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Kidney Transplantation: Choices and Challenges

~ by Jo Jordan

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One in three Americans is destined to develop diabetes, reports the Centers for Disease Control and Prevention (CDC).¹

What’s this got to do with kidney transplantation? Well, diabetes is the most common cause of kidney failure:

• In the United States, diabetes accounts for twenty-five percent of all kidney transplants (also known as a renal transplantation).


• Nearly forty-seven thousands Americans were on a waiting list for a kidney in 2000.²

If you do the math, the effect of these combined statistics is staggering – just consider the potential number of kidneys that may be required in the near future for transplantation purposes.

Unfortunately, organ shortages mean that today only a small percentage of kidney transplantation patients receive organs each year. This stagering fact makes it all that much more important to practice prevention and consider some form of internal cleansing or kidney detox program.

When Your Kidneys Fail to Function

Your kidneys act as a filter for your blood, taking out whatever is not supposed to be there such as the natural byproducts of metabolism, drugs, and other toxins, including the elimination of excess water as urine.

The kidneys are responsible for many other vital functions; other organs depend on them, too. If you are in the market for a kidney transplant, you may already be receiving dialysis, a necessary part of sustaining life with malfunctioning kidneys.

Acute Kidney Failure

Kidney failure (also referred to as acute renal failure) may be the result of a sudden, short-term illness – a situation in which someone has suddenly, and temporarily, lost kidney function. Acute kidney failure is often an immediate response to complications from other illnesses, and is usually reversible. Dialysis, an artificial means of filtering waste from the blood, is a common treatment for acute renal failure.

Chronic Kidney Failure / End-Stage Renal Disease (ESRD)

For patients who are in the end stages of chronic kidney disease, and have permanently lost kidney function, dialysis and kidney transplantation are the only options for prolonging life. In these cases, kidney function has been permanently lost, and cannot be treated with drugs. In other words, their kidney failure so advanced that it can never be corrected.

ESRD is normally the response to an ongoing, long-term health problem such as diabetes or high blood pressure. In addition, drugs and other toxins, including infection, can cause permanent scarring and, eventually, lead to complete renal failure.

ESRD Risk Factors³

The National Kidney Foundation estimates that approximately 350,000 Americans have end-stage renal disease.⁴ Many conditions and substances put people at a higher than average risk for developing ESRD:

• Amyloidosis (a disease resulting from the abnormal depositing of the protein amyloid in body tissue)



• Antibiotics



• Certain cancers



• Chemotherapy



• Cyclosporin



• Diabetes (types 1 and 2)



• Diseases affecting structures in the kidneys (acute interstitial nephritis, acute tubular necrosis, acquired obstructive nephropathy)



• Glomerular diseases (conditions that damage certain capillary blood vessels in the kidney)



• Gout



• Heart disease or heart attack



• Hemolytic uremic syndrome (a condition characterized by the breakup of red blood cells and kidney failure)



• Heroin use



• HIV infection



• High blood pressure



• Inherited kidney diseases (cystinosis, congenital obstructive uropathy, polycystic kidney disease, prune belly syndrome)



• Liver disease or liver failure



• Major surgery



• Past kidney transplant (graft failure)



• Rheumatoid arthritis



• Severe injury or burns



• Sickle cell anemia



• Systemic lupus erythematosus (SLE)



• Vascular diseases (conditions that block blood flow)



• Vesicoureteral reflux (a urinary tract problem)

The Symptoms of ESRD⁵

In the early stages, the majority of sufferers report no symptoms whatsoever. While kidney failure is not painful, there is sometimes pain as a result of damage to other body systems.

Some people do experience mild, subtle, or vague symptoms:

• Bleeding
• Bone pain or fractures
• Confusion
• Dehydration (thirst, rapid heart rate, dry mucous membranes – i.e. inside the mouth and nose – feeling weak or lethargic)
• Easy bruising
• Fatigue
• Fluid retention (puffiness, swelling of arms and legs, shortness of breath, due to pulmonary edema) Nausea
• Itching
• Loss of appetite
• Pain (muscles, joints, flanks, chest)
• Pale skin (from anemia)
• Urinary problems (frequency and urgency changes)
• Vomiting

Evaluation for Transplant Eligibility

Glomerular filtration rate (GFR) estimates the filtering capacity of the kidneys. When the GFR of the kidneys is twenty to twenty-five percent of normal, patients are considered to be at the end-stage of renal disease.

