Chapter 12 KIDNEY TRANSPLANTATION A Guide for Patients
The Most Commonly Asked Questions About Transplantation
What is a kidney trans-
from one person is placed into anotherwhose kidneys have stopped working. Who is a candidate for a kidney transplant?
tial candidate for a kidney transplant. However, many factors must be con-sidered in choosing between trans-plantation and chronic dialysis for agiven individual. Among these factorsare age, other medical problems, andpersonal considerations of work andlifestyle. You should discuss the op-tions with your doctor and attempt toobtain as much information as possiblein reaching your decision. Where do kidneys for
for transplantation: living related, living
transplantation come Kidney Transplantation
recipient’s immediate family, such assiblings, parents or children. Only suchclose relatives are likely to have anacceptable tissue match, althoughrecent data suggests that success withliving unrelated kidneys is closer tothat of related grafts than that ofcadavers. This may be due to betterstate of the donor and less storagetime. Cadaver donor kidneys are re-moved from victims of brain death,usually the result of an accident or astroke. Can an unrelated living person donate a kidney?
living unrelated kidneys are beingconsidered increasingly. Spouses arethe usual donors, although rarely,friends can be used if extensivelyscreened. What are the chances my transplanted kidney will
recipient. A kidney from a brother orsister with a “complete” match has a95% chance of working at the end ofone year. A kidney from a parent, child,or “half-matched” sibling has an 85%chance of working for at least one year. Finally, a cadaver donor kidney has an80% change of working at least oneyear.
your first transplant, and that you willbe taking the anti-rejection drugs de-scribed elsewhere in this chapter. Ifyou are having a repeat transplant, thesuccess rate will be 10%-15% less. Kidney Transplantation
however, with 50% of cadaver kidneysdeclining over 6 – 10 years, a ratefaster than the relatively stable successof related kidneys. What happens if my new kidney fails?
plant will be removed only if it is caus-ing symptoms, such as fever or pain. This is often necessary if the kidneyfails soon after transplant, but rarely ifit fails after several months. You maybe able to have another transplantlater, if you desire. What are the chances that I will die as a result of re- ceiving a kidney trans-
hospital, the risk of death in the firstyear after a kidney transplant is about3 – 5%, occurring primarily in high riskpatients, particularly those over 60 –65 and, to a less extent, those withjuvenile diabetes. This includes deathfrom any cause, whether or not relatedto the transplant. This risk is notsignificantly different from thatsustained during a year of dialysis. During your transplant evaluation, anyrisk factors you may have that willincrease your risk for transplantationwill be identified and discussed withyou. What are some of the fac- tors which would increase the risk of transplantation?
patients. Significant heart disease, par-ticularly a history of angina or priorheart attacks, will also increase therisk. Kidney Transplantation
diabetics must undergo an exercisestress test before being accepted fortransplantation. Chronic lung diseaseincreases the risk of pneumonia aftertransplantation.
and all potential transplant patientsare urged not to smoke. Patients whoare significantly overweight are morelikely to have complications in anysurgical procedure, and should attemptto reduce before transplantation. Ahistory of other systemic diseases suchas cancer or hepatitis may also affectthe risk; indeed, many patients with ahistory of cancer or abnormal liverenzymes secondary to hepatitis maynot be accepted for transplantation. Allof these factors vary in importance indifferent individuals, and should bediscussed with your doctor, as well aswith the transplant surgeon when youhave your transplant evaluation. Will my own kidneys be
own kidneys prior to transplantation. removed?
