Kidney Transplant: A Comprehensive Handbook for Patients looking for treatment abroad

Overview

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.

What are the functions of the kidney?

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:

• Removes wastes and toxic substances from the blood.
• Maintain the pH level of the blood
• Regulates the ion concentration
• Regulates the amount of plasma present in the extracellular system
• Activates Vitamin D and regulates bone health
• Controls blood pressure through a hormonal mechanism
• Maintains electrolytic balance which is required for normal heart rhythm
• Secretes erythropoietin hormone that regulates the production of red blood cells

When Is Kidney transplantation required?

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.

What are the causes of Kidney Failure?

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:

• Heart disease: Abnormal flow of blood through kidneys because of poor heart functioning may result in kidney failure. The research suggests that when the heart is no longer capable of efficiently pumping the blood, the blood gets congested in the main artery of the kidney leading to increased pressure. Further, poor supply of blood to the kidneys due to cardiac disease also causes kidney failure.
• Allergic reaction: Anaphylactic reactions may result in kidney damage. The allergic reactions hamper the supply of blood to the diseases leading to reduced renal function. Chronic abnormal blood supply significantly affects the health of the kidneys.
• Severe burn: In cases of a severe burn, there is an excess of fluid loss. Significant fluid loss leads to poor cardiac output.  This may result in kidney failure which is one of the primary causes of increased mortality in cases of a severe burn.
• Acute and severe infection: Severe kidney infections such as pyelonephritis has the potential to permanently damage the kidneys. Pyelonephritis is a life-threatening condition characterized by swelling of the kidneys.
• Dehydration: Dehydration causes a plethora of circumstances that may lead to kidney failure. Dehydration causes fluid loss, which reduces cardiac output. Further, the concentration of waste material in the blood is increased and myoglobin or muscle protein may block the kidney. Dehydration also increases the risk of urinary stone formation and urinary tract infections.
• Other causes: Various other causes may lead to kidney failure. These include liver failure, accidental injuries or trauma, surgical complications, advanced stage diabetes, autoimmune disease, uncontrolled hypertension, and some genetic diseases.

Who might require a kidney transplant?

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.

Who can donate a Kidney?

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.

Types of Donors

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.

Donor Compatibility

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.

ABO-incompatible transplants

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.

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How is Kidney Transplant surgery is performed?

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:

• Blood typing: Blood typing is the initial test that is performed to evaluate the compatibility of donor and recipient. If your blood type matches that of the recipient, you must undergo another test. If your blood type does not match with the recipient’s blood then there is an increased risk of rejection.
• Cross-matching: Cross-matching is done to evaluate the presence of antibodies in the blood of the recipient. A cross-matching test is performed twice at different times. The antibodies can be formed during pregnancy and blood transfusion. If the cross-matching test comes positive then the patient must undergo a desensitization procedure to remove antibodies from his blood. This process is like removing waste through dialysis.
• Tissue typing:  Tissue typing is done to compare the presence of antigens in both the recipient and donor. There are generally six antigens. If the kidney is taken from a parent, there is a match of at least 50% and if the donor is a person other than a parent, the cross-typing match has the range of 0 % to 100%. Doctors prefer a 100% match for successful transplantation. A 100 % match is also known as zero mismatches.
• Computer tomography: CT scan is performed to view the image of internal organs and tissues. It helps in evaluating any inflammation or swelling in the internal organs.

List of tests required for the recipients before undergoing a kidney transplant

• Blood and tissue type test: A blood test is an initial test to be performed on the recipient. For kidney transplant surgery, the donor and recipient should have to need the same blood type. For example:

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:

• Colon exam
• Mammogram and pap smear (for women)
• Test for HIV and hepatitis
• Kidney and liver tests
• Heart and lungs exam
• Prostate exam (for men)

Search for Donor

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.

Search for the transplant centre

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:

• The team comprises various people such as a nephrologist, anesthesiologists, surgeons, nutritionists, nurses, pharmacists, and various other people. The experience of the team performing the surgery should be evaluated.
• Technological advancement and post-surgical care facilities also determine if the centre is suitable for carrying the kidney transplant procedures. Further, the ability of the centre for handling complications during surgery is also critical in choosing a centre.
• The success rate should also be analyzed before admission to a centre for kidney transplant surgery.

Surgical procedure

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.

What are the conditions which can be treated via Kidney Transplantation?

Following are some of the conditions that can be treated via kidney transplantation:

• Kidney failure
• End-stage renal disease
• Chronic kidney disease
• Renal carcinoma
• Polycystic kidney disease
• Glomerulonephritis

What is the recovery process post 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

• Always wash fruits and vegetables before eating as it can reduce the chances of infection. Avoid foods that cause obesity, blood pressure, increase sugar levels, and body fluid retention.
• Some dietary sources that you should need to avoid are:

• Raw and undercooked meat, poultry and fish (sushi, prawns, shrimps, crab, clams, and mussels).
• Dairy products such as unpasteurized milk, yoghurt, and cheese.
• Uncooked and undercooked egg and egg-containing products.
• Grapefruit, pomegranate and their juice (do not consume that product especially when you take cyclosporine and tacrolimus, a type of immunosuppressant).
• Sprouts such as bean sprouts and alfalfa.

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.

Medicines post-surgery

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:

• Prednisone
• Sirolimus
• Cyclosporine
• Tacrolimus
• Imuran (azathioprine)
• Mycophenolate mofetil

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.

