Kidney transplant

A kidney transplant is the transfer of a healthy kidney from one person (the donor) into the body of a person who has little or no kidney activity (the recipient).

The most common reason for a kidney transplant is when someone loses most or all of their kidney functions due to chronic kidney disease. The loss of kidney function is known as kidney failure.

The kidneys

The kidneys are two bean-shaped organs that are located on either side of the body, just underneath the ribcage. The main role of the kidneys is to filter out waste products from the blood before converting them into urine.

Living donations

A person only needs one kidney to survive. Therefore, unlike other types of organ donation, such as heart and liver, a living person can donate a kidney. Ideally, this will be a close relative.

This type of donation is known as a living donation.

Receiving a donation from a close relative means that there is less risk of the body rejecting the kidney.

Kidney donations are also possible from donors who have recently died. However, this type of kidney donation has a lower chance of long-term success. Over 1,800 people in Ireland are living with a kidney transplant

Outlook

The outlook for a person who receives a donated kidney will depend to a large extent on a number of factors, including:

  • whether the donation was a living donation or not (living donations usually have a better outlook)
  • whether the donation was from a close relative or someone with the same tissue type (this lowers the risk of the body rejecting the kidney)
  • the age of the person receiving the donation (the younger the person, the better the outlook)

On average, 80% of people who receive a live donation will live for at least five years after receiving the donation (and many people, particularly children, will live much longer).

Around 70% of people who receive a donation from a recently deceased person will live for at least five years after receiving a donation.

Donor

A donor is a person (living or dead) who donates blood, an organ or other body parts to another person in need.

Kidney

Kidneys are a pair of bean-shaped organs located at the back of the abdomen. They remove waste and extra fluid from the blood and pass them out of the body as urine.

Recipient

A recipient is a person who receives donated blood, tissue or an organ from another person.

Rejection

One of the biggest risks involved in receiving a donated kidney is that your immune system (your body’s natural defence against injection) will mistake the donated kidney for a foreign object, such as a viral or bacterial infection.

If this occurs, your immune system will attempt to destroy the kidney. This is known as rejection. Potentially, it can be very serious and, in some cases, fatal. To minimise the risks of rejection, the kidney should be donated by somebody who has:

  • the same tissue type as the recipient. Human tissue carries a special genetic 'marker' or code, known as a human leukocyte antigen (HLA). Ideally, you should receive your transplant from someone with an identical, or very similar, HLA tissue type
  • the same blood group as the recipient. As with tissue, each red blood cell is marked with a specific antigen marker
  • the same levels of antibodies as the recipient

Kidney failure

Kidney failure is the most common reason for having a kidney transplant.

The kidneys contain millions of tiny filters, known as nephrons. As blood passes through the kidneys, nephrons filter out excess fluid and waste products from the blood. These are released from the body when we urinate.

However, if the nephrons become damaged, the kidneys can lose their filtering abilities and dangerous levels of fluid and waste products can build up. Kidney failure occurs once the kidneys have lost around 90% of their filtering ability.

The two most common causes of kidney failure are:

  • diabetes: the high blood glucose levels that are associated with diabetes can damage the filters in the kidneys, leading to chronic (long-term) kidney damage
  • high blood pressure (hypertension): hypertension causes damage by putting strain on the small blood vessels in the kidneys, which prevents the filtering process from working properly

Less common causes of kidney failure include:

If kidney failure is not treated, the amount of waste products in the blood will build up to a dangerous level, resulting in coma (unconsciousness) followed by death.

There are two main treatment options when it is known that kidney failure is likely to occur:

  • dialysis, where a mechanical device is used to replicate the functions of the kidney
  • kidney transplant, which, if possible, is usually the preferred option because it is much less inconvenient than having dialysis

Ideally, a kidney transplant should be performed when testing shows that the extent of the damage to your kidney is so great that you will require dialysis within six months due to kidney failure.

However, due to the lack of available kidneys, it is highly unlikely that you will receive a kidney donation at this time, unless a family member or friend who has a similar tissue type to you is willing to make a living donation.

Most people with kidney failure need dialysis while they wait for a donated kidney to become available. Usually, only one transplant in ten is performed on people who are not on dialysis.

The average time that a person spends on the waiting list for a kidney transplant is two years. However, those with rarer blood groups, such as groups A and O, tend to wait longer than people with more common blood groups, such as groups AB and B.

Most people are able to have a kidney transplant, regardless of their age. However, a number of factors could mean that it is not safe to have one.

Factors that signify that a treatment cannot be safely used are known as contraindications.