This may be required if you have severehigh blood pressure uncontrollable bymedication and dialysis, or if your kid-neys are chronically infected. However,whenever possible, your own kidneyswill be left alone. Even if not function-ing normally, they continue to makeerythropoietin, a hormone your bodyrequires to make red blood cells, andthey may make some urine. This isparticularly important if your trans-plant should fail. What is rejection?
mechanism, called the immune system,which protects it from foreign sub-stances, such as bacteria and viruses. The body sees a kidney transplant asforeign and attacks it to get rid of it. This process is called rejection, and is a
normal response of the body’s immunesystem. Even though rejection may beprevented by medication, the possibilityof rejection never goes away. The bodywill not adapt to the kidney, nor willthe kidney change to accommodate thebody, although after the first 3 – 6months, rejection is less of a problem. How is rejection pre-
given drugs, called immunosuppressive
medications. These drugs work by low-ering the body’s immune response,making it incapable of destroying thekidney. There are now several immuno-suppressive medications available, giv-ing transplant physicians newflexibility in treating recipients. Mostpatients will receive a combination ofdrugs. The newest of these medicationsis called cyclosporine, a highly effectivedrug which has considerably improvedthe results of transplants of all sorts.
drug was done at the Brigham andWomen’s Hospital. Cyclosporine worksby interfering with the ability of yourlymphocytes to cooperate normally inattacking the transplant. It is nowgiven in pill form in combination withprednisone, a steroid medication withanti-inflammatory properties. Thecombination of cyclosporine, Imuran(an older drug), and prednisone, all inlow doses, is used currently at theBrigham and Women’s Hospital for allrecipients of unrelated kidney trans-plants, and for all living related donortransplants that are not perfectlymatched.
drug mentioned above is azathioprineor Imuran. Occasionally, patients areswitched from cyclosporine to Imuranseveral months after transplant toavoid some potential side effects of longterm cyclosporine administration. Your
doctor will advise you if this isnecessary. How long will I have to take these drugs?
for as long as you have the transplant. Because the body never accepts thekidney as part of itself, rejection canoccur even years later, particularly ifyou stop your medicines. However, itwill be possible to reduce the dosage ofmedications gradually over time, as therisk of rejection lessens with time. Do these immunosuppres- sive drugs have side ef-
such drugs, and some are particularfor the individual drug. The mostimportant side effect these drugs havein common is that by reducing thebody’s immune defenses, they mayactually increase the risk of infection. Because they depress the body’simmune system in a non-specific way,the body is less able to fight off somekinds of infection. This does not meanthat you will be ill frequently, butrather that there are some kinds of in-fection only contracted by patientstaking these or similar drugs. Most ofthese infections are treatable, if de-tected early enough. Therefore, it isvery important that you report anysymptoms such as fever or a cough toyour doctor without delay. Despite therisk, these infections are not common;only about 15% of transplant recipientsever have any significant infection.
cial side effects, of which the mostimportant is kidney toxicity. Sometimescyclosporine will cause your creatinineto rise, even in the absence of any otherproblem. Usually this improves with areduction in the dose. Serial
cyclosporine blood levels are currentlyavailable to help decide the best dosefor an individual patient. Other sideeffects rarely caused by cyclosporineinclude mild hand tremors, hairgrowth, and inflammation of the gums. These generally improve if the dose islowered.
occur much less commonly now thanthey did years ago, because so muchlower doses are used. The mostcommon side effect now rarely seen is atendency to gain weight and develop afat face. Other possible effects includefluid retention, stomach irritation orulceration, thinning of the hair, acne,mood swings, bone disease, anddelayed wound healing. Sugar controlwill be more difficult for diabetics, andan occasional borderline diabetic mayrequire insulin for the first time. Manyof these side effects improve as theprednisone dose is lowered over thefirst year and, in general, areinfrequently seen. Is any research being done to improve the treatment and prevention of rejection?
continues to be done at Brigham andWomen’s Hospital. When you receive atransplant, you may be asked to helpin a research project. Complete in-formation will be furnished before anyresearch is undertaken, and you will beunder no obligation to participate. What is tissue typing?
