Renal Transplantation

The kidneys have several important functions in the body.

• They filter wastes from your bloodstream and maintain the balance of electrolytes in your body.
• They remove chemical and drug by-products and toxins from your blood.
• They eliminate these substances and excess water as urine.
• They secrete hormones that regulate the absorption of calcium from your food (and thus bone strength), the production of red blood cells (thus preventing anemia), and the amount of fluid in your circulatory system (and thus blood pressure). 

 

When blood enters the kidneys, it is first filtered through structures called glomeruli. The second step is filtering through a series of tubules called nephrons.

• The tubules both remove unwanted substances and reabsorb useful substances back into the blood.
• Each of your kidneys contains several million nephrons, which cannot be restored if they are damaged.

Renal failure
Various conditions can damage your kidneys, including both primary kidney diseases and other conditions that affect the kidneys.

• If kidney damage becomes too severe, your kidneys lose their ability to function normally. This is called kidney failure.
• Kidney failure can happen rapidly (acute kidney failure), usually in response to a severe acute (sudden, short-term) illness in another body system or in the kidneys. It is a very common complication in patients hospitalized for other reasons. It is often completely reversible with resolution of the underlying condition.
• Kidney failure can also happen very slowly and gradually (chronic kidney failure), usually in response to a chronic (ongoing, long-term) disease such as diabetes or high blood pressure.
• Both types of kidney failure can occur in response to primary kidney disease as well. In some cases this kidney disease is hereditary.
• Infections and substances such as drugs and toxins can permanently scar the kidneys and lead to their failure.

People with the following conditions are at greater-than-normal risk of developing kidney failure and end-stage renal disease:

• Diabetes (type 1 or type 2)
• High blood pressure - Especially if severe or uncontrolled
• Glomerular diseases - Conditions that damage the glomeruli, such as glomerulonephritis
• Hemolytic uremic syndrome
• Systemic lupus erythematosus
• Sickle cell anemia
• Severe injury or burns
• Major surgery
• Heart disease or heart attack
• Liver disease or liver failure
• Vascular diseases - Conditions that block blood flow to different parts of your body, including progressive systemic sclerosis, renal artery thrombosis (blood clot), scleroderma
• Inherited kidney diseases - Polycystic kidney disease, congenital obstructive uropathy, cystinosis, prune belly syndrome
• Diseases affecting the tubules and other structures in the kidneys - Acquired obstructive nephropathy, acute tubular necrosis, acute interstitial nephritis
• Amyloidosis
• Taking antibiotics, cyclosporin, heroin, chemotherapy - Can cause inflammation of kidney structures
• Gout
• Certain cancers - Incidental carcinoma, lymphoma, multiple myeloma, renal cell carcinoma, Wilms tumor
• HIV infection
• Vesicoureteral reflux - A urinary tract problem
• Past kidney transplant (graft failure)
• Rheumatoid arthritis

Chronic kidney failure is associated with complications that can be debilitating or have a negative effect on quality of life.

• Anemia
• Fluid retention
• Pulmonary edema - Fluid retention in the lungs that can cause breathing problems
• High blood pressure - From chemical imbalances and fluid retention
• Renal osteodystrophy - Weakening of the bones from calcium depletion, can fracture easily
• Amyloidosis - Deposition of abnormal proteins in the joints, causes arthritislike symptoms
• Stomach ulcers
• Bleeding problems
• Neurological damage
• Sleeping problems - Related to dialysis

Kidney Transplant Symptoms

The symptoms of kidney failure vary widely by 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 the 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 - Puffiness, swelling of arms and legs, shortness of breath (due to fluid collection in the lungs, called pulmonary edema)
• Dehydration - Thirst, rapid heart rate (tachycardia), dry mucous membranes (such as inside the mouth and nose), feeling weak or lethargic

Other common symptoms of kidney failure and end-stage renal disease 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 anemia)

End-stage renal disease cannot be prevented in some cases. You may be able to prevent your kidneys from failing, or slow the progression of the failure, by controlling your underlying conditions.