Completing the evaluation process for a kidney transplant can take many weeks and sometimes even months. While potential transplant candidates undergo detailed medical evaluations, they are normally treated with dialysis.

You and your family will be required to answer numerous questions about your medical and surgical history, as well as list past and present medications, and lifestyle habits.

Several visits to a transplantation center for lab work and examinations may be required in order to type your blood and tissue for a donor match. Blood and urine tests are also required to monitor electrolyte and creatinine levels (a chemical waste molecule generated from muscle metabolism) and organ functions.

Imaging tests such as X-rays, ultrasounds, CAT scans (computerized axial tomography) and/or MRI (magnetic resonance imaging) will be carried out as needed to ensure all organs are healthy and functioning, and to determine whether or not you would benefit from transplantation. Other tests to judge your ability to undergo surgery and handle anti-rejection medications will also be necessary.

Certain conditions – such as active cancer, hepatitis C, and other serious infections – may make you ineligible for transplant due to the increased possibility of organ rejection.

Once your eligibility testing has been completed and approved, your name is put on a donor transplant waiting list. How long you will have to wait is entirely dependent upon the number of available kidneys, and the ease with which a compatible kidney can be found for you.

The Kidney Transplant – What Are Your Choices?

Kidney transplants are available from two sources: individuals who have died suddenly (deceased donors) and organs from living people (live donors).

Deceased Donor Transplants

This type of transplant has a high success rate; after one year, eighty-five⁶ to ninety of every one hundred deceased donor transplants will still be working. Deceased donor transplants last an average of ten to twelve years.

There is a long waiting list for a deceased donor kidney, but once a kidney from someone who has died suddenly becomes available and the donor’s family has consented, various tests are done to confirm the health of the organs. The donor’s identity will remain confidential.

Living Donor Transplants

The success rate for living donor transplants is somewhat higher than it is for deceased: after one year, ninety to ninety-five⁷ percent of every one hundred living donor transplants will still be working. Living donor transplants function for an average of fifteen to twenty years.

Though the waiting period is shorter for living donor transplants than for deceased, extensive testing is still required to confirm the health of the organ, as well as to ensure the blood and tissue type are compatible. The transplant itself is scheduled for a mutually convenient time for you and your donor.

Healthy donors are rarely at risk, and life with one kidney is simply business as usual.

The live donor may be a family member, such as a parent, child, brother, or sister (live related donor). A live donor may also be someone who is not genetically related to you, such as a spouse or friend (live unrelated donor).

Kidney Transplant Surgery – What to Expect...

While many kidney transplant recipients have normal post-surgery lives, transplantation is not an absolute cure. A kidney transplant is not considered a complicated procedure; however, all surgery has risks attached to it.

The Surgery

The transplant operation generally takes two to four hours. In most cases, unless they are causing difficulties such as an infection, the old kidneys are left intact because removal tends to increase the death rate due to surgery.

Kidneys are located on either side of the spleen, under the lower ribs. Donor kidneys are usually transplanted in a new location, often in a space in the groin area, just below the lower abdomen.

The surgeon attaches the new kidney to the artery that supplied blood to one of the kidneys, and to the vein that transports blood away from the kidney. The kidney is also attached to the ureter, a tube through which the urine flows into the bladder.

In order to drain the urine produced by the transplanted kidney, the bladder is fit with a catheter for several days. In addition, a drainage tube is sometimes placed close to the new kidney to carry out any build-up of fluids.

Post Surgery

Kidney transplant patients generally require a two- to seven-day hospital stay. The most critical time for new kidney recipients is the period following surgery. Will the new kidney function properly? Will it be rejected?

Sometimes, dialysis is required immediately after surgery until the new kidney begins to function. Normally, the transplanted kidney begins to function immediately, reaching proper functioning levels within three to fifteen days. Additional medication may be required to help the kidney produce urine.

Various post-surgery tests are carried out to ensure the new kidney is working properly.

Facing the Challenges of Kidney Transplantation – Complications and Post-surgery Care

Protection from Rejection

The immune system poses the largest stumbling block to a successful transplant between a donor and recipient who are not genetically identical. Recognizing that the transplanted kidney is not its own, the recipient’s immune system will attack this perceived intruder, battle against it, and immediately or chronically reject it.