tory blood tests which compare the ge-netic makeup, the natural differencesand similarities between the recipientand donor. These tests cannot compareall genetic differences, but look at thosewhich have been found to be important
Kidney Transplantation HLA (human lymphocyte antigen)
typing examines a set of six antigens,three of which are inherited from eachparent. Four of these are the A and Bantigens which have been known for along time; two are the Dr (region)antigens which have been morerecently discovered. Cadaver donorkidneys may be matched for from 0 to6 of these antigens. Living relateddonor kidneys are generally matchedfor three or six of these antigens, be-cause they are inherited in groups ofthree. Individuals are classified as highor low responders. How does tissue typing
determine if a relative is an appropriatekidney donor. The tests also help to
predict the outcome of a transplant. Tissue typing is also used to determinewho would be the best recipient when acadaver donor organ becomes available,particularly if there is a six antigenmatched donor available. How is the operation
tion, although occasionally a spinal orepidural technique may be recom-mended by the anesthesiologist. An-tibiotics are given to prevent infection,and a catheter is placed in yourbladder after anesthesia has beengiven. The transplanted kidney isplaced in the pelvis just above thepelvic bone, on either the right or theleft side. The kidney’s artery and veina r e s e w n t o
to your iliac artery and vein, which arethe large blood vessels leading to yourleg. The ureter is connected directly tothe bladder. This technique is illus-trated in the drawing on this page. Theoperation normally takes about threehours.
Is the operation risky?
self is quite safe. Over 1,500 kidneytransplants have been performed atBrigham and Women’s Hospital, thetechnique is well established, and tech-nical complications are rare. Nev-ertheless, as with any operation, diffi-culties may arise.
quire a blood transfusion, particularlyif you are already anemic. Aftersurgery, the most common com-plication is a urine leak, occurringabout 5% of the time. This may occurbecause of damage to the ureter duringharvesting of the donor kidney that wasnot recognizable at the time of thetransplant. The problem is almostalways correctable, but may require asecond operation. Wound infections arevery uncommon, thanks to modern
Kidney Transplantation How long will I be in the hospital?
transplantation. Recovery from thesurgery itself is generally rapid. Pa-tients are encouraged to be out of bedon the day following surgery, and manyare eating solid food within two or threedays. However, the possibility that thekidney may not work right away, andthe risk of rejection, may prolong yourhospitalization. How long will I be out of
each individual, depending upon yourresponse to the transplant, any com-plications which develop, the type ofwork you do, and most importantly,how you feel. Because close follow up isparticularly important during the firstthree months after transplantation, youshould plan on frequent visits to thetransplant clinic and your own physi-cian during this period.
tended to return you to as normal alifestyle as is possible, and you will beencouraged to return to your usualactivities as soon as you are able. Will I need a special diet
will have a wider variety of food choices
after the transplant?
and will no longer need to restrict flu-ids, protein, or phosphorus. However,you may need to restrict sodium if youhave high blood pressure. You may alsoneed to limit potassium, as some pa-tients have high potassium levels whiletaking cyclosporine. A feeling of wellbeing and increased appetite mayfollow transplant and cause you to gainweight, and you may need to watchyour calories. Kidney Transplantation Will my new kidney work right away?
away. During the process of removingthe kidney, storing it as long as one ortwo days, and placing it in therecipient, some damage may occur. This damage is called acute tubularnecrosis (ATN), and is almost alwaysreversible. It may be one to three ormore weeks before the kidney begins tomake urine. During this time you willrequire dialysis. ATN can also occura f t e r l i v i n g r e l a t e d d o n o rtransplantation, but it is much lesscommon. What is a rejection
extra effort to reject the kidney despite
the immunosuppressive medications. This is referred to as a rejectionepisode. The symptoms and signs ofsuch an episode may be decreasedurine output, fever, tenderness over thekidney, high blood pressure, and a risein creatinine, although not all of thesewill necessarily be present. Sometimesa biopsy of the kidney is required tomake the diagnosis. This is done with aneedle under ultrasound guidance andis a minor and non-painful procedure.
