Apollo Hospital
Chennai,India
A kidney transplant is one of the most prominent and lasting treatment options available for patients with end-stage kidney disease. In a kidney transplant, the diseased kidney is replaced with a healthy kidney extracted from a suitable donor. A healthy kidney can either be taken from a living donor or a deceased donor. Kidney transplant surgery is performed in patients with chronic kidney failure, characterized by irreversible kidney damage. Patients may suffer from this condition due to uncontrolled hypertension, side effects of some medications, genetic disease that significantly affects the functioning of kidneys, and advanced stage of diabetes, among other reasons. Now with better infection control practices at the hospital and continuously evolving treatment strategies and approached, the kidney transplant success rate has improved as compared to what it was decades before. The duration of kidney transplant surgery is around 2 to4 hours. Generally, the dysfunctional kidney is not removed from the body during kidney transplantation. The new kidney right away starts functioning or it may take some time to come into action. Patients get discharged from the hospital within 5 to 7 days after surgery and need to visit the hospital for a routine checkup regularly.
The kidney is an essential organ in our body. It is interesting to note that although there are two kidneys present in the human body, only one kidney is enough to perform the physiological function. Kidneys are present on the right and left side, back of the abdominal cavity, just below the rib cage. The kidney performs the following functions in the human body:
Nephrons are the structural and functional unit of the kidney. Nephrons are the functional units in the kidney that are responsible for filtering the blood and removing waste through urine. The kidney has millions of nephrons that work continuously to filter waste. There is a reduction in the capacity of nephrons to filter blood because of various reasons. If the kidney function or the capacity of nephrons is reduced by almost 90% and is still progressive, the patient is said to suffer from end-stage renal disease. A kidney transplant is required in cases where the patient suffers from end-stage renal disease and is on dialysis, whether hemodialysis or peritoneal dialysis. Kidney transplantation may also be opted by the patient who has a progressive end-stage renal disease but is not on dialysis. Such type of kidney transplantation is known as pre-emptive kidney transplantation. The end-stage renal disease requires kidney transplantation because through dialysis only the blood gets filtered, however, other functions of the kidney such as activation of Vitamin D, production of hormones and regulation of blood pressure are still abnormal.
Kidney failure is a serious medical condition that requires immediate medical intervention. Failure to provide adequate support may lead to fatal consequences. Kidney failure results in the accumulation of toxic substances which may affect the vital organs such as the brain, heart, lungs, and liver.
Following are some of the causes of kidney failure:
A kidney transplant is a lifesaving surgery required in patients suffering from end-stage renal disease. Patients with such conditions suffer from kidney failure, that is, in these patients, the kidneys are not able to effectively perform the physiological function of filtering blood and other essential functions.
A person who is physically fit and in a healthy condition is an ideal candidate for donating the kidney. A comprehensive health evaluation of the donor is done before kidney donation. A genetic relationship between the donor and the recipient plays an important role in minimizing post-transplant complications. However, due to advanced treatment options available in many hospitals, a genetic relationship is not an essential condition for a kidney transplant. The child, brother, sister or parent of the patient can donate a kidney. The kidney can also be donated by a friend or spouse. Normally, the kidney donor should be in good health and is not suffering from medical conditions such as diabetes, high blood pressure, heart disease, hepatitis or cancer. The kidney function of such patients should be normal. The ideal age of the donor should be between 18 and 55 years.
Kidney donors are broadly classified into two main types:
Living donor: Living donor is a person who voluntarily donates his kidney during his lifetime. Living donors may be relatives, spouses, or friends. The living donors can be classified in various ways depending upon the criteria for classification. A living donors can be classified as Living related donors, living unrelated donors and altruistic or non-directed donors. Based on the arrangement of donation, living donors are also classified as a list of exchange living donors and paired exchange living donors. In the list exchange living donor arrangement, the relative of the donor who requires kidney transplant should be given priority on the waiting list. This is because the donor is not able to donate a kidney to his/her relative because of a mismatch. In the paired exchange living donor, the donors swap the recipients to have a better match.
Deceased donor: Deceased donor is defined as the donor whose kidney is donated after his death. The kidney can be donated because of the wish of the donor or through the consent of the substitute decision-maker. A deceased donor is further divided into a heart beating deceased donor, non-heart-beating deceased donor and an expanded criteria deceased donor. A heart beating deceased donor is a person who suffered from irreversible brain injury while in non-heart-beating donors, the heart stops working. Expanded criteria deceased donors are the people who suffer from certain medical conditions not ideal for transplantation such as blood pressure or diabetes. Research support that it is better to transplant the kidneys of such donors rather than wait for a long time.
Compatibility in donor-recipient pairs increases the success rate of kidney transplantation. Transplanting a kidney from a compatible donor increases the life and functioning of the kidney. The compatibility is decided by evaluating three important parameters:
Blood type matching: Blood type matching holds a similar importance in kidney transplantation as it is in blood transfusion. A recipient with O type blood can receive a kidney from only O type donors, and a recipient with AB type can receive a kidney from donors with A, B, AB, and O blood types. Recipients with A-type blood can receive a kidney from donors with A and O blood types while recipients with B type blood can receive a kidney from B and O blood type donors.
