kidney failure (> 90-95% of kidney function is lost). There is a threat to life. Kidney failure can be of 2 types. 1) Acute kidney failure (Temporary failure), which is potentially recoverable. 2) chronic kidney failure (permanent kidney failure), where there is permanent, irreversible damage to the kidney.

We are fortunate that artificial kidney is available to do kidney function i:e, dialysis adding many years to life. When the kidney fails permanently – end-stage kidney disease, diseased kidney function can be replaced surgically by a healthy kidney. It is called a kidney transplant. Kidney transplant is the preferred treatment because it is associated with better quality of life, longer survival, fewer dietary restrictions, lower cost, and almost full capacity to work compared to lifelong dialysis.

Causes of End-stage kidney failure (Permeant irreversible damage to the kidney)

Common causes include:

• Diabetes: persistently uncontrolled blood sugar can damage kidneys. This has become the most common cause of end-stage kidney failure.
• Chronic glomerulonephritis: This is a condition characterized by inflammation of the filter, usually by the altered immune system, and presents with proteins in the urine, high Blood pressure, and increased creatinine.
• Chronic uncontrolled high blood pressure.
• Chronic recurrent infection of the kidney is known as chronic pyelonephritis.
• Chronic obstruction to urine flow by stones, prostate, cervical cancers (in females)
• Hereditary or familial disease like multiple cysts in the kidney, single kidney, developmental abnormality of urinary storage bag i:e bladder can damage kidneys.

For patients suffering from end-stage kidney disease to keep alive, we have options like:

Hemodialysis This is like an artificial kidney. It does almost all excretory functions of the kidney, like removal of waste products, excess of salt, water, potassium, and phosphorus. It helps to control acid balance and blood pressure. Blood is pumped from the body by vascular access through a dialyzer filter (artificial kidney) by machine and then returned to the body. Hemodialysis can be done at the center or at home.

Peritoneal dialysis Here, our peritoneal membrane in our abdomen, which covers our organs act as a filtering membrane. Fluid is pumped into the abdomen (peritoneal) via a catheter; fluid is exchanged every 4-6 hours daily. This is slow dialysis. There is no stress on heart or blood pressure fluctuations, and there is slow removal of toxins and water like our normal kidneys. This is a home-based therapy.

A Kidney transplant Is the treatment of choice for end-stage kidney disease. It does all functions of a kidney with better quality of life, longer life span at a lesser cost overall. One healthy kidney from a donor is removed surgically and inserted into the patient (recipient). A transplanted kidney does the job of a failed kidney. One kidney is sufficient to maintain life and to live a long healthy life.

Types of kidney transplant

Living donor Kidney comes from usually a family member like father, mother, brother, sister, or wife preferably. If a related donor is not available unrelated may be considered, but there should not be a commercial deal between the donor and recipient.

Braindead donor If a living donor is not available, one can register through a hospital with a zonal coordination center for a deceased donor transplant (Braindead/ cadaver transplant). A transplant will be performed when a kidney becomes available. The main problem is the long waiting list which maybe takes 3-5 years to get a kidney depending on the frequency of donations.

While waiting for a transplant, living donor, or deceased donor, you have to remain relatively healthy and free from infection.

• Take regular and adequate dialysis
• Avoid excessive weight gains between dialysis
• Do not miss dialysis
• Take adequate proteins when you are on dialysis
• Control your blood pressure
• Maintain hemoglobin between 10-12 g/dl
• Regular monthly check-up of health and blood test
• Regular exercise, avoiding smoking, and consumption of alcohol
• Take all medication regularly
• Do heart check-up regularly while on dialysis

Pre Transplant Evaluation:

Once it is decided to go for a kidney transplant before undergoing this procedure, you may need to be evaluated to determine (1) whether you are fit to undergo a transplant and its technical feasibility (2) there are no active infection and other comorbidities like advance age, advance cardiac disease, a liver disease which will affect your long-term survival after transplant. It may need correction prior to kidney transplant, or a combined organ transplant may be considered.

Detailed history, physical examination is done to find out what is your native kidney disease, what are the chances it can recur in a transplanted kidney. Your heart will be evaluated by a cardiologist for any heart disease which may need correction before transplant. Pulmonologist will evaluate your lung function whether its adequate for giving anesthesia, and there is no active lung disease like pulmonary tuberculosis or other chest infections.

