Kidney transplantation in detail
What is a kidney transplant?
Replacing a non-working or abnormally working kidney with a healthy kidney. There are various kinds of reasons to undergo a kidney transplant which are dealt with in detail later. When the glomerular filtration rate falls below 18ml per minute there may be a need for transplant. Dialysis is the non surgical approach to managing the same condition. But dialysis is proved to not have a very good effect in the long term. Transplant gives the patient more years and a better quality of life than the patient on dialysis.
A thorough analysis and examination are done to check if the patient is eligible to receive a kidney. Then the patient has to wait until a kidney is found that matches the patient. Blood group matching and other tests are done to avoid other health issues and later with all the approval and agreement transplant surgery are scheduled.
It is a complex surgery that needs a group of highly qualified professionals such as a surgeon, nephrologist, nurses, anesthesiologist, physician, technician, attenders, etc. The failed kidney is removed by nephrectomy and the donor’s kidney is anastomosed with the arteries of the recipient. The renal function gets back to normal in 15-20 days post-operation usually. There can be various complications and precautionary measures that have to be taken into account to avoid rejection and other risks after the kidney transplant is done.
What are the Indications for kidney transplantation?
- A patient with chronic renal failure or CKD.
- A patient has renal cell carcinoma.
- A patient with kidney failure.
- Patient on dialysis.
- A patient with necrosed kidneys.
- A patient with renal calcifications of a higher degree.
- Sepsis of the renal gland.
- Damage to the kidney due to trauma, injury, etc.
- Congenital malformations are due to various reasons.
- A patient who has glomerulonephritis.
- Long-standing uncontrolled diabetes can be type 1 and type 2.
- Renal hypertension which has failed to be under control by other medical measures.
- Cysts in the kidneys of the patient.
- Nephritic syndrome.
- Nephrotic disease.
- Goodpasture’s syndrome.
- Autoimmune disorders of kidneys.
- Patient suffering from Nephrotoxicity.
- Obstruction in the renal pelvis or ureter.
- Patient with Emboli in the renal arteries.
- Sickle cell disease.
- Adrenal gland carcinoma.
- Long-standing renal tubular acidosis.
- Alport syndrome.
- Infection of the kidney which has to be cured but the condition has left kidneys nonfunctional.
- Patients with Severe swelling and destruction of kidneys due to unknown etiologic factors.
What are the Contraindications for renal transplant in the patient?
- A kidney transplant is not the right option for patients with cardiac failure, liver failure, pulmonary dysfunction, pancreatic abnormalities.
- Patient with a brain haemorrhage.
- Patient with bleeding tendencies.
- Epileptic or CNS impairments.
- The patient who is addicted to alcohol, tobacco, and drugs.
- Poor socioeconomic status and environmental factors.
- The patient who does not follow the medical regime of treatment and is neglecting the pieces of advice.
- Very old patient.
- Malnutrition and lack of energy in the patient.
- The patient who does not wish to take this treatment by self-understanding.
- Very less life expectancy.
What are the criteria for a donor to donate a kidney?
- A donor should be physically fit.
- The donor should be above 18 years of age.
- The donor should not have cardiovascular diseases.
- The donor should be of appropriate weight and height with normal levels of haemoglobin and other blood components.
- The donation can be considered also from a brain dead person who has previously decided to donate their kidney voluntarily or with the consent of their family members post brain death.
- The donor should be psychologically stable.
- The donor should not have any history of malignancy or benign tumour.
- Renal function should be fine for the donor.
- The donor should be fine with all the changes and complications that he or she can have post-operation.
- The donor should not have any practice of consuming alcohol and other drugs.
- The donor should not have any communicable or sexually transmitted diseases like acquired immunodeficiency syndrome( AIDS), syphilis, gonorrhea, etc.
- The donor should not have any pre-existing renal complications.
- The donor should be able to cope with the post-operative life. This should be made sure beforehand with assessment and evaluation.
What are the criteria to be eligible to receive a kidney?
- The patient has a life expectancy of more than 7 years.
- A patient who has a good cardiovascular and pulmonary system.
- A young patient is preferred more than the older ones.
- A patient who does not have incurable diseases like STDs.
- A patient who does not have cancer.
- A patient who is otherwise fit.
- A patient who has a supportive family and financial stability and who will abide by the care post operation.
- A patient who is psychologically stable.
What are the types of kidney donors?
Kidney donation is done by live donors and dead donors. There are different cases where donors are selected for a particular recipient.
Live donor: this is a category that is further divided into two. One can donate a kidney voluntarily when a patient needs a kidney. For example, when a family member has kidney failure the other member can donate a kidney. Patients who are brain dead but are on mechanical ventilation can also donate kidneys with required consent and procedures.
Dead or deceased donors: when a person meets with an accident or is pronounced dead due to other issues where kidneys are fine. The kidneys are viable only for a specific period and it has to reach the patient in time and in proper working condition. The process for it is mentioned later.
How is the kidney matched for the recipient?
- HLA matching is done.
- Other Blood tests are done to check compatibility.
- Antigen and antibody testing should match.
- Usually, blood relatives are the best match.
- Initially, only a son, father, or any first-degree relatives were considered. But nowadays spouses, cousins, and even friends are considered.
- And also strangers are donors too recently.
How are kidneys transplanted from different donor types?
- In dead donors, hospitals are informed about the donor and in case of requirements, the kidneys are extracted with permission and ethical standards. The kidneys are taken out in a nearby centre and preserved in Low temperature and special liquids like lactate and acetate solutions. It is then quickly transported to the hospital where it is required.
- In live donors, especially in volunteering cases, it is a well planned process. At the exact time, the kidney is removed and immediately anastomosed in the recipient.
What is preoperative evaluation and education to be given?
- Vitals monitoring.
- Urinary output and electrolyte levels should be monitored.
- Blood should be kept ready in case of extreme blood loss.
- The patient should be ambulating for a short distance from time to time.
- The liquid diet should be consumed and nothing should be consumed before surgery for a few hours.
- Water intake should be as per the suggestion from the respective doctors.
- The patient should be counselled along with the family members about the operation in detail.
- Preoperative deep breathing exercises have been shown to relieve the complications of lungs post operation.
- Splinting techniques should be taught.
- Diet and lifestyle education should be given in detail.
- Motivation and relaxation are the keys to maintaining the vitals and mental stability of the patient.
- Consent of high risk should be explained to the patient and patient party and should be taken consent of.
What is the procedure for a kidney transplant?
- The patient is initially assessed and examined for kidney disease.
- If no other treatments work, a kidney transplant is advised.
- The patient has to fit the criteria and wait for the donor on the list.
- Once the donor is ready voluntarily, a date for transplant is fixed.
- All general examinations are done like blood pressure and blood glucose levels before surgery.
- If everything is fine, the patient is taken into the surgery room.
- The patient is given general anaesthesia by the anesthesiologist.
- The patient’s position is supine.
- The patient is temporarily put on mechanical ventilation.
- The surgical area is painted and sterilised.
- Endotracheal intubation and catheterization are done.
- Incisions change from surgeon to surgeon. But the majorly used are subcostal incision, paramedian incision, Chevron’s incision, modified transperitoneal incision, etc.
- The arteries and veins are clipped or sutured and detached from the renal arteries and veins.
- Same procedure for both the donor and recipient.
- Then the donor’s kidney is anastomosed with the arteries, veins, and ureter of the recipient.
- The peritoneum, deep fascia, superficial fascia, and skin are sutured with absorbable or non-absorbable suture material.
- Staples are used in recent times. They have to be removed after two to three weeks post surgery.
- Drain is put to drain the excess blood and water.
- The patient is on observation for 2 days and then shifted to the ward.
What is the post operative care to be taken after a kidney transplant?
- The patient should be checked frequently for fever, rashes, colour changes in the abdominal area.
- Checking for edema in the extremities.
- Checking for leakage in the dressing.
- Check if the patient is oriented and is responsive after the anaesthesia effect reduces.
- The patient should be on prophylactic antibiotics.
- Pain can be addressed with analgesic medication.
- The suture site should be observed for necrosis, tightness, infection, sepsis.
- Check the drain tubes and catheters.
- Splinting should be done before coughing by pressing a towel against the sutures to avoid the removal of sutures due to increased abdominal pressure.
- Psychological support and encouragement are a must.
- A bland diet with less sugar and salt, a semisolid diet which should be preferably cooked for a longer time period.
- Adequate sleep and rest are a must.
- To avoid anaesthesia complications of the lungs which can lead to pneumonia and fluid retention in the lung which can lead to infection, the patient must practice airway and lung clearance techniques. They include deep breathing, coughing, huffing, active cycle breathing techniques, autogenic drainage, positioning, etc, by consulting a physiotherapist.
What are the normal or physiological changes after a kidney transplant?
- Another kidney may go into hypertrophy and hyperplasia.
- Renal function drops initially and then starts to rise gradually.
- Pain in the back region.
- Pain at the suture site.
- Blood in the catheter bag initially.
- Weakness and dizziness.
- 7-10 days of hospital stay in which gradual recovery is seen.
What are the complications of a kidney transplant?
Immediate complications include:
- Thrombus formation or its embolization.
- Heart attack.
- Severe blood loss leads to hypovolemia.
- Epileptic seizures.
- Injury by the instruments to the nearby structures while performing surgery.
- Blood pressure drops during surgery.
- Internal bleeding and haemorrhage.
Early complications include:
- Graft versus host reaction. This is a type four hypersensitivity reaction where the body rejects the new kidney.
- Infection of the kidney and suture site.
Late complications include:
- Renal calculi
- Urinary tract infections
- Strictures in the ureter.
- Necrosis of kidney.
- Abnormal urine output.
- Irritation and other urinary issues.
What is the lifelong management after renal transplant?
- The patient has to be on immunosuppressive drugs for the rest of his or her life.
- The patient has to be on anticoagulant therapy for the rest of his or her life.
- The patient has to visit his doctor at frequent intervals for a check-up and status of the kidney.
- Diet should be with low potassium, low sodium, and low calcium. Food should be consumed in intervals and not at a time.
- Leafy vegetables should be washed well and fully cooked. Avoid milk products, curd, dry fruits, carbonated drinks, and packaged food with preservatives.
- Compulsory exercise as directed by the physiotherapist.
- The patient should rest and sleep adequately throughout the night.
- Medicines should be taken on time and shouldn’t be missed.
- Walking and swimming after proper healing of the surgical site are very suitable for young patients.
- Exercises involving lower abdominal muscles should be done with precautions.
- Frequent renal function tests and blood pictures are better for prognostic purposes.
- Strict cessation of alcohol, tobacco is mandatory.
- The patient should be psychologically balanced.
Kidney transplant and India.
Most of the kidney diseases and need for transplantation go undetected due to poverty, lack of education, lack of medical services, and unskilled workers. There are approximately two lakh people who need a kidney transplant in India as the study suggests. A total of 700-800 kidney transplants have successfully been completed. The number of people who donate kidneys is negligible in number which is the main reason and barrier for the treatment of kidney disease at the end-stage. The death rate due to a lack of donors is quite prevalent in this country.
As morbid conditions like diabetes, hypertension are increasing day by day. These are the basic risk factors that pave the way for kidney complications which further lead to the condition which demands a new kidney. Kidney conditions in India are increasing more and more due to more people engaging in alcohol consumption and adopting a bad lifestyle. Citizens of younger age groups are now having diabetes which requires lifelong treatment. Hypertension is very common due to stress in young individuals who are on medications throughout their life. Early deterioration of health is an emerging cause for the necessity of renal transplants.
In India, there are about 30-35 centres that have kidney transplantation available. The cities include Delhi, Mumbai, Pune, Bangalore, Pondicherry, Dharwad, Kolkata, and other metropolitan cities of the country.
The kidney transplant lasts for about one to two decades. And again the issue arises for which another transplant may be necessary.
Kidney transplant costs five to seven lakh rupees in India.
What is the alternative method for kidney transplant surgery?
- Dialysis can be done throughout the life of the patient who does not want a kidney transplant. But it is seen that the patient has a better life and better health with a transplant than dialysis.
- Dialysis is costly if the patient has a considerable life expectancy. It is also very mentally challenging.
- Dialysis has its own set of complications and challenges.
Kidney transplant and the world.
In the United Kingdom and the United States of America, kidney transplantation is the most prevalent. There have been reports of seven thousand and twenty two thousand kidney transplants respectively. The reasons might be increasing obesity, early diabetes, hypertension, bad eating habits with less nutrition, and more gluten and fatty foods.
A sedentary lifestyle and carelessness towards health have now been reflected in the lives of the youth in the form of kidney diseases and other systemic diseases.
Unethical kidney donation.
- As the data suggest Kidneys are high requirements world wide. Kidneys are being donated unethically in countries like India, Pakistan, America, and so on. Reports suggest the money earned by this method is huge. This is against the law and the people involved in such trafficking have been sentenced to serious punishments.
- Doctors and surgeons unethically and without consent have reported having removed the kidneys and have been a part of making money in a bad way. These crimes have been reported and the licence of the professionals can be in serious threat.
- Black marketing has a strong hold over the medical field too.
- Underqualified professionals, unhygienic surgery rooms, unethical practices have been shown to have led to death, life long health issues, penalties for not abiding by the laws and rules of the government.
- The Indian government is taking necessary measures to control the unethical practices of doctors and the people who are involved in this business. Strict rules have been implemented in order to avoid burden on the nation by any means.
- Illegal organ removal is yet a serious problem and hazardous to that person’s own health.