Tissue matching: Tissue matching is another criterion required for kidney transplantation. Based on human leukocyte antigen (HLA) antigen evaluation, the doctors can identify the closeness of tissue matching. The six sets of antigens are matched and people with all the six-antigen sets similar are a perfect match. Evaluation of thousands of transplantation reveals that the number of antigens that are matching has an impact on the overall success of transplantation.
Cross-matching: Crossmatching is done to identify the presence of preformed antibodies. These antibodies may be formed due to pregnancy, prior transplantation or blood transfusion. The presence of preformed antibodies may damage the kidney.
Before the advancement in technology and the absence of effective anti-rejection medications, it was not possible to transplant the kidney to unmatched donors. It is to be noted that although donor-recipient compatibility is best for minimizing the complications, in the absence of such blood group compatibility, kidney transplants can still be possible. The strategy for minimizing the rejection of donated kidneys depends upon the number of antibodies present in the patient against a donor’s kidney blood type. This can be easily evaluated through a blood test. In most cases, the rejection can be effectively managed through a two-step process:
Desensitization: In this process, the antibodies present in the blood are removed through a process known as plasmapheresis. This may require several sessions depending upon the number of antibodies.
Immune modulation: Intravenous immunoglobulin is given to the patient after desensitization which prevents the cells from generating further antibodies.
Types of tests and evaluations to be performed
A kidney transplant is a complex process. Various tests of the patient are to be performed before considering him as a candidate for kidney transplantation. These tests are done in both cases, that is, whether the kidney is obtained from a living donor or a deceased donor. Following are some of those tests:
List of tests required for the recipients before undergoing a kidney transplant
If you have A-type blood then the blood type of the donor must be A or O.
If you have AB type of blood then the blood type of the donor may have A, B AB or O.
If you have O type blood then the blood type of the donor must be O.
If you have a B type of blood then the blood type of the donor must be B or O.
Apart from the blood test, cross-match and tissue typing test, various other tests are performed to evaluate whether the patient is fit for undergoing transplantation surgery. These tests include:
Finding a suitable donor is hard unless the near relative donates his kidney to the patient. Getting a kidney from a near relative such as a child, sibling, or parent increases the success of transplantation. A kidney can also be donated by a spouse or close friend.
Choosing a kidney transplant centre is one of the important decisions that may affect the overall success rate of kidney transplant surgery. Various factors should be evaluated by the patient before choosing the centre. The factors not only comprise the surgical expertise of the centre but also include post-surgical care which has equal importance in successful transplantation. The following factors determine the choice of kidney transplant centre:
Before surgery: Before the surgery, the health of the patient is comprehensively evaluated. If you are receiving the kidney from a living donor then you are informed well in advance. However, if the donor is a deceased person, you must rush to the hospital the moment you have been informed.
During Surgery: The surgery is performed under general anesthesia. In almost all the cases of a kidney transplant, the surgery done is heterotrophic. This means that the place of the new kidney would be different from the old kidney. It is different from an orthotropic transplant done in the case of a liver or heart. The old kidney is usually not removed unless there are some health issues such as significant enlargement, frequent infection or uncontrollable high blood pressure. The surgery takes around 2 to 4 hours to complete. The arteries and veins are connected to the kidneys and the ureter from the kidney is connected to the bladder. The patient gets discharged from the hospital within a week after surgery. The duration of the stay for the recipient is ranging from 20 to 30 days, based on the complexity of the case and the country where the transplantation is performed.
Post-surgical care: Close monitoring of the critical parameters is done after surgery. These parameters include early organ rejection, the optimum dose of treatment, and the side effects of immunosuppressive drugs such as infection and cancer. Rejection is the most common condition occurring in almost 30% of the patient. In most cases, the rejection occurs within 6 months of the surgery but can occur at any time. Timely diagnosis and immediate medical intervention result in the reversal of rejection.
Following are some of the conditions that can be treated via kidney transplantation:
How Long Will the Hospital Stay Be for Recipient and Donor?
The time of hospital stay for donors depends on the type of procedure performed (laparoscopic surgery and traditional surgery) and the rate of recovery time. Usually, after this process, the patient needs to stay in the hospital for 4 to 6 days. Since the rate of the recovery process is different in various patients, the time of hospital stay may vary. The donor should confirm the recovery time before surgery. After getting discharged from the hospital the donor may feel some pain, tenderness, and itching on the incision during the recovery process.
The hospital stays for the recipient depends on the age, underlying medical condition, and type of surgery that is performed. During the recovery, the nephrologist monitors the patient for rejection, infection and other complications. The doctor will provide various medications after surgery and ask the patient for follow-up visits to evaluate the working of the transplanted kidney.
Dietary Restrictions Are to Be Followed Post-Surgery
You need to avoid these food items to lower the risk of infection. After kidney transplant surgery, your doctor recommends immunosuppressive medicines. These medicines are used to lower the chance of rejection of the new kidney by your body. These medications reduce the ability of the body for fighting against infection. Certain foods increase the risk of infection and those foods should strictly be avoided.