The urologist will evaluate whether your bladder is adequate capacity, there is no obstruction to urinary flow, and there are no kidney stones, also evaluate blood vessel caliber, flow and are not calcified so that anastomosis is possible. The urologist will also investigate whether your original kidneys need to be removed or not.

The gynaecologist will evaluate women recipients between age 21 to 65 years of age for cervical cancer by Papanicolaou (Pap) smear. Women, more than 40 years should have mammography to screen for breast cancer.

Psychological assessment will be done by a psychiatrist to identify any social, financial, circumstances behavioural issues that may influence adherence after transplant. The psychologist also assesses fitness to give informed consent.

Dental, dermatology, ENT evaluation to rule out septic foci if present eradicated before transplant.

Laboratory evaluation

• Blood group (ABO): To know the blood group for a compatible donor
• CBC: To find out the degree of anemia and its treatment before transplant
• Urine routine and culture: To rule out urinary tract infection and check the degree of proteinuria pre-transplant.
• Liver function To detect liver impairment
• Blood glucose: To rule out diabetes and check sugar control in diabetics
• Lipid profile: To detect abnormalities and treat.
• Renal function tests: Preoperative electrolytes for fitness.
• PT/PTT/BT: To rule out bleeding and coagulation abnormalities
• HbsAg/HCV/HIV/EBV/CMV IgG: To detect these viral diseases and treat them. Some of these viral diseases may get activated, or CMV may require prophylaxis after transplant.
• Tissue typing/HLA: To determine compatibility with donor relationship with the recipient.
• Lymphocyte cross-match: To detect any antibody against donor T cell and B cell in the blood of the recipient (compatibility of donor and recipient and chances of rejecting organ)
• Uroflowmetry post-void residue: To find out obstruction and bladder status before transplant.
• CT scan plain/iliofemoral vessel doppler: To detect kidney stones or calcification in your iliac blood vessels where donor kidney vessels will be joined.
• Gastrointestinal endoscopy: Selected patients showing stool occult blood positive or past history of peptic ulcer may require gastrointestinal endoscopy.

Donor evaluation:

If a donor is available, preferably an 18 to 65 years of age pre-emptive transplant before going on to long-term dialysis may be considered. Pre-emptive transplant is cost-saving and has better outcomes. You as a donor will be evaluated, and short and long-term risks will be discussed as per the donor's health profile.

ABO compatibility will be tested nowadays because of advances in technology, and immunosuppression medication transplants can be done across the ABO barrier. The cost will be higher, and the risk will also be higher.

There is also an option of paired or swap kidney transplant.

compatibility and cross-match testing will be done to assess your immunological risk and is mandatory by HOTA (Human Organ and Tissue transplant Act.)

Medical evaluation:

The purpose of medical evaluation of a donor is to determine that you are in good health, don’t have any renal problems, diabetes, hypertension, psychologically sound, no disease that can be transmitted to the recipient. It will be confirmed that you don’t have long term or short-term risk for removing one kidney. You will undergo the following investigations as a donor.

• Cardiac evaluation: ECG, 2D echocardiography, and cardiac stress test.
• Pulmonary evaluation: X-ray Chest, ABG (arterial blood gases) &Lung function tests.

Lab tests

• CBC: To find out anemia
• Urine routine and culture: To check for urine infection, blood in the urine
• 24 hours urine protein: proteinuria should be less than 200 mg/day
• Kidney function test and GFR (Filtration rate) measurements: your GFR should be > 80 ml/min.
• Oral GTT (Glucose Tolerance Test)/HbA1c to rule out diabetes
• Liver function tests: To rule out liver disease.
• BT/PT/PTT:To rule out bleeding and coagulation disorders.
• Ultrasonography of abdomen: To confirm the presence of 2 kidneys and other structural abnormalities.
• CT angiography or selective renal angiography: To confirm single or multiple blood vessels their anatomical position and size for surgical resection.
• Isotope renogram: To assess individual kidney function.
• HIV, Hepatitis B, Hepatitis C, CMV: To prevent transmission of these viral illnesses to recipient and requirement of prophylaxis after transplant in the recipient.
• Psychological evaluation: You will be evaluated for mental health issues that might complicate recovery after kidney donation. Assess whether the donation decision is free of inducement, coercion, and generous donation understanding all risks involved. It will be confirmed that there is no undue force to donate kidneys.

