Kidney Transplant in India

Overview

Kidneys are very versatile organs, and most people can manage perfectly well with only 15% kidney function. However, in the case of complete kidney failure, our kidneys are no longer able to excrete the toxic waste products into the urine. The constant ratios of the waste products in the bloodstream increases and we become ill. There are two types of kidney failure. In acute kidney failure, which can occur because of a sudden trauma to the kidneys, the kidneys may stop working for a short while and then partly or wholly recover. Chronic renal failure is a progressive condition where the kidneys become irreversibly damaged over a long period, often many years. This condition can develop because of an infection, diabetes, hypertension, or inherited abnormalities. Advanced chronic renal failure is known as end-stage renal disease, where your kidneys are no longer able to function.

Symptoms of Kidney Failure

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

When your kidneys are no longer working properly, there are treatments such as haemodialysis and peritoneal dialysis which can filter the waste products from your body. However, dialysis does not perform many of the other vital functions such as stimulating the production of red blood cells. In this case, only a kidney transplant can work.

Dietary Management

Five main constituents of the diet have to be included while planning the diet for a patient with chronic renal failure. These are fluid (water), protein, sodium, potassium (salts), and phosphorus.

Fluid & food restrictions for Chronic Renal Failure patients

It is necessary to restrict the quantity of drinking water, fruit juices, coffee, tea, milk, salt, butter, cheese, egg, meat, fish, spinach, fruits, dry fruits, sauces, pickles, cake, pastry, biscuits, ice cream, squashes, beer, wine, honey, soft drinks, condensed and dry milk. Our dietary department will give you all the details about your diet and advise you on the restrictions you may have to follow.

Dialysis

A patient with end-stage kidney failure has DIALYSIS and TRANSPLANTATION as the only options available for his/her survival. As and when the patients reach a stage, where their kidneys fail to sustain body functions they have to be put on regular dialysis for keeping them alive. Even if the patient decides to have a transplant, he will need the support of dialysis till the preparations for kidney transplantation are made. Dialysis is a substitute for failed kidneys but does not replace kidney function. Patients on dialysis do not do well in the long run and develop some complications, which are not seen after transplantation. Patients live longer after transplantation than on dialysis.

There are two main types of dialysis

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.

Why a Transplant?

A kidney transplant operation involves taking out a kidney from the body of one person and implanting it surgically in the body of a patient whose own kidneys have failed. The transplanted kidney functions as the patient's kidneys. While a transplant is not a permanent cure for renal (kidney) failure, it does allow patients to live a more normal life than that experienced on dialysis. Patients with well- functioning transplants have a greater sense of well-being and can enjoy a lifestyle free of dependence on dialysis treatment. However, they must always continue with their transplant drug treatment to prevent rejection of the transplanted kidney.

Advantages of Transplant

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.

How to obtain a Kidney?

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.

Living related Kidney donor

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:

Advantages of a live donor transplant

• 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.

Who can be a live related donor?

A close blood relative such as brother, sister, parent or child may be a suitable donor. Second-degree relatives like grandparents, cousins, niece, in-laws, etc. are also eligible for donation. The prospective donor must also be an adult (over 18yrs and below 70yrs of age) and be in perfect health. A spouse is also included in this category.

Can strangers be considered as donors?

• 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.

What tests are necessary?

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.

Donor and family concerns

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

The Operation

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).

Kidney removal is done by two methods

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.

Kidney Transplant 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.

Robotic assisted Kidney Transplant

Nowadays, kidney can be transplanted with the help of a robotic system. Here is kidney is placed in the abdomen after making a 5-6 cm incision, and rest of the operation is done with the help of a robot. The advantages are a small incision, less pain, early recovery, no wound infection and no lymphocele. This operation is beneficial in obese and young females. However, it an expensive procedure due to the high cost of robotic instruments

Transplant success rate

The success rate of a kidney transplant after one year of living- donor related kidneys are 90-95%. If the transplant works well for the first year, the chances are good that it is likely to function for a much longer period. Many patients who received renal transplants 15-20 years ago are still alive with functioning grafts and are leading normal lives. 80% patients have good kidney functioning even after five years and around 40-50% up to 10 years. About 20% of the patients have functioning graft at 20 years. If the transplant fails, a second transplant is possible and can be fully successful. One can also have a successful third and fourth transplant.

Preparing for a transplant

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.

Pre-transplant preparation

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

Daily hospital routines

• 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.

Physiotherapy

After surgery, your physician or transplant team may refer you to a physiotherapist. The goals of physiotherapy for organ transplant patients are to: Minimise post-operative pulmonary complications; Minimise the deconditioning effects of bed rest; Increase general strength, endurance and flexibility; Develop and reinforce a habit of regular exercise.

Post-transplant Care

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.

Tests & procedures

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.