Kidney transplantation or renal transplantation is the organ transplant of a kidney into a patient with end-stage renal disease. Kidney transplantation is typically classified as deceased-donor (formerly known as cadaveric) or living-donor transplantation depending on the source of the donor organ.
Living-donor renal transplants are further characterized as genetically related (living-related) or non-related (living-unrelated) transplants, depending on whether a biological relationship exists between the donor and recipient.
Exchanges and chains are a novel approach to expand the living donor pool. In February 2012, this novel approach to expand the living donor pool resulted in the largest chain in the world, involving 60 participants organized by the National Kidney Registry. In 2014 the record for the largest chain was broken again by a swap involving 70 participants.
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The indication for kidney transplantation is end-stage renal disease (ESRD), regardless of the primary cause. This is defined as a glomerular filtration rate below 15 ml/min/1.73 m2. Common diseases leading to ESRD include malignant hypertension, infections, diabetes mellitus, and focal segmental glomerulosclerosis; genetic causes include polycystic kidney disease, a number of inborn errors of metabolism, and autoimmune conditions such as lupus.
Diabetes is the most common known cause of kidney transplantation, accounting for approximately 25% of those in the United States. The majority of renal transplant recipients are on dialysis (peritoneal dialysis or hemodialysis) at the time of transplantation. However, individuals with chronic kidney disease who have a living donor available may undergo pre-emptive transplantation before dialysis is needed. If a patient is put on the waiting list for a deceased donor transplant early enough, they may also be transplanted pre-dialysis.
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Contraindications include both cardiac and pulmonary insufficiency, as well as hepatic disease and some cancers. Concurrent tobacco use and morbid obesity are also among the indicators putting a patient at a higher risk for surgical complications.
Kidney transplant requirements vary from program to program and country to country. Many programs place limits on age (e.g. the person must be under a certain age to enter the waiting list) and require that one must be in good health (aside from the kidney disease). Significant cardiovascular disease, incurable terminal infectious diseases and cancer are often transplant exclusion criteria. In addition, candidates are typically screened to determine if they will be compliant with their medications, which is essential for survival of the transplant. People with mental illness and/or significant on-going substance abuse issues may be excluded.
HIV was at one point considered to be a complete contraindication to transplantation. There was fear that immunosuppressing someone with a depleted immune system would result in the progression of the disease. However, some research seem to suggest that immunosuppressive drugs and antiretrovirals may work synergistically to help both HIV viral loads/CD4 cell counts and prevent active rejection.
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Since medication to prevent rejection is so effective, donors do not need to be similar to their recipient. Most donated kidneys come from deceased donors; however, the utilisation of living donors in the United States is on the rise. In 2006, 47% of donated kidneys were from living donors. This varies by country: for example, only 3% of kidneys transplanted during 2006 in Spain came from living donors. In Spain all citizens are potential organ donors in the case of their death, unless they explicitly opt out during their lifetime.
Approximately one in three donations in the US, UK, and Israel is now from a live donor. Potential donors are carefully evaluated on medical and psychological grounds. This ensures that the donor is fit for surgery and has no disease which brings undue risk or likelihood of a poor outcome for either the donor or recipient. The psychological assessment is to ensure the donor gives informed consent and is not coerced. In countries where paying for organs is illegal, the authorities may also seek to ensure that a donation has not resulted from a financial transaction.
The relationship the donor has to the recipient has evolved over the years. In the 1950s, the first successful living donor transplants were between identical twins. In the 1960s–1970s, live donors were genetically related to the recipient. However, during the 1980s–1990s, the donor pool was expanded further to emotionally related individuals (spouses, friends). Now the elasticity of the donor relationship has been stretched to include acquaintances and even strangers (‘altruistic donors’). In 2009, US transplant recipient Chris Strouth received a kidney from a donor who connected with him on Twitter, which is believed to be the first such transplant arranged entirely through social networking.