Contraindications to a kidney transplant include:

  • cancer that has spread to several places in your body (metastatic cancer)
  • an ongoing infection (the infection will need to be successfully treated before a transplant can take place)
  • severe heart disease
  • liver failure (where your liver is unable to function properly as a result of damage or disease)
  • AIDS, which is the final and most serious stage of an HIV infection (due to your vulnerability to infection, it would be too dangerous to weaken your immune system after surgery to prevent your body rejecting the kidney)

People who have HIV that is being effectively controlled with medication can have a kidney transplant.

Preparing for surgery

While you are waiting for a kidney donation, it is important that you take steps to improve your general level of health and wellbeing. This is because the healthier you are, the greater the chances of the donation being successful.Kidney transplants in Ireland are performed in Beaumont Hospital.www.beaumont.ie

Yoor treating doctor can give you more detailed advice for your individual circumstances. Two particular important pieces of advice are:

  • give up smoking (if you are a smoker) as continuing to smoke could lead to further kidney damage
  • lose weight (if you are overweight or obese) because, in addition to the health risks posed by obesity, performing surgery on someone who is obese is technically more difficult and has a higher risk of post-operative complications

The hospital will need to able to contact you at short notice, so inform staff at the centre if there are any changes to your personal contact details. Also inform them about any changes to your health, for example if you develop an infection.

It is a good idea to prepare an overnight bag and make arrangements with your friends, family and employer so that you can go to the transplant centre as soon as a donor kidney becomes available.

When a suitable donor kidney is found, the transplant centre will contact you. It will check that no new medical problems have occurred and will ask you to go to the centre.

When you hear from the transplant centre:

  • do not eat or drink anything
  • take all current medicines with you
  • take a bag of clothes and essential items for your hospital stay

When you arrive at the transplant centre, you will be quickly reassessed. Some of the tests that you had at your initial assessment may be repeated to ensure that no new medical conditions have developed.

At the same time, a second medical team will examine the donor kidney. The procedure must be carried out as quickly as possible for the transplant to have the best chance of success. After the medical team has confirmed that the kidney is in good condition and is suitable, you will be given the general anaesthetic.

Surgery

A number of different methods can be used to carry out a kidney transplant. The most widely used method is known as a Gibson incision.

A Gibson incision involves a three-stage procedure:

  • First, an incision (cut) is made in your lower abdomen (stomach), through which the donated kidney is put into place. Your own kidneys can usually be left where they are, unless they are causing a problem, such as an infection.
  • Second, blood vessels from your lower abdomen are attached to the blood vessels of the donated kidney. This is to provide the donated kidney with the blood supply that it needs to function properly.
  • Finally, the ureter (the tube that carries urine from the kidney to the bladder) of the donated kidney is connected to your bladder.

While the above procedure may sound relatively straightforward, it is demanding and complex surgery that usually takes three to four hours to complete.

After surgery

Once you have recovered from the effects of the anaesthetic, it is likely that you will feel some pain at the site of the incision. If you are in pain, painkillers will be provided.

After the operation, you will immediately begin treatment with medication, which is designed to prevent your immune system from rejecting your new kidney. These types of medication are known as immunosuppressants. See Kidney transplant - recommendations for more information about immunosuppressants.

In around 70% of people who have a kidney transplant, their new kidney begins working immediately after surgery. However, transplanted kidneys sometimes take up to six weeks to start working. If this is the case, you will need to use dialysis during this time. Dialysis involves using a mechanical device to replicate the functions of the kidney.

Most people are fit enough to leave hospital after having kidney surgery, but you will need to attend frequent appointments at the transplant centre so that your kidney function can be assessed. Tests are also used to check how well your immunosuppressants are working.

For the first few weeks after surgery, you may need to have two to three appointments a week. However, over time, your appointments will become less frequent. After a year, as long as you do not have any serious problems, you should only have to attend the centre once every two to three months.

After having kidney surgery, you should be able to return to work and normal activities within a few months, provided you make good progress.

Appendix
The appendix is a narrow muscular pocket in the abdomen that has no known function. It is attached to the large intestine.
Artery
Arteries are blood vessels that carry blood from the heart to the rest of the body.
Bladder
The bladder is a small organ near the pelvis that holds urine until it is ready to be passed from the body.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Kidney
Kidneys are a pair of bean-shaped organs located at the back of the abdomen, which remove waste and extra fluid from the blood and pass them out of the body as urine.
Vein
Veins are blood vessels that carry blood from the rest of the body back to the heart.

Who’s in the transplant team?

The team includes the surgeon, specialist transplant nurse, physiotherapists, psychologists and a transplant co-ordinator.

