Kidney Transplantation

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What is a kidney transplant?

A kidney transplant is a surgical procedure performed to replace a diseased kidney with a healthy kidney from another person. The kidney may come from a deceased donor or from a living donor. Family members or individuals who are