Treatments

The body takes nutrients from food and converts them to energy. After the body has taken the food that it needs, waste products are left behind in the bowel and in the blood.
The kidneys and urinary system keep chemicals, such as potassium and sodium, and water in balance, and remove a type of waste, called urea, from the blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys. Kidneys also regulate fluid and acid-base balance in the body.
Two kidneys, a pair of purplish-brown organs, are located below the ribs toward the middle of the back. Their function is to:

• Remove liquid waste from the blood in the form of urine
• Keep a stable balance of salts and other substances in the blood
• Produce erythropoietin, a hormone that aids the formation of red blood cells
• Regulate blood pressure

The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule.
Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.
A kidney transplant may be recommended for people with end stage renal disease (ESRD), a permanent condition of kidney failure that often requires dialysis (a process used to remove wastes and other substances from the blood). Some conditions of the kidneys that may result in ESRD include, but are not limited to, the following:

• Repeated urinary infections
• Kidney failure caused by diabetes or high blood pressure
• Polycystic kidney disease or other inherited disorders
• Glomerulonephritis, which is inflammation of the kidney’s filtering units
• Haemolytic uremic syndrome, a rare disorder that causes kidney failure
• Lupus and other diseases of the immune system
• Obstructions
• Other conditions, such as congenital defects of the kidneys.

There may be other reasons for doctors to recommend a kidney transplant.

Symptoms
The symptoms of kidney failure vary widely by the cause of the kidney failure, severity of the condition, and the other body systems that are affected. Most people have no symptoms at all in the early stages of the disease, because the kidneys are able to compensate so well for the early impairments in their function. Others have symptoms that are mild, subtle, or vague. Generally, obvious symptoms appear only when the condition has become severe or even critical.
Kidney failure is not painful, even when severe, although there may be pain from damage to other systems. Some types of kidney failure cause fluid retention. However, severe dehydration (fluid deficiency) can also cause kidney failure.

• Fluid retention: This causes puffiness, swelling of arms and legs, and shortness of breath [due to fluid collection in the lungs, called pulmonary edema].
• Dehydration: This results in thirst, rapid heart rate [tachycardia], dry mucous membranes [such as inside the mouth and nose], and feeling weak or lethargic.

Other common symptoms of kidney failure and end-stage renal disease (ESRD) include the following:

• Urinating less than usual
• Urinary problems (frequency, urgency)
• Bleeding due to impaired clotting, from any site
• Easy bruising
• Fatigue
• Confusion
• Nausea, vomiting
• Loss of appetite
• Pain in the muscles, joints, flanks, chest
• Bone pain or fractures
• Itching
• Pale skin (from anaemia)

One may be able to prevent kidney failure, or slow the progression of the failure, by controlling underlying conditions. End-stage renal disease cannot be prevented in some cases. Kidney failure has usually progressed fairly significantly by the time symptoms appear.
If a person is at high risk of developing chronic kidney failure, he or she should see their health care professional as recommended for screening tests. If one has a chronic condition such as diabetes, high blood pressure, or high cholesterol, he or she should follow the treatment recommendations of their health care professional.
One should see their health care professional regularly for monitoring. Aggressive treatment of these diseases is essential to preserve kidney function and prevent complications. The person should avoid exposure to alcohol, drugs, chemicals, and other toxic substances as much as possible.