Once a donor is evaluated, and the recipient is fit and prepared-made medically fit by treating nephrologist, there will be a meeting between recipient, donor, relatives, surgical and medical team. Anesthesia team will again re-examine all documents and explain in detail the plan. The transplant coordinator will help to prepare legal documents to apply for permission as per HOTA to the local,/ state level/, central level authorization committee.

Once a donor is evaluated, and the recipient is fit and prepared-made medically fit by treating nephrologist, there will be a meeting between recipient, donor, relatives, surgical and medical team. Anesthesia team will again re-examine all documents and explain in detail the plan. The transplant coordinator will help to prepare legal documents to apply for permission as per HOTA to the local,/ state level/, central level authorization committee.

The recipient, donor, and relatives will have to attend committee meetings. All your documents will be reviewed and assessed that there is no commercial interest in transplant and there is no money transaction, sale/buying of kidney between the recipient and donor. Committee will approve/disapprove the surgery and donation. Once the committee has approved, you will be posted for kidney transplant surgery.

Living on dialysis

Patients whose kidney has failed will need to dialysis for their entire life until they get a kidney transplant. Life expectancy on dialysis may vary depending on the other medical conditions and how well the patients follow their treatment plan. The average life expectancy of a patient on dialysis is 5-10 years; however, many patients have lived quite well on dialysis for 20-30 years. One of the reasons for the short survival is that most patients with kidney failure are relatively older. The benefit of transplants is much better in younger patients, and a living donor kidney transplant is more beneficial than a deceased donor transplant.

Kidney transplant operation process

• You will be admitted to the hospital 48 hours before transplant.
• A nephrologist, transplant surgeon, anesthesiologist will assess your fitness.
• Lymphocyte crossmatch test to check if there are no preformed antibodies in recipient towards donor cells are rechecked and confirmed again.
• If you are found to be fit in this final assessment and repeat crossmatch is negative, and there is no evidence of active infection, you will be started on immunosuppressive medications- which will prevent kidney rejection.
• You will be given a hemodialysis session 24 hours prior to operation so that creatinine, electrolytes, and water status is optimal and safe for anesthesia and surgery. CBC, electrolytes, PT, PTT Xray chest will be re-done to check for same.

Operation procedure

Surgical technique: If you have got living donor, the nephrectomy (removal of kidney) is performed via laparoscopy technique. The left kidney is usually preferred. Once the kidney is removed, it will be flushed with preservative fluid as soon as possible, and the kidney will be cooled and kept on ice. If its deceased donor is surgically removed with other organs and transferred to the respective hospital in perfusion fluid and ice, the kidney will be examined, all clots and blood removed renal artery and vein prepared to be joined in the recipient.

Recipient procedures kidneys are usually kept in the right iliac fossa. Donor kidneys artery is joined to recipients external/internal iliac artery. Donor’s vein is joined to recipient external iliac vein. Once joining is over recipient s blood will flow through the transplanted kidney, and filtration starts immediately in almost 95% of live donors and 60% of deceased donors. Once the kidney blood supply starts, the ureter is implanted into the bladder through an opening created and sutured. Usually, a ureteric tube (stent) is kept in the ureter to the bladder, which is removed after 4 weeks. Both donor and recipient surgeries are done under general anesthesia. Native recipient kidneys are not usually removed unless they have stones, infection, or are too big for a new kidney to accommodate.

After both donor and recipient are out of anesthesia and can breathe on their own, ventilators are removed, and recipient and donor are shifted to ICU. Both monitored in ICU for fluid balance, urine output, BP, respiration every hourly. The recipient will be continued immunosuppressive drugs.

The donor will be shifted towards in 2 days and discharged on 4-5 days. The recipient will have an ICU stay of 4 days and a subsequent ward stay of 6-7 days. The urine catheter will be removed on days 3-5. Drain tube from a surgical site that is in place to drain all the fluid or blood accumulating in the surgical site will be removed when drained fluid stops draining. Daily both will be monitored for CBC, renal functions, blood sugars in ICU and wards Will be educated on care, precautions, medication doses, diet to be followed, and follow up visits schedule and monitoring.

