CHRONIC KIDNEY DISEASE
Oakwood Kidney Institute
Transplantation: Treatment Methods for Kidney Failure
If you have advanced and permanent kidney failure, kidney transplantation may be the treatment option that allows you to live much like you lived before your kidneys failed. Since the 1950's, when the first kidney transplants were performed, we've learned much about how to prevent rejection and minimize the side effects of medicines.
But transplantation is not a cure; it's an ongoing treatment that requires you to take medicines for the rest of your life. And the wait for a donated kidney can be years long.
A successful transplant takes a coordinated effort from your whole health care team, including your nephrologist, transplant surgeon, transplant coordinator, pharmacist, dietitian, and social worker. But the most important members of your health care team are you and your family. By learning about your treatment, you can work with your health care team to give yourself the best possible results, and you can lead a full, active life.
When Your Kidneys Fail
Healthy kidneys clean your blood by removing excess fluid, minerals, and wastes. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, harmful wastes build up in your body, your blood pressure may rise, and your body may retain excess fluid and not make enough red blood cells. When this happens, you need treatment to replace the work of your failed kidneys.
How Transplantation Works
Kidney transplantation is a procedure that places a healthy kidney from another person into your body. This one new kidney takes over the work of your two failed kidneys.
A surgeon places the new kidney inside your lower abdomen and connects the artery and vein of the new kidney to your artery and vein. Your blood flows through the new kidney, which makes urine, just like your own kidneys did when they were healthy. Unless they are causing infection or high blood pressure, your own kidneys are left in place.
Illustration of a kidney transplant:
The Transplant Process
The transplantation process begins when you learn that your kidneys are failing and you must start to consider your treatment options. Whether transplantation is to be among your options will depend on your specific situation. Transplantation isn't for everyone. Your doctor may tell you that you have a condition that would make transplantation dangerous or unlikely to succeed.
Medical Evaluation at a Transplant Center
If your doctor sees transplantation as an option, the next step is a thorough medical evaluation at a transplant hospital. The pretransplant evaluation may require several visits over the course of several weeks or even months. You'll need to have blood drawn and x-rays taken. You'll be tested for blood type and other matching factors that determine whether your body will accept an available kidney.
The medical team will want to see whether you're healthy enough for surgery. Cancer, a serious infection, or significant cardiovascular disease would make transplantation unlikely to succeed. In addition, the medical team will want to make sure that you can understand and follow the schedule for taking medicines.
If a family member or friend wants to donate a kidney, he or she will need to be evaluated for general health and to see whether the kidney is a good match. (See the "Organ Donation" section.)
Placement on the Waiting List
If the medical evaluation shows that you're a good candidate for a transplant but you don't have a family member or friend who can donate a kidney, you'll be put on the transplant program's waiting list to receive a kidney from someone who has just died. You may hear your health care team refer to this as a cadaveric kidney.
Every person waiting for a cadaveric organ is registered with the Organ Procurement and Transplantation Network (OPTN), which maintains a centralized computer network linking all regional organ gathering organizations (known as organ procurement organizations, or OPOs) and transplant centers. The United Network for Organ Sharing (UNOS), a private nonprofit organization, administers OPTN under a contract with the Federal Government. (See the "Resources" section.) For more information on UNOS or OPO, click here:
UNOS rules allow patients to register with multiple transplant centers. Each transplant center will probably require a separate medical evaluation, even if a patient is already registered at another center. Some observers of OPTN operations have raised the concern that people in some parts of the country have to wait longer than others because allocation policies for some organs give preference to patients within the donor's region. Kidneys, however, are assigned to the best match regardless of geographic region. The Federal Government continues to monitor policies and regulations to ensure that every person waiting for an organ has a fair chance. Everyone agrees that the key to making waiting times shorter is to increase the number of donated organs.
How long you'll have to wait depends on many things but is primarily determined by the degree of matching between you and the donor. Some people wait several years for a good match, while others get matched within a few months.
While you're on the waiting list, notify the transplant center of any changes in your health. Also, let the transplant center know if you move or change telephone numbers. The center will need to find you immediately when a kidney becomes available.
OPOs are responsible for identifying potential organs for transplant and coordinating with the national network. The 69 regional OPOs are all UNOS members. When a cadaveric kidney becomes available, the OPO notifies UNOS, and a computer-generated list of suitable recipients is created. Suitability is initially based on two factors:
* Blood type. Your blood type (A, B, AB, or O) must be compatible with the donor's blood type.
* HLA factors. HLA stands for human leukocyte antigen, a genetic marker located on the surface of your white blood cells. You inherit a set of three antigens from your mother and three from your father. A higher number of matching antigens increases the chances that your new kidney will last for a long time.
If you're selected on the basis of the first two factors, a third is evaluated:
* Antibodies. Your immune system may produce antibodies that act specifically against something in the donor's tissues. To see whether this is the case, a small sample of your blood will be mixed with a small sample of the donor's blood in a tube. If no reaction occurs, you should be able to accept the kidney. Your transplant team might use the term negative cross-match to describe this lack of reaction.
If you have a living donor, you'll schedule the operation in advance. You and your donor will be operated on at the same time, usually in side-by-side rooms. One team of surgeons will perform the nephrectomy--that is, the removal of the kidney from the donor--while another prepares the recipient for placement of the donated kidney.
If you're on a waiting list for a cadaveric kidney, you must be ready to hurry to the hospital as soon as a kidney becomes available. Once there, you'll give a blood sample for the antibody cross-match test. If you have a negative cross-match, it means that your antibodies don't react and the transplantation can proceed.