Signs of kidney rejection include the following:

• Abdominal pain
• Decreased urine output
• Fever – an indication of infection
• High blood pressure
• Shortness of breath – a sign of fluid retention in the lungs
• Swelling or puffiness – a sign of fluid retention, usually in the arms, legs, or face
• Tenderness, redness, or swelling at the surgical site

Anti-rejection medication and monitoring is begun following the transplant, a regimen which kidney transplant patients must follow for the rest of their lives. These medicines suppress the immune system so that it will not reject the donor kidney.

The most common medication regimen today is mycophenolate, prednisone, and tacrolimus. Some recipients receive azathioprine, cyclosporine, or rapamycin. Newer anti-rejection drugs include mizoribin, sirolimus, tacrolimus, and there are others as well.

Immunosuppressives are used to prevent as well as to treat rejection. Some medications may cause side effects, and some of the effects are severe. Ask your health care provider to explain the risks associated with specific medications.

Other Complications

Immunosuppressives work by blocking immune system activity, placing recipients at greater risk of infection and cancer (especially lymphoma and/or skin cancer).

Other problems associated with immunosuppressant drug use include the following:

• Acne
• Diabetes type 2
• Electrolyte imbalances, including calcium and phosphate (which can lead to a weakening of the bones)
• Excessive hair growth
• Gastrointestinal inflammation
• Hair loss
• High blood cholesterol level
• Infections and/or sepsis (blood stream infection)
• Liver disease
• Obesity
• Post-transplant lymphoproliferative disorder (a form of lymphoma)
• Relapse – a return to the original disease post transplantation
• Ulceration of the stomach and esophagus

There is an increased risk of kidney rejection and fetal complications for women who become pregnant post-surgery. It is recommended that women wait two years after transplantation to conceive.

Post-surgery Care

Rejection can occur at anytime, but the two months following kidney transplantation are vital since rejection usually occurs during the first sixty post-surgery days.⁸ The sooner rejection is detected, the higher the likelihood that it can be reversed, and the new kidney's function preserved via additional treatment.

Most rejections can be treated successfully, but if the transplanted kidney stops working altogether, a return to dialysis may be necessary for a time as an intermediary solution; a second transplant is an option.

Once you arrive home, it will be important to ensure that the appropriate dosage of anti-rejection medications is taken at scheduled times because these medications can harm the new kidney if taken incorrectly.

You will be required to measure and log your blood pressure, temperature, and urine output, as well as adhere to some dietary restrictions. Frequent appointments with various health care providers to monitor your recovery and review your logs will be necessary.

Adjustments to medications may be required, as well as regular blood and urine tests in order to watch for any signs of kidney failure. Ultrasounds of the transplanted kidney may also be necessary to be on the alert for any structural abnormalities suggesting rejection, as well as an arteriogram or nuclear medicine scan to confirm that blood is flowing to the transplanted kidney.

Long-term Prognosis

While the National Kidney Foundation estimates that around 67,000⁹ people die of kidney failure every year, the success rate for transplantation is really very good.

In the United States, eighty percent of kidney transplant recipients have a three-year survival rate following transplantation.¹⁰ While some donor kidneys have lasted for more than thirty years, the average life span for a transplanted kidney is ten to fifteen years.

Today, the key to successful kidney transplantation appears to lie in the careful monitoring of immunosuppressives, and the early detection of rejection symptoms.

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Notes:
1. American Diabetes Association, “1 in 3 Americans Born in 2000 Will Develop Diabetes,”
http://www.diabetes.org/for-media/scientific-sessions/06-14-03-2.jsp
(accessed September 30, 2008).
2. eMedicineHealth, “Kidney Transplant,”
http://www.emedicinehealth.com/kidney_transplant/article_em.htm (accessed September 30, 2008).
3. Ibid.
4. Ibid.
5. Ibid.
6. The Kidney Foundation of Canada, “Kidney Transplantation,”
http://www.kidney.ca/page.asp?intNodeID=22133 (accessed September 30, 2008).
7. Ibid.
8. Wikipedia.org, “Kidney transplantation,”
http://en.wikipedia.org/wiki/Kidney_transplantation (accessed September 30, 2008).
9. eMedicineHealth, “Kidney Transplant,”
http://www.emedicinehealth.com/kidney_transplant/article_em.htm (accessed September 30, 2008).
10. Ibid.