The acceptance of altruistic donors has enabled chains of transplants to form. Kidney chains are initiated when an altruistic donor donates a kidney to a patient who has a willing but incompatible donor. This incompatible donor then ‘pays it forward’ and passes on the generosity to another recipient who also had a willing but incompatible donor. Michael Rees from the University of Toledo developed the concept of open-ended chains. This was a variation of a concept developed at Johns Hopkins University. On July 30, 2008, an altruistic donor kidney was shipped via commercial airline from Cornell to UCLA, thus triggering a chain of transplants. The shipment of living donor kidneys, computer-matching software algorithms, and cooperation between transplant centers has enabled long-elaborate chains to be formed.
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In carefully screened kidney donors, survival and the risk of end-stage renal disease appear to be similar to those in the general population. However, some more recent studies suggest that lifelong risk of chronic kidney disease is several-fold higher in kidney donors although the absolute risk is still very small. A 2017 article in the New England Journal of Medicine suggests that persons with only one kidney, including those who have donated a kidney for transplantation, should avoid a high protein diet and limit their protein intake to less than one gram per kilogram body weight per day in order to reduce the long-term risk of chronic kidney disease. Women who have donated a kidney have a higher risk of gestational hypertension and preeclampsia than matched nondonors with similar indicators of baseline health. Traditionally, the donor procedure has been through a single incision of 4–7 inches (10–18 cm), but live donation is being increasingly performed by laparoscopic surgery. This reduces pain and accelerates recovery for the donor. Operative time and complications decreased significantly after a surgeon performed 150 cases. Live donor kidney grafts have higher long-term success rates than those from deceased donors. Since the increase in the use of laparoscopic surgery, the number of live donors has increased. Any advance which leads to a decrease in pain and scarring and swifter recovery has the potential to boost donor numbers. In January 2009, the first all-robotic kidney transplant was performed at Saint Barnabas Medical Center through a two-inch incision. In the following six months, the same team performed eight more robotic-assisted transplants.
In 2004 the FDA approved the Cedars-Sinai High Dose IVIG therapy which reduces the need for the living donor to be the same blood type (ABO compatible) or even a tissue match. The therapy reduced the incidence of the recipient’s immune system rejecting the donated kidney in highly sensitized patients.
In 2009 at the Johns Hopkins Medical Center, a healthy kidney was removed through the donor’s vagina. Vaginal donations promise to speed recovery and reduce scarring. The first donor was chosen as she had previously had a hysterectomy. The extraction was performed using natural orifice transluminal endoscopic surgery, where an endoscope is inserted through an orifice, then through an internal incision, so that there is no external scar. The recent advance of single port laparoscopy requiring only one entry point at the navel is another advance with potential for more frequent use.
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In the developing world some people sell their organs illegally. Such people are often in grave poverty or are exploited by salespersons. The people who travel to make use of these kidneys are often known as ‘transplant tourists’. This practice is opposed by a variety of human rights groups, including Organs Watch, a group established by medical anthropologists, which was instrumental in exposing illegal international organ selling rings. These patients may have increased complications owing to poor infection control and lower medical and surgical standards. One surgeon has said that organ trade could be legalised in the UK to prevent such tourism, but this is not seen by the National Kidney Research Fund as the answer to a deficit in donors.
In the illegal black market the donors may not get sufficient after-operation care, the price of a kidney may be above $160,000, middlemen take most of the money, the operation is more dangerous to both the donor and receiver, and the buyer often gets hepatitis or HIV. In legal markets of Iran the price of a kidney is $2,000 to $4,000.
An article by Gary Becker and Julio Elias on “Introducing Incentives in the market for Live and Cadaveric Organ Donations” said that a free market could help solve the problem of a scarcity in organ transplants. Their economic modeling was able to estimate the price tag for human kidneys ($15,000) and human livers ($32,000).
Jason Brennan and Peter Jaworski of the CATO Institute have also argued that any moral objections to a market for organs are not inherent in the market, but rather the activity itself.
Now monetary compensation for organ donors is being legalised in Australia and Singapore. Kidney disease organisations in both countries have expressed their support.