Donating a kidney (living donation)

If you are going to donate one of your kidneys, you will need to attend a series of appointments so that:

  • the state of your kidneys can be checked
  • your general health can be assessed
  • tests can be carried out to see if you have any serious illnesses that could affect the donation, such as HIV or hepatitis B

This assessment procedure can take three to nine months, and some overnight stays at the hospital may be required. Surgery usually requires you to spend a week at the transplant centre.

Laparoscopic (keyhole) surgery is often used to remove a kidney from a living donor. This involves only making a small incision (cut) in your abdomen (stomach), which results in minimal scarring.It will probably take you about eight to twelve weeks to recover from the surgery.

As with any type of surgery, providing a kidney donation has risks. Make sure that you fully understand all the risks associated with kidney donation before you consent to the procedure.

Due to the introduction of newer, more effective immunosuppressant medications during the 1980s, the rates of serious complications that arise after a kidney transplant have fallen sharply. However, kidney transplants, like any other type of surgery, are not risk free.

Potentially serious complications arising from a kidney transplant are discussed below.

Infection

After a transplant, minor infections are common. They affect an estimated one in two people. These infections usually take the form of:

  • urinary tract infection (UTI)
  • colds
  • influenza (flu)

More serious infections, such as pneumonia (inflammation of the tissues in one or both lungs) and cytomegalovirus (a viral infection that can be severe in people with weakened immune systems) can occur and may require aggressive treatment and admission to hospital.

Blood clots

Blood clots can develop in the arteries that have been connected to the donated kidney. They are estimated to develop in around 1-4% of kidney transplant cases.

In some cases, it may be possible to dissolve the blood clots using medication. In more serious cases, where clotting does not respond to treatment, it is usually necessary to remove the donated kidney.

Narrowing of an artery

In an estimated 2-10% of cases, the arteries that are connected to the donated kidney become narrowed. This is known as arterial stenosis.

Arterial stenosis can develop many months or even years after the transplant. It can cause a sudden rise in blood pressure, which is potentially dangerous. Surgery is usually required to widen the artery, often using a small metal tube called a stent.

Ureteral obstruction and urinary leakage

Ureteral obstruction is a common complication after a kidney transplant. It develops when the ureter (the tube that carries urine from the kidney to the bladder) becomes blocked from clots of tissue or fluid that form during or after the operation.

The symptoms of a ureteral obstruction include:

  • a high temperature (fever) of 38C (100.4F) or above
  • pain in the side of your abdomen (stomach)
  • vomiting
  • nausea
  • blood in your urine

It may be possible to unblock the ureter by draining it with a small tube called a catheter. The catheter is inserted into your urethra (the opening in the penis or vagina which urine flows out of), before being guided into your ureter. If this treatment does not work, surgery may be required to unblock the ureter.

Urine may leak from any part of the urinary system (the kidney, bladder, ureter and urethra) as a result of damage or disruption caused during surgery. Urine leakage usually occurs during the first month after surgery.

Symptoms of urine leakage include:

  • fluid leaking from the site of your surgical incision
  • abdominal (stomach) pain
  • swelling of your perineum (the area of skin between your genitals and anus)

Small leaks can be treated using a catheter to drain away the excess urine. However, larger leaks may require surgery to correct them. Ureteral obstruction and urinary leakage occur in an estimated 3-5% of kidney transplant cases.

Acute rejection

Acute rejection is where the immune system suddenly begins to attack the donated kidney because it mistakes it for a foreign object.

Despite the use of immunosuppressants, acute rejection is a common complication in the first year after a transplant, affecting an estimated 15-25% of people.

In many cases, acute rejection does not cause any noticeable symptoms, and it is only detected during a blood test. Acute rejection can usually be successfully treated using a short course of more powerful immunosuppressants (medicines to prevent your immune system rejecting the new kidney).

Medication

After having a kidney transplant, you will need to take a combination of three different medications.

These are:

  • immunosuppressants, which prevent your immune system from rejecting the new kidney
  • medicines to reduce the risks of taking immunosuppressants
  • medicines to prevent high blood pressure (hypertension) and high cholesterol

Immunosuppressants

Immunosuppressants prevent your body's immune system from attacking the new kidney, which would cause the transplanted kidney to be rejected.

Immunosuppressants are usually taken by mouth (orally) at a dose that is high enough to 'dampen' the immune system sufficiently to stop rejection, but not so high that the body is unable to fight off infection.

Finding the optimal dose to achieve both goals is often a difficult balancing act. It may take several months to find the most effective dose that causes the least amount of side effects.