• Kidney failure has usually progressed fairly significantly by the time symptoms appear. If you are at high risk of developing chronic kidney failure, see your health care provider as recommended for screening tests.
• If you have a chronic condition such as diabetes, high blood pressure, or high cholesterol, follow the treatment recommendations of your health care provider. See your health care provider regularly for monitoring. Aggressive treatment of these diseases is essential to preserving kidney function and preventing complications.
• Avoid exposure to alcohol, drugs, chemicals, and other toxic substances as much as possible.

To learn more about kidney failure, click here.

Kidney Transplantation

When your health care provider makes the diagnosis of end-stage renal disease, he or she will discuss your treatment options. Whether kidney transplantation is an option for you depends on your specific situation. If your health care provider thinks you may be eligible for a transplant, you will learn about the pros and cons of this treatment. If you are a potential candidate, you will undergo a thorough medical evaluation. In the meantime, you will be treated with dialysis.
Kidney transplantation is replacement of nonworking kidneys with a healthy kidney from another person (the donor). The healthy kidney (the "graft") takes over the functions of your nonworking kidneys. You can live normally with only one kidney as long as it functions properly.
The transplantation itself is a surgical operation. The surgeon places the new kidney in your abdomen and attaches it to the artery that supplied blood to one of your kidneys and to the vein that carries blood away from the kidney. The kidney is also attached to the ureter, which carries urine from the kidney to the bladder. Your own kidneys are usually left in place unless they are causing you problems, such as infection.
Every operation has risks, but kidney transplantation is not a particularly difficult or complicated operation. It is the period after the surgery that is most critical. Your medical team will watch very carefully to make sure that your new kidney is functioning properly and that your body is not rejecting the kidney.
Are you eligible for a transplant?
Before you can receive a kidney transplant, you must undergo a very detailed medical evaluation.

• This evaluation may take weeks or months and require several visits to the transplant center for tests and examinations.
• The purpose of this thorough evaluation is to test whether you would benefit from a transplant and can withstand the rigors of the surgery and antirejection medications and the adjustment to a new organ.

Your medical team, which includes a nephrologist, a transplant surgeon, a transplant coordinator, a social worker, and others, will conduct a series of interviews with you and your family members.

• You will be asked many questions about your medical and surgical history, the medications you take and have taken in the past, and your habits and lifestyle.
• It will seem like they ask every imaginable question at least twice! It is important that they know every detail about you that could bear on a future transplant.
• They also want to make sure you are mentally prepared for following the necessary medication regimen.

You will also have a complete physical examination. Lab tests and imaging studies complete the evaluation.

• Your blood and tissue will be typed so that you can be matched to a donor kidney. This significantly lessens the chance of rejection.
• You will have blood and urine tests to monitor your creatinine level, other organ functions, and electrolyte levels.
• You will have x-rays, ultrasounds, CT/MRI scans, and other imaging tests as needed to make sure your other organs are healthy and functioning.

Any of the following conditions significantly increase your chance of rejecting the new kidney and may make you ineligible for transplant:

• Active cancer
• HIV infection
• Serious heart or lung disease
• Positive results for hepatitis C
• Severe infection

Potential kidney donors also must be in good health and undergo a thorough medical evaluation.
If you are considered eligible for a transplant, every effort will be made to find a donor among your family members (who are most likely to match) and friends. If no suitable donor can be found, your name will be added to the waiting list for a donor kidney.

• This list is administered by the Organ Procurement and Transplantation Network, which maintains a centralized database of everyone waiting for a transplant and of living donors.
• OPTC is run by the United Network for Organ Sharing, a private nonprofit organization.
• Every new kidney that becomes available is tested and checked against this list to find the most perfect match.

       

Kidney Transplant Medical Treatment

The most critical part of kidney transplantation is preventing rejection of the graft kidney.