addition to your immunosuppression isrequired. Normally, this is a steroidpulse, three daily intravenous injec-tions of high doses of a steroid drugcalled Solu-medrol. Administration of apulse requires hospitalization. Rejec-tion episodes can also be treated withmonoclonal antibodies, which aredesigned to destroy the cells whichtrigger rejection. The transplant teamwill discuss these options with you. Many rejection episodes can be suc-cessfully reversed, but not all. Limita-tions on the amount of treatment forrejection are observed in order to pre-vent complications of overimmunosup-
pression. No more than three pulsesare given in the first six months aftertransplantation. Who determines the re- cipient for a cadaver donor organ?
gan Bank, an independent organizationthat serves the transplantation centersin the region. These centers haveagreed on an objective set of rules todetermine who gets a particular organ. When a donor becomes available,tissue typing is performed to determinethe characteristics of the donor. A com-puter then compares this informationwith a list of the available recipients todetermine the best match.
depends on the length of time waiting;those waiting longest are on the top. Inaddition, if a 6-antigen match becomesavailable anywhere in the country, thiswill go to the most appropriate localmatched donor. Other factors deter-mining the average waiting time for akidney include the number of donors,red blood cell type of the recipient, andthe level of sensitization. What does sensitization
bodies against other people’s HLA anti-
gens. These antibodies may arise be-cause of blood transfusions, priortransplants, pregnancy, or for un-known reasons. The more peopleagainst whom you have antibodies, themore highly sensitized you are.
reacting a sample of your serum with apanel of lymphocytes from many peo-ple. The results are expressed as thepercent of the panel to which you react,and are sometimes called PRA’s (panelreactive activity). It may be difficult tofind a kidney for you if you are highly
sensitized, because you cannot receivean organ from a person against whomyou have antibodies. Such a graftwould be rejected immediately. To pre-vent this possibility, patients waitingfor cadaver organs are requested tosend a monthly serum sample to thetissue typing laboratory. These samplesare screened for antibody levels andstored. If the computer assigns a kid-ney to you, these serum samples willbe tested directly against theprospective donor. This final test forantibody against the donor is called acrossmatch. Should I have a living re- lated or cadaver donor transplant?
ability of donors. The best results fol-lowing transplantation are obtainedwith HLA-identical (6 antigen matched)living related donors, which almost al-ways come from a sibling, rarely from acadaver. As noted before, the availableresults on living unrelated donorkidneys show them to be better thanthose for cadavers.
transplants is the ready availability ofthe donor. This allows the transplant tobe performed without a long waiting pe-riod, as there are currently more poten-tial recipients than available cadaverdonors. For this reason, we encourageliving related donation whenever thefamily situation is appropriate, and, ifcircumstances are correct, donationsfor spouses. How is a living related donor chosen?
your family and your doctor. Tissuetyping is then scheduled; the requiredtests include blood group typing, HLAtyping, and a mixed lymphocyte cul-
ture. Based on these tests it is fre-quently possible to identify the donormost likely to result in a successfultransplant. Choosing the donor is bestdone in consultation with your doctorand the transplant team.
uled for admission to the hospital for adonor evaluation. This evaluation isprimarily on an out-patient basis andinvolves a wide variety of tests toensure the health of the donor. Included in these tests is an ar-teriogram, an x-ray procedure in whichdye is injected into the arteries sup-plying the kidney. This test allows thesurgeon to decide which kidney wouldbe best to remove. After completion ofall tests, the physician responsible forthe donor evaluation, who is not amember of the transplant team, willdiscuss the results with the potentialdonor privately. Only donors who arehealthy and have two completely nor-mal kidneys will be accepted. Are there any risks to the
including the risks of general anesthe-sia, wound infection, and the possibleneed for a blood transfusion. Theserisks are very small in healthy people. The donor evaluation process is de-signed to identify any special factorswhich would place a donor at increasedrisk; such donors would not be ac-cepted. The longer term risks areslightly more uncertain. Some studiesof donors 10 – 15 years following dona-tion have suggested a slightly higherincidence of mild high blood pressureand protein in the urine; althoughthese changes are not particularlydifferent from the general agingpopulation. Kidney Transplantation
renal failure in prior donors. The re-maining kidney expands and takes overthe function previously performed bytwo. Because most kidney diseases af-fect both kidneys simultaneously, thedonor is not at increased risk of kidneyfailure should he or she contract sucha disease. Donors are cautioned toavoid contact sports or other activitieswhich could cause major trauma to theremaining kidney. We believe thatdonors will lead perfectly normal lives. It is fair to state, however, that possibleconsequences of donation after morethan twenty years are unknown,primarily because transplantation ofkidneys in significant numbers onlybegan about twenty years ago. Who pays for kidney transplantation?