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Deceased donors can be divided in two groups:
Although brain-dead (or ‘heart beating’) donors are considered dead, the donor’s heart continues to pump and maintain circulation. This makes it possible for surgeons to start operating while the organs are still being perfused (supplied blood). During the operation, the aorta will be cannulated, after which the donor’s blood will be replaced by an ice-cold storage solution, such as UW (Viaspan), HTK, or Perfadex. Depending on which organs are transplanted, more than one solution may be used simultaneously. Due to the temperature of the solution, and since large amounts of cold NaCl-solution are poured over the organs for a rapid cooling, the heart will stop pumping.
‘Donation after Cardiac Death’ donors are patients who do not meet the brain-dead criteria but, due to the unlikely chance of recovery, have elected via a living will or through family to have support withdrawn. In this procedure, treatment is discontinued (mechanical ventilation is shut off). After a time of death has been pronounced, the patient is rushed to the operating room where the organs are recovered. Storage solution is flushed through the organs. Since the blood is no longer being circulated, coagulation must be prevented with large amounts of anti-coagulation agents such as heparin. Several ethical and procedural guidelines must be followed; most importantly, the organ recovery team should not participate in the patient’s care in any manner until after death has been declared.
In general, the donor and recipient should be ABO blood group and crossmatch (human leukocyte antigen — HLA) compatible. If a potential living donor is incompatible with their recipient, the donor could be exchanged for a compatible kidney. Kidney exchange, also known as “kidney paired donation” or “chains” have recently gained popularity.
In an effort to reduce the risk of rejection during incompatible transplantation, ABO-incompatible and densensitization protocols utilizing intravenous immunoglobulin (IVIG) have been developed, with the aim to reduce ABO and HLA antibodies that the recipient may have to the donor.
In the 1980s, experimental protocols were developed for ABO-incompatible transplants using increased immunosuppression and plasmapheresis. Through the 1990s these techniques were improved and an important study of long-term outcomes in Japan was published. Now, a number of programs around the world are routinely performing ABO-incompatible transplants.
The level of sensitization to donor HLA antigens is determined by performing a panel reactive antibody test on the potential recipient. In the United States, up to 17% of all deceased donor kidney transplants have no HLA mismatch. However, HLA matching is a relatively minor predictor of transplant outcomes. In fact, living non-related donors are now almost as common as living (genetically)-related donors.
In most cases the barely functioning existing kidneys are not removed, as removal has been shown to increase the rates of surgical morbidity. Therefore, the kidney is usually placed in a location different from the original kidney. Often this is in the iliac fossa so it is often necessary to use a different blood supply:
The donor ureter is anastomosed with the recipient bladder.
There is disagreement in surgical textbooks regarding which side of the recipient’s pelvis to use in receiving the transplant. Campbell’s Urology (2002) recommends placing the donor kidney in the recipient’s contralateral side (i.e. a left sided kidney would be transplanted in the recipient’s right side) to ensure the renal pelvis and ureter are anterior in the event that future surgeries are required. In an instance where there is doubt over whether there is enough space in the recipient’s pelvis for the donor’s kidney, the textbook recommends using the right side because the right side has a wider choice of arteries and veins for reconstruction. Smith’s Urology (2004) states that either side of the recipient’s pelvis is acceptable; however the right vessels are ‘more horizontal’ with respect to each other and therefore easier to use in the anastomoses. It is unclear what is meant by the words ‘more horizontal’. Glen’s Urological Surgery (2004) recommends putting the kidney in the contralateral side in all circumstances. No reason is explicitly put forth; however, one can assume the rationale is similar to that of Campbell, i.e. to ensure that the renal pelvis and ureter are most anterior in the event that future surgical correction becomes necessary.
Occasionally, the kidney is transplanted together with the pancreas. University of Minnesota surgeons Richard Lillehei and William Kelly perform the first successful simultaneous pancreas-kidney transplant in the world in 1966. This is done in patients with diabetes mellitus type 1, in whom the diabetes is due to destruction of the beta cells of the pancreas and in whom the diabetes has caused renal failure (diabetic nephropathy). This is almost always a deceased donor transplant. Only a few living donor (partial) pancreas transplants have been done. For individuals with diabetes and renal failure, the advantages of earlier transplant from a living donor (if available) are far superior to the risks of continued dialysis until a combined kidney and pancreas are available from a deceased donor. A patient can either receive a living kidney followed by a donor pancreas at a later date (PAK, or pancreas-after-kidney) or a combined kidney-pancreas from a donor (SKP, simultaneous kidney-pancreas).