• Different transplant centers use different drug combinations to fight rejection of a transplanted kidney.
• The drugs work by suppressing your immune system, which is programmed to reject anything "foreign," such as a new organ.
• Like any medication, these drugs can have unpleasant side effects.
• Some of the most common immune-suppressing drugs used in transplantation are described here.
  • Cyclosporine: This drug interferes with communication between the T cells of the immune system. It is started immediately after the transplant to suppress your immune system and continued indefinitely. Common side effects include tremor, high blood pressure, and kidney damage. These side effects are usually related to the dose and can often be reversed with proper dosing.
  • Corticosteroids: These drugs block T-cell communication as well. They are usually given at high doses for a short period immediately after the transplant and again if rejection is suspected. Corticosteroids have many different side effects, including easy bruising of the skin, osteoporosis, avascular necrosis (bone death), high blood pressure, high blood sugar, stomach ulcers, weight gain, acne, mood swings, and a round face. Because of these side effects, many transplant centers are trying to reduce the maintenance dose of the drug as much as possible or even to replace it with other drugs.
  • Azathioprine: This drug slows the production of T cells in the immune system.Azathioprine isusually used for long-term maintenance of immunosuppression. The most common side effects of this drug are suppression of the bone marrow, which produces blood cells, and liver damage. Many transplant centers are now using a newer drug called mycophenolate mofetil instead of azathioprine.
  • Newer antirejection drugs include tacrolimus, sirolimus, and mizoribin, among others. These drugs are now being used to try to reduce side effects and to replace drugs after episodes of rejection.
  • Other costly and experimental treatments include using antibodies to attack specific parts of the immune system to decrease its response.

Outlook After Kidney Transplantation

Self-care at home The period immediately following your transplant can be very stressful. You will not only be recovering from major surgery, you will also be anxious about organ rejection.

• You, your family, and the transplant coordinators must keep in contact and close follow-up with the transplant team.
• Before leaving the hospital, you will be given instructions on proper doses of and schedule for antirejection medication. Keeping track of these medications is extremely important, because they can actually harm your transplanted kidney if the doses are not appropriate.
• You will be taught how to measure your blood pressure, temperature, and urine output at home, and you should keep a log of these readings.
• Your social worker and dietitian will counsel you before you leave the hospital.

In the first few weeks after leaving the hospital, you will meet with members of your team frequently to monitor your 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.

• In the United States, the 3-year graft survival rate after transplantation is almost 80%.
• The earlier you can detect rejection, the better the chance it can be reversed and the new kidney's function preserved.

Complications

• Rejection
• Infection
• Cancer: Certain cancers, such as basal cell carcinoma, Kaposi sarcoma, carcinoma of the vulva and perineum, non-Hodgkin lymphoma, squamous cell carcinoma, hepatobiliary carcinoma, and carcinoma in situ of the uterine cervix, occur more frequently in people who have undergone kidney transplantation.
• Relapse: A small number of people who undergo transplantation for certain kidney disease experience a return of the original disease after the transplant.
• High blood cholesterol level
• Liver disease
• Weakening of the bones

Women who wish to become pregnant are usually told to wait for 2 years after the operation. Many women have taken their pregnancies to term after transplantation, but there is an increased risk of kidney rejection and fetal complications.
Signs of kidney rejection
One of your greatest concerns as a transplant recipient will be that your body's immune system will reject and attack the transplanted kidney. If not reversed, rejection will destroy the transplanted organ. For this reason, you and your family must keep aware of warning signs and symptoms of rejection. You must contact the transplant team immediately if any of these symptoms develop.

• Hypertension (high blood pressure) - An ominous sign that the kidney is not functioning properly
• Swelling or puffiness - A sign of fluid retention, usually in the arms, legs, or face
• Decreased urine output

If you are a kidney transplant recipient, any of the following symptoms warrant immediate care at a hospital emergency department, preferably the hospital where the transplant was done.

• Fever - A sign of infection
• Abdominal pain
• Tenderness, redness, or swelling at the surgical site
• Shortness of breath - A sign of fluid retention in the lungs

Follow-up

You must keep follow-up appointments with your transplant team to monitor for signs of rejection.

• You will have regular blood and urine tests to detect any signs of organ failure. One or more ultrasounds of the graft kidney may be done to see if there are structural abnormalities suggesting rejection.
• An arteriogram or nuclear medicine scan may be needed to confirm that blood is flowing to the transplanted kidney.