You'll be given a general anesthetic to make you sleep during the operation, which usually takes 3 or 4 hours. The surgeon will make a small cut in your lower abdomen. The artery and vein from the new kidney will be attached to your artery and vein. The ureter from the new kidney will be connected to your bladder.
Often, the new kidney will start making urine as soon as your blood starts flowing through it, but sometimes a few weeks pass before it starts working.
Recovery From Surgery
As after any major surgery, you'll probably feel sore and groggy when you wake up. However, many transplant recipients report feeling much better immediately after surgery. Even if you wake up feeling great, you'll need to stay in the hospital for about a week to recover from surgery, and longer if you have any complications.
Your body's immune system is designed to keep you healthy by sensing "foreign invaders," such as bacteria, and rejecting them. But your immune system will also sense that your new kidney is foreign. To keep your body from rejecting it, you'll have to take drugs that turn off, or suppress, your immune response. You may have to take two or more of these immunosuppressant medicines, as well as other medications to treat other health problems. Your health care team will help you learn what each pill is for and when to take it. Be sure that you understand the instructions for taking your medicines before you leave the hospital.
If you've been on hemodialysis, you'll find that your posttransplant diet is much less restrictive. You can drink more fluids and eat many of the fruits and vegetables you were previously told to avoid. You may even need to gain a little weight, but be careful not to gain too much weight too quickly and avoid salty foods that can lead to high blood pressure. Work with your clinic's dietitian to make sure you're following a healthy eating plan.
You can help prevent rejection by taking your medicines and following your diet, but watching for signs of rejection, like fever or soreness in the area of the new kidney or a change in the amount of urine you make, is important. Report any such changes to your health care team.
Even if you do everything you're supposed to do, your body may still reject the new kidney and you may need to go back on dialysis. Unless your health care team determines that you're no longer a good candidate for transplantation, you can go back on the waiting list for another kidney.
Side Effects of Immunosuppressants
Immunosuppressants can weaken your immune system, which can lead to infections. Some drugs may also change your appearance. Your face may get fuller; you may gain weight or develop acne or facial hair. Not all patients have these problems, though, and diet and makeup can help.
Immunosuppressants work by diminishing the ability of immune cells to function. In some patients, over long periods of time, this diminished immunity can increase the risk of developing cancer. Some immunosuppressants cause cataracts, diabetes, extra stomach acid, high blood pressure, and bone disease. When used over time, these drugs may also cause liver or kidney damage in a few patients.
Treatment for kidney failure is expensive, but Federal health insurance plans pay much of the cost, usually up to 80 percent. Often, private insurance or state programs pay the rest. Your social worker can help you locate resources for financial assistance. For more information on assistance, click here:
Patient Assistance Programs From Prescription Drug Companies
The immunosuppressants and other drugs you must take after your transplant will be a large part of your medical expenses. Most drug manufacturers have patient assistance programs giving discounts to patients who can show that they can't afford the cost of their prescribed medications. To get more information on prescription assistance, please click here:
An organization called the Medicine Program offers help in finding and applying for free medicines supplied by pharmaceutical companies. To get more information on free medicines, please click here:
UNOS maintains a website called Transplant Living to help patients learn about their treatment and find resources. To get more information, please click here:
Most transplanted kidneys come from people who have died. However, the number of people waiting for kidneys has increased in recent years, while the number of kidneys available from deceased donors has remained constant. The result is a shortage of kidneys and a longer waiting time for people with kidney failure.
Many suitable kidneys go unused because family members of potential donors don't know their loved one's wishes. People who wish to donate their organs should talk about this issue with their families. Several organizations, including UNOS and the National Kidney Foundation (see the "Resources" section), provide organ donor cards for people who wish to make this life-preserving gift when they die. A properly completed organ donor card notifies medical officials that you've decided to donate your organs. In most states, you can indicate your desire to be an organ donor on your driver's license.
A growing number of transplanted kidneys are donated by living family members or friends. Potential donors need to be tested to make sure that donating a kidney won't endanger their health, as well as for matching factors. Most people, however, can donate a kidney with little risk.
A kidney from a living donor often has advantages over a deceased donor kidney:
* People who receive a kidney from a family member or friend don't have to wait until a kidney becomes available. Living donation allows for greater preparation and for the operation to be scheduled at a convenient time.
* Kidneys from family members are more likely to be good matches, although there's no guarantee.
* Kidneys from living donors don't need to be transported from one site to another, so the kidney is in better condition when it's transplanted.
* Living donation helps people waiting for kidneys from deceased donors by lowering the number of people on the waiting list.
Diseases of the kidney are found more frequently in racial and ethnic minority populations in the United States than in the general population. African Americans, Asian Americans, Hispanic Americans, and Pacific Islander Americans are three times more likely to suffer from kidney failure than Americans of European descent. Successful transplantation is often enhanced if organs are matched between members of the same ethnic and racial group. A shortage of organs donated by minorities can contribute to longer waiting periods for transplants for minorities.
The National Minority Organ/Tissue Transplant Education Program (MOTTEP), with the support of the National Institutes of Health's (NIH's) Office of Research on Minority Health and NIDDK, is the first national program to empower minority communities to promote minority donation and transplantation, as well as good health habits. In turn, this effort should improve the chances for a well-matched organ among all those waiting for a transplant. To get more information, click here:
(Adapted from NIDDK)