kidney transplant. After the transplant,Medicare will pay for 80% of your out-patient clinic visits. Your Medicare willterminate 36 months after yourtransplant, unless you have restarteddialysis before that date. In addition,Medicare pays for 80% of the cost ofFDA-approved immunosuppressivemedications for one year followinghospital discharge after the transplant. No one will be denied the best possiblemedical care because of his or herf i n a n c i a l c i r c u m s t a n c e s . T h etransplant social worker is available toassist with any financial or insuranceconcerns. How does one enter the transplant program at Brigham and Women’s Hospital?
transplant coordinator. Prior to yourappointment, the following informationshould be sent to us:1. Kidney Transplantation
copies of pertinent hospital and of-fice records
Report of a chest x-ray within thelast year
Names and blood types (ABO) ofpotential living donors.
meet with one of the transplant sur-geons, a transplant nurse, a socialworker, and the transplant coordinator. Your medical condition will be reviewedand further information about trans-plantation will be provided. Tissuetyping is frequently performed duringthis visit. A tour of the transplant unitcan be arranged if you desire. You areencouraged to ask as many questionsand to spend as much time with us asyou like. We believe it is very importantfor you and your family to be as well in-formed about transplantation as is pos-sible.
sent to your physician informing him ofthe results and requesting any furtherinformation needed. If you are to re-ceive a living donor transplant, ar-rangements for both the donor evalu-ation and the transplant will be com-pleted by the transplant coordinator. Ifyou are to receive a cadaver donortransplant, your name will be listedwith the New England Organ Bank. You will be required to send one red toptube of blood to the tissue typing labo-ratory each month for sensitivityscreening; instructions for this will be
furnished during your transplant eval-uation. What do I do if a cadaver
of the possible availability of a cadaver
donor kidney becomes available for me?
you. Occasionally, you may need to betold before the final crossmatch hasbeen completed, particularly if the kid-ney has already been stored for a pro-longed length of time. Normally, a ca-daver donor kidney can be safely storedfor 48 hours. About 12-18 hours arerequired for tissue typing, leaving 30-36 hours to make arrangements forand to perform the transplant.
assigned, you should not have anythingfurther to eat or drink. If you are a dia-betic, be sure to discuss this with thephysician who notifies you of the trans-plant. You may need to be dialyzed be-fore the transplant, depending uponwhen you were last dialyzed, yourblood chemistries, and your generalmedical status. This dialysis will bearranged at either your own unit orhere, depending on the dialysisschedule and the timing of theoperation. You should make ar-rangements to travel to the hospital asquickly as possible. However, extremespeed is not required, so please drivenormally and safely. It would be prefer-able to have someone else drive for you. How can I check my sta- tus on the transplant list?
tests are completed and the tissuetyping laboratory has received twomonthly screening samples. You willthen remain on the list as long asmonthly screening blood samples aresent, until such time as you receive atransplant. If you develop medicalproblems which require that you be
temporarily removed from the list,please be sure your doctor notifies uswhen you are able to be relisted. Yourposition on the list will not be affectedby temporary inactivation. If you haveany questions about your currentstatus, please contact the transplantcoordinator.
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