Exams & Tests
Extensive testing must be done before an individual can undergo a renal transplant.
Because of the wide range of information necessary to determine eligibility for transplant, the evaluation process is carried out by a transplant team. The team includes a transplant surgeon, a transplant nephrologist (doctor specializing in the treatment of the kidneys), one or more transplant nurses, a social worker, and a psychiatrist or psychologist. Additional team members may include a dietician and an anaesthesiologist.
Components of the transplant evaluation process include, but are not limited to, the following:

• Psychological and social evaluation: Psychological and social issues involved in organ transplantation, such as stress, financial issues, and support by family and/or significant others are assessed. These issues can significantly impact the outcome of a transplant. The same kind of evaluation is performed for a living donor.
• Blood tests: Blood tests are performed to help determine a good donor match, to assess the patient’s priority on the donor list, and to help improve the chances that the donor organ will not be rejected.
• Diagnostic tests: Diagnostic tests may be performed to assess the patient’s kidneys as well as overall health status. These tests may include X-rays, ultrasound procedures, kidney biopsy, and dental examinations. Women may receive a Pap test, gynaecology evaluation, and a mammogram.

The transplant team will consider all information from interviews, medical history, physical examination, and diagnostic tests in determining the patient’s eligibility for kidney transplantation. Once the patient has been accepted as a transplant candidate, the patient is usually placed on a waiting list. When a donor organ becomes available, the patient will be notified and told to come to the hospital immediately.
If the patient is to receive a kidney from a living family member (living-related transplant), the transplant may be performed at a planned time. The potential donor must have a compatible blood type and be in good health. A psychological test will be conducted to ensure the donor is comfortable with the decision.

Before the Surgery

• The doctor will explain the procedure to the patient/family and offer the opportunity to ask any questions about the procedure.
• The patient will be asked to sign a consent form that gives permission to do the surgery. The patient/family must read the form carefully and ask questions if something is not clear.
• If the patient has been on routine dialysis before the procedure, he/she will receive dialysis prior to the procedure.
• For a planned living transplant, the patient should fast for eight hours before the operation, generally after midnight. In the case of a cadaver organ transplant, the patient should begin to fast once he/she is notified that a kidney has become available.
• The patient will be asked to wear a hospital gown.
• The patient may be given a sedative prior to the procedure to help him/her relax.
• Based on medical condition of the patient, the doctor may request other specific preparation.

Kidney transplantation requires stay in hospital. Procedures may vary depending on the patient’s condition.

During the Surgery

• An intravenous (IV) line will be started in the arm or hand of the patient. Additional catheters will be inserted in the neck and wrist to monitor the status of the heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.
• The patient will be positioned on the operating table, lying on his/her back.
• If there is excessive hair at the surgical site, it may be clipped off.
• A catheter will be inserted into the bladder to drain urine.
• Kidney transplant surgery is performed under general anaesthesia. After the patient is sedated, the anaesthesiologist will insert a tube into the lungs so that breathing can be controlled with a ventilator. The anaesthesiologist will continuously monitor the patient’s heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
• The skin over the surgical site will be cleansed with an antiseptic solution.
• The doctor will make a long incision into the lower abdomen on one side.
• The doctor will visually inspect the donor kidney prior to implanting it.
• The donor kidney will be placed into the abdomen. A left donor kidney will be implanted on the right side; a right donor kidney will be implanted on the left side. This allows the ureter to be accessed easily for connection to the bladder.
• The renal artery and vein of the donor kidney will be sutured (sewn) to the external iliac artery and vein.
• After the artery and vein are attached, the blood flow through these vessels will be checked for bleeding at the suture lines.
• The donor ureter (the tube that drains urine from the kidney) will be connected to the bladder.
• The incision will be closed with stitches or surgical staples.
• A drain may be placed in the incision site to reduce swelling.
• A sterile bandage or dressing will be applied.