Complications after kidney transplant:

Rejection: When the recipient's blood flows through the donor’s kidney, the defence cells of the recipients' blood recognize new kidneys as foreign cells and try to fight with them to remove them. This process will cause rejection and lead to a decline in the function of the kidney. We give drugs that will depress the immune system of the recipient so that it will not fight/ reject the new donor kidney; these medications are called immunosuppressives. Fortunately, because of the availability of potent drugs rejection rate is less than 10% and 90% of rejections are reversible. Rejection will be suspected when there is a decrease in urine output, increasing creatinine, fever, or tenderness over the kidney. Diagnosis of the rejection is proved by biopsy of transplant kidney. As you are on immunosuppressive drugs your defence power is less, and you will be prone to infections. you will be given drugs to prevent infection(prophylaxis). You should take precautions to prevent infections, like wearing a mask, hand washing. If you get fever, breathlessness, contact your transplant team immediately. Early detection of infection and treatment is important. Complete all your vaccination two weeks prior to transplant. Other early complications include a clot in the renal artery, vein, leakage of urine around the kidney, but due to improvement in surgical techniques, these complications are rare now to the tune of 3-5%.

Long term complications:

• Obesity
• Infection
• Heart attack
• Stroke
• Side effects of steroids: osteoporosis, cataract
• Chronic rejection leads to total failure of transplant kidneys.
• Very rarely, kidney transplant patients can get cancers as a complication of immunosuppressive therapy.

Life after kidney transplant

A kidney transplant can remarkably improve the quality of life of the patients. However, there are certain practices and measures that you need to follow to live everyday life.

Regular follow-ups: You may have to do frequent follow up with your nephrologist for the initial few months after the transplant. They will keep a check on the body's response to transplant and any complications which may arise. It is critical to comply with the doctor's advice and does not miss the appointments.

Immunosuppressants: As our body have a tendency to reject the foreign object and organ. You may have to take immunosuppressant medicines to avoid the possibility of rejection of the organ.

Hygiene and lifestyle: Staying active and practising good hygiene is an excellent contributory factor for recovery. Live a healthy lifestyle by engaging in any form of physical activity, eating a balanced diet, avoiding smoking, alcohol, etc.

Living well with kidney transplant:

Living healthy after a kidney transplant may require various modifications in your daily lifestyle and to avoid complications. Therefore, it is recommended that you:

Eat a healthy diet: Prefer eating food that includes fresh fruits, vegetables, whole grains, etc. This will keep you fit and healthy.

Stop smoking: Smoking has been linked with a high risk of cancer and various other health problems. It is important to quit smoking.

Lose weight: Being overweight or obese increase the risk of cancer and various other health problems. Indulge in some form of physical activity like regular exercising, yoga, etc., to ensure you stay fit and healthy.

Listen to your doctor: Follow your doctor's advice and instruction diligently as it will not only help you to prevent infection but also help it recover soon.

Success rate and life expectancy after kidney transplant:

Because of progress in surgical technique, new potent immunosuppressive drugs, overall care survival after kidney transplant has improved

Living donor kidney survival:

• 1 year – 97%
• 5 year: 88%
• 10 year 80%

Deceased donor kidney:

• 1 year – 97%
• 5 years: 80%
• 10 years: 72%

Causes of death

• Cardiovascular disease (heart attack/stroke) - 42-47%
• Infection- 15-18%
• Cancers- 9-15%
• Unknown- 23-31%

Choosing ideal kidney transplant centre:

It is essential to learn about different transplant hospitals and centers before finalizing the one. Here are a few things to keep in mind while choosing a transplant hospital/center:

• Consult more than one doctor, talk to patients who have undergone kidney transplants in the hospital, and know about their experience.
• Whether the center/hospital has expertise in living or deceased donor transplants.
• The reputation of the hospital/center and its mortality rate for kidney transplant patients.
• If the hospital/center is covered under your insurance policy.
• Total experience the hospital/center hold in dealing with kidney transplant cases.

Cost analysis of Kidney Transplant

Living with a disease that badly affects your life is an extremely painful experience for the patient and his family. Patients who opt for dialysis may need to spend around Rs. 25000 per month on 7-10 sessions. Getting a kidney transplant can undoubtedly improve the quality of life of the patient. The average cost of Kidney transplants in India varies between 7-10 lakh approximately. It is important to check with your insurance company whether the transplant cost is covered in your plan. Various factors that will affect the cost are:

• Hospital infrastructure and location
• Organ and transport charges
• Length of stay in hospital
• The expertise of surgeons, their team, and use of advanced technology
• Any health complications
• Recovery and rehabilitation
• Post-transplant medications

A patient who travels from home to hospitals for transplant also needs to keep the cost of staying near the new city's hospital. The cost of staying also adds up over the course of a few months.