Some Tips for A Healthy Recovery

As a patient, you should need strictly follow some tips for a healthy recovery process such as:

• Eat washed and fresh vegetables and fruits.
• Avoid driving for two weeks after a kidney transplant surgery.
• Do not do any strenuous lifting for at least 6-8 weeks after your kidney transplant.
• You can do mild physical activities such as walking, or jogging. However, you should consult with your doctor before starting these activities.
• Avoid getting pregnant for one year after a kidney transplant.
• Avoid alcohol consumption during the recovery period as it may interact with medications and may affect your health.
• Never skip any medications and strictly adhere to the prescription. In case of any confusion regarding the dose and schedule of medicines, confirm it with your doctor.

Which are the best countries for Kidney Transplantation across the world?

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.

Which are the top hospitals across the world-renowned for Kidney Transplantation

• • Manipal Hospital, Bangalore, India
  • Indraprastha Apollo Hospitals, New Delhi, India
  • Kokilaben Dhirubhai Ambani Hospital, Mumbai, India
  • Medipol Mega Hastaneler Kompleksi, Istanbul, Turkey
  • Medicana hospital group, Istanbul, Turkey
  • Acibadem international hospital, Istanbul Turkey
  • Medicana Camlica, Istanbul, Turkey
  • The Catholic University of Korea Seoul St.Mary`s Hospital, Seoul, South Korea
  • Seoul National University Hospital, Seoul, South Korea
  • Mount Elizabeth Hospital, Singapore, Singapore
  • Parkway East Hospital,  Singapore, Singapore
  • Rabin Medical Center, Petah Tikva, Israel
  • Rambam Hospital, Haifa, Israel
  • Vejthani Hospital, Bangkok, Thailand
  • Bangkok Hospital, Thailand
  • Liv Hospital, Turkey

What is the Average Cost of Kidney Transplantation?

• Cost of kidney transplant in India is $12500
• Cost of kidney transplant in Israel is $50,000
• Cost of kidney transplant in Turkey is $21,000
• Cost of kidney transplant in Singapore is $60,000
• Cost of kidney transplant in Thailand is $30,000
• Cost of kidney transplant in the US is $260,000
• Cost of kidney transplant in the United Kingdom is $76,000

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Who are the most renowned and sought-after Transplant Surgeons for Kidney Transplantation across the world?

• Dr. D Bhowmik, AIMS (All India Institute of Medical science), Delhi, India
• Dr. Sankaran Sundar, Manipal Hospital, Bangalore, India
• Dr. Sandeep Guleria, Indraprastha Apollo Hospitals, New Delhi, India
• Dr. Shruti Tapiawala, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India
• Dr. Hüseyin Çağatay Aydin, Medipol mega hastaneler, Kompleski, Istanbul, Turkey
• Dr. Ulas Sozener, Medicana hospital group, Istanbul, Turkey
• Dr. Volkan turunc, Medicana Camlica, Istanbul, Turkey
• Dr. Ibrahim Berber, Acibadem international hospital, Istanbul Turkey
• Dr. Sang-Seob Yun, The Catholic University of Korea Seoul St.Mary`s Hospital, Seoul, South Korea
• Dr. Sangil Min, Seoul National University Hospital, Seoul, South Korea
• Dr. Gilchun Park, Asan Medical Center, Songpa-gu, South Korea
• Dr. LYE Wai Choong, Mount Elizabeth Hospital, Singapore, Singapore
• Dr. Pary Sivaraman, Parkway East Hospital, Singapore, Singapore
• Prof. Eytan Mor, Rabin Medical Center, Piteh Tikva, Israel

What is the Legal status of Kidney transplants in India?

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.

What are the measures to be taken when you travel back to your country?

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:

• Get all the information: You should gather all the information related to caring for a kidney transplant. You should also quart about the availability of medications in your country. You should try to get the direct contact information of the doctor as this may be important in case of an emergency. Make a list of all the medications and understand the dosing schedule comprehensively.
• Keep your medicines with you in flight: Medications play an important role in the success of kidney transplants. The unfortunate loss of your checked luggage may result in non-adherence to the dosing schedule which is a prerequisite to a successful kidney transplantation process. So, you should keep the medications with you. It is also important in case the next scheduled dose is during the flight.
• Eat or drink cautiously in flight: Please remember that your immune system is compromised and you are on immunosuppressants. Choose the food and drink wisely on the flight as well as at home as this may lead to infection and diarrhoea.
• Maintain originality: Always keep the medications in their original packaging. Never transfer medicines into another bottle as this may create confusion.
• Take care of the time zone: Ask about the dosage window from a nephrologist before leaving for your country. The difference in time zone may create non-adherence to the dosing schedule. If you are flying to a country having a significant difference in the time zone, you must adjust your dosing schedule.
• Rest: Once you reached your country and at your home, you should take enough rest. Rest helps you to conserve your energy for routine activities.
• Avoid social gatherings: You should avoid public gatherings and crowded places because your immune system is not doing well and you have a high risk of contracting the infection.
• Limit the visitors: It is obvious that once you reached your country, people will visit you for getting information about your health. You should limit the number of visitors as meeting more people increase the risk of infection.
• Driving and exercise: Ask your healthcare professional about the period in which general activities can be started. Generally, driving should be avoided for at least 4-6 weeks. You may perform mild exercise but avoid lifting heavyweights.
• Do not hesitate to seek support: Always remember that your family members are keen to support you but they do not know when you require support.  Seek support from them when required.
• Take good care of your health: Self-care is the best help that you can do for accelerating the recovery process. Stay hygienic and eat and drink wisely.