After the Surgery

After the surgery the patient will be taken to the recovery room for observation. Once blood pressure, pulse, and breathing are stable and the patient is alert, he/she may be taken to the intensive care unit (ICU) or hospital room. Kidney transplantation usually requires an in-hospital stay of several days.
A kidney from a living donor may begin to make urine immediately, but urine production in a cadaver kidney may take longer. Until urine output is sufficient, dialysis may be required. The patient will have a catheter in the bladder to drain urine. The amount of urine will be carefully measured to evaluate the new kidney’s function.
The patient will receive IV fluids until he/she is able to take in adequate food and fluids. Immunosuppression (anti-rejection) medications will be closely monitored to make sure the patient is receiving the optimum dose and the best combination of medications.
Blood samples will be taken frequently to monitor the status of the new kidney, as well as other body functions, such as the liver, lungs, and blood system.
The patient’s diet will be gradually advanced from liquids to more solid foods as tolerated. Liquid intake may be restricted until the new kidney is fully functional.
The patient may begin physical activity by the day after the procedure. He/she should get out of bed and move around several times a day.
Pain relievers may be taken for soreness as recommended by the doctor. Aspirin or certain other pain medications may increase the chance of bleeding. Hence the patients should take only recommended medications.
Nurses, pharmacists, dieticians, physical therapists, and other members of the transplant team will teach the patient how to take care of themselves once discharged from the hospital.

Rehabilitation

Once at home, it will be important to keep the surgical area clean and dry. The doctor will give specific bathing instructions. The stitches or surgical staples will be removed during a follow-up visit, if they were not removed before leaving the hospital. The patient should not drive until the doctor says so. The patient should avoid any activity or position that causes pressure to be placed on the new kidney. Other activity restrictions may apply.

Notify the doctor to report any of the following:

• Fever: This may be a sign of rejection or infection.
• Redness, swelling, or bleeding or other drainage from the incision site
• Increase in pain around the incision site: This may be a sign of infection or rejection.

Fever and tenderness over the kidney are some of the most common symptoms of rejection. An elevation of blood creatinine level (blood test to measure kidney function) and/or blood pressure (monitored by the doctor) may also indicate rejection. The symptoms of rejection may resemble other medical conditions or problems. The patient should consult the transplant team with any concerns that he/she may have. Frequent visits to and contact with the transplant team are essential.
The doctor may give additional or alternate instructions after the procedure, depending on the patient’s particular situation.
To allow the transplanted kidney to survive in a new body, the patient will be given medications for the rest of his/her life to fight rejection. Each person may react differently to medications, and each transplant team has preferences for different medications. The anti-rejection medications most commonly used singly, or in combination, include:

• Cyclosporine
• Tacrolimus
• Azathioprine
• Mycophenolate mofetil
• Prednisone
• OKT3
• Antithymocyte Ig (ATGAM)
• Sirolimus

New anti-rejection medications are continually being developed and approved. Doctors tailor medication regimes to meet the needs of each individual patient.
Usually several anti-rejection medications are given initially. The doses of these medications may change frequently, depending on the patient’s response. Because anti-rejection medications affect the immune system, people who receive a transplant will be at higher risk for infections. A balance must be maintained between preventing rejection and making the patient very susceptible to infection. Some of the infections the patient will be especially susceptible to include oral yeast infection (thrush), herpes, and respiratory viruses. Patients should avoid contact with crowds and anyone who has an infection for the first few months after surgery.

Outlook

The period immediately following the transplant can be very stressful. The patient will not only be recovering from major surgery, he or she will also be anxious about organ rejection. The patient, his or her family, and the transplant coordinators must keep in contact and close follow-up with the transplant team. Before leaving the hospital, the patient will be given instructions on proper doses of and schedule for anti-rejection medication. Keeping track of these medications is extremely important, because they can actually harm the transplanted kidney if the doses are not appropriate. The patient will be taught how to measure their blood pressure, temperature, and urine output at home, and he or she should keep a log of these readings. The social worker and dietician will counsel the patient before they leave the hospital. In the first few weeks after leaving the hospital, the patient will meet with members of their team frequently to monitor their recovery, review the logs, undergo blood tests, and adjust medication doses.
The outcome for kidney transplants continues to improve with advances in immune-suppressing medications. Usually, the 3-year graft survival rate after transplantation varies between 83% to 94%. The earlier the patient can detect rejection, the better the chance it can be reversed and the new kidney’s function preserved.