Transplanting just the islet cells from the pancreas is still in the experimental stage, but shows promise. This involves taking a deceased donor pancreas, breaking it down, and extracting the islet cells that make insulin. The cells are then injected through a catheter into the recipient and they generally lodge in the liver. The recipient still needs to take immunosuppressants to avoid rejection, but no surgery is required. Most people need two or three such injections, and many are not completely insulin-free.
The transplant surgery takes about three hours. The donor kidney will be placed in the lower abdomen and its blood vessels connected to arteries and veins in the recipient’s body. When this is complete, blood will be allowed to flow through the kidney again. The final step is connecting the ureter from the donor kidney to the bladder. In most cases, the kidney will soon start producing urine.
Depending on its quality, the new kidney usually begins functioning immediately. Living donor kidneys normally require 3–5 days to reach normal functioning levels, while cadaveric donations stretch that interval to 7–15 days. Hospital stay is typically for 4–10 days. If complications arise, additional medications (diuretics) may be administered to help the kidney produce urine.
Immunosuppressant drugs are used to suppress the immune system from rejecting the donor kidney. These medicines must be taken for the rest of the recipient’s life. The most common medication regimen today is a mixture of tacrolimus, mycophenolate, and prednisolone. Some recipients may instead take ciclosporin, sirolimus, or azathioprine. The risk of early rejection of the transplanted kidney is increased if corticosteroids are avoided or withdrawn after the transplantation. Ciclosporin, considered a breakthrough immunosuppressive when first discovered in the 1980s, ironically causes nephrotoxicity and can result in iatrogenic damage to the newly transplanted kidney. Tacrolimus, which is a similar drug, also causes nephrotoxicity. Blood levels of both must be monitored closely and if the recipient seems to have declining renal function or proteinuria, a biopsy may be necessary to determine whether this is due to rejection or ciclosporin or tacrolimus intoxication .
Post operatively, kidneys are periodically assessed by ultrasound to assess for the imaging and physiologic changes that accompany transplant rejection. Imaging also allows evaluation of supportive structures such as the anastomosed transplant artery, vein, and ureter, to ensure they are stable in appearance.
The major sonographic scale in quantitative ultrasound assessment is with a multipoint assessment of the resistive index (RI), beginning at the main renal artery and vein and ending at the arcuate vessels. It is calculated as follows:
The normal value is ≈ 0.60, with 0.70 being the upper limits of normal.
Kidney transplant recipients are discouraged from consuming grapefruit, pomegranate and green tea products. These food products are known to interact with the transplant medications, specifically tacrolimus, cyclosporin and sirolimus; the blood levels of these drugs may be increased, potentially leading to an overdose.
Acute rejection occurs in 10–25% of people after transplant during the first 60 days. Rejection does not necessarily mean loss of the organ, but it may necessitate additional treatment and medication adjustments.
Problems after a transplant may include: Post operative complication, bleeding, infection, vascular thrombosis and urinary complications
A patient’s age and health condition before transplantation affect the risk of complications. Different transplant centers have different success at managing complications and therefore, complication rates are different from center to center.
The average lifetime for a donated kidney is ten to fifteen years. When a transplant fails, a patient may opt for a second transplant, and may have to return to dialysis for some intermediary time.
Infections due to the immunosuppressant drugs used in people with kidney transplants most commonly occur in mucocutaneous areas (41%), the urinary tract (17%) and the respiratory tract (14%). The most common infective agents are bacterial (46%), viral (41%), fungal (13%), and protozoan (1%). Of the viral illnesses, the most common agents are human cytomegalovirus (31.5%), herpes simplex(23.4%), and herpes zoster (23.4%). BK virus is now being increasingly recognised. Infection is the cause of death in about one third of people with renal transplants, and pneumonias account for 50% of the patient deaths from infection.
Postoperative bleeding following kidney transplant as seen on ultrasound
Postoperative bleeding following kidney transplant as seen on ultrasound
Postoperative bleeding following kidney transplant as seen on ultrasound