Three widely used immunosuppressants are:

  • cyclosporin
  • azathioprine
  • prednisolone

Immunosuppressants can cause a wide range of side effects, including:

  • loss of appetite
  • nausea
  • vomiting
  • stomach pain
  • diarrhoea
  • swollen gums
  • bruising or bleeding more easily
  • convulsions
  • dizziness
  • headache
  • acne
  • extra hair growth
  • weight gain

These side effects should improve once the right dosage is identified. Even if your side effects become very troublesome, never suddenly stop taking your medication because your kidney could be rejected.

Around 1 in 20 people who take prednisolone develop mental health problems, such as:

  • depression
  • suicidal thoughts
  • mania (feeling unusually excited and 'high')
  • rapid mood swings
  • anxiety
  • difficulties thinking
  • feeling very confused
  • loss of memory
  • hallucinations (seeing and hearing things that are not really there)
  • having strange and frightening thoughts

Contact your GP as soon as possible if you experience any of these mental health problems.

Medicines to reduce the risks of taking immunosuppressants

Developing a severe infection is one of the greatest risks associated with taking immunosuppressants. This is because immunosuppressants 'dampen down' your body's immune system, making you more vulnerable to infection.

The medications listed below may be taken to prevent the more common or more serious infections:

  • Aciclovir is taken to prevent cytomegalovirus (CMV) infection, which is most likely to occur during the first few months after the transplant.
  • Amphotericin lozenges or nystatin mouthwash are taken to prevent candida (thrush) infections of the mouth.
  • Co-trimoxazole is taken to prevent pneumocystis carinii pneumonia (a rare chest infection that is also known as PCP), which may develop when your immune system is suppressed.
  • Isoniazid is taken to prevent tuberculosis (TB) (a serious chest infection) if the person has previously had TB or has come into contact with someone who has it.

If you are taking immunosuppressants, you also have a higher risk of developing skin and lip cancers. Avoid going out in the sun during the hottest part of the day and apply complete sun block to your lips and all exposed areas of your skin every day, regardless of whether or not it is sunny.

Also avoid close contact with a known chickenpox, shingles or measles infection. Due to your weakened immune system, these types of infection could make you very ill.

Immunocompromised

Having a weakened immune system is known as being immunocompromised.

If you are immunocompromised, you will need to take extra precautions against infection. Follow the advice below:

  • Practise good personal hygiene. Take daily baths or showers and make sure that clothes, towels and bed linen are washed regularly.
  • Avoid contact with people with serious infections, such as chickenpox or influenza (flu).
  • Wash your hands regularly with soap and hot water, particularly after going to the toilet and before preparing food and eating meals.
  • Take extra care not to cut or graze your skin. If you do, clean the area thoroughly with warm water, dry it, then cover it with a sterile dressing.

Be aware of any initial signs that you may have an infection. A minor infection could quickly turn into a major one.

Immediately report any possible symptoms of an infection to your GP or transplant centre. Prompt treatment may be required to prevent serious complications developing. Symptoms of infection include:

  • high temperature (fever) of 38C (100.4F) or above
  • headache
  • aching muscles
  • diarrhoea
  • tiredness

Also ensure that your vaccinations are up to date.

Your GP or transplant centre can advise you about this.

Living donation

Most organs for transplants are donated by people who have died. If you wish to become an organ donor you can carry an organ donor card or sign the organ donation option on the back of your driving licence.However, every year, more and more people receive organs from living donors. This involves major surgery, but operations involving living donors are often very successful. The risks to the donor are minimal and can be reduced by a detailed assessment of the donor before donation. 

Living donor kidney transplantation is an established and successful technique for the treatment of kidney disease. Risks to the donor are minimal, but donating a kidney is an important decision and one that needs serious consideration.

Who can be a living donor?

Close relatives are most likely to donate, but it's possible to donate a kidney even if the donor is unrelated to the recipient. In cases where the donor's and recipient's blood group or tissue-type are incompatible, it may be possible to be part of a paired donation (where you're matched with another donor and recipient in the same situation). A non-direct altruistic donation is when you donate to someone who is unknown to you.

How will I know if I can donate?

You'll have a thorough medical, surgical and psychological assessment to make sure that you're fit and healthy. This can take at least three months. In some cases, potential donors find they can't donate because of health problems that are discovered during the assessment.

What should I do if I want to donate a kidney?

If you know the recipient, contact their hospital or transplant centre. You'll need to give your blood group to see if it's compatible with your recipient. After this, an appointment will be made to discuss donation and carry out blood tests. If you don't have a recipient in mind, but would like to donate a kidney, contact your GP, who will put you in touch with your regional transplant centre.

Can I change my mind?

You have the right to withdraw your offer at any time. The transplant will only take place if both donor and recipient are willing.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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