After a kidney transplant surgery, your doctor should prescribe you certain medications during the recovery process. Medicines generally prescribed are known as immunosuppressive medicines, also called antirejection medicines. The most commonly used immunosuppressive medicines such as:
Apart from these medications, the doctor may also prescribe antiviral medications such as valganciclovir, anti-ulcer medications such as ranitidine, and antibacterial drugs such as co-trimoxazole.
As a patient, you should need strictly follow some tips for a healthy recovery process such as:
Following are some of the countries with the best and most cost-effective kidney transplantation Surgical techniques:
India: India is one of the fastest-growing countries in kidney transplantation procedures. With the informative approach adopted by the Government and various hospitals, the rate of organ donation in the country is significantly increased after 2012. The Live kidney transplantation program in India is now the second-largest kidney transplantation program after the USA. Hospitals situated in New Delhi, Mumbai, Pune, Bangalore, Chennai, and Chandigarh are equipped with the latest infrastructure, technology, and post-operative care. These hospitals have access to the latest anti-rejection medications that play a major role in successful Kidney transplantation.
Turkey: Turkey is one of the favourite destinations for foreigners requiring organ transplantation. The reason for this growth amount medical tourist is an escalation in the hospital infrastructure that provides better care at an affordable price and more importantly the availability of expert surgeons in Turkey for kidney transplantation. The success rate of Kidney transplants is high in Turkey which is the reason it is attracting patients from Europe, Asia, Africa, and the USA.
South Korea: The first successful kidney transplantation was done in the year 1969 through a living donors and there is no way back for this country after that. The country achieved another milestone when the kidney was transplanted from a deceased donor in 1979. To make a kidney available to patients, the country has done excellent work in increasing its donor pool and significantly uses the expanded criteria of the donor.
Singapore: Singapore has achieved the feat of the first kidney transplant in the year 1970. Various hospitals are equipped with the latest technology and advanced surgical procedure to make kidney transplants less complicated and successful. Post-surgical care in this country is exceptional because of trained and experienced para-medical staff. The hospitals for Kidney transplant in Singapore maintains a high standard of care and this is the reason that many of the hospitals are accredited by the International Society of Nephrology.
Israel: With an above 90% of success rate in kidney transplant surgeries, Israel is a growing hub for organ transplantation. As the law does not allow the kidney of a deceased donor to be transplanted to non-Israeli citizens, foreign medical tourists are taking with them the living relative donor for processing the surgery. The rate of organ transplantation in 2017 was at an all-time high then and there is a gradual increase in the rate of kidney transplantation.
Thailand: A kidney transplant was the first organ transplant done in Thailand way back in 1972. Today, there are many hospitals in the country that are successfully performing not only kidney transplants but heart, lung, liver and bone marrow transplants. Because of the advanced technology, huge infrastructure, access to modern anti-rejection medications and experienced surgeons and para-medical staff, the survival rate has significantly increased in the last few years in Thailand.
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The ethics committee dictates the execution of kidney transplantation by interviewing every recipient and donor before they head for the surgery. The function of the ethical board is to evaluate the formal process of kidney transplantation critically and comprehensively.
Organ transplantation is regulated in India through The Transplantation of Human Organs Act, 1994. This act provides provision for the constitution of the authorization committee which investigates the ethical aspect of a kidney transplant.
The function of this committee is to ensure that there should be no financial transaction between the donor and recipient, and the link between the donor and recipient should be made available to this committee. It also examines the reason why the donor is offering his kidney to the recipient, and if there is any involvement of tout. This committee also has the power to examine if the donor has given free consent and is not a drug addict.
The authorization committee is formed at two levels. One is the state-based authorization committee while the other is a hospital-based authorization committee. The State committee comprises of Chief Medical Officer of any government hospital, two senior registered medical practitioners of the state who are not part of the transplant team, two persons of high integrity and social standing, a health secretary or nominee, and a Director of health services or nominee.
Hospital-based authorization committee comprises of Medical director of the hospital, two senior registered medical practitioners of the same hospital who are not part of the transplant team, two persons of high integrity and social standing, a health secretary or nominee, and a Director of health services or nominee.
In case the recipient or donor is a foreigner, there should be a certificate issued by a senior official from the embassy of the country of origin to state the relationship between recipient and donor. In case there is no Embassy of that country in India, the Government of that country should issue the certificate.
The decision of the Authorization Committee for approval or rejection should be stated in writing.
Kidney transplantation is a complicated surgery. Ample care is required to prevent complications and improving the kidney transplant success rate. Various measures are to be taken during the flight as well as at home when you travel back to your country. These measures include:
Amit Bansal is a serial entrepreneur, Co-Founder, and CEO of MediGence. He has more than 17 years of strong technology experience. Having worked for some of the recognized companies in India, Australia and traveled worldwide to help businesses to grow multi-folded under his leadership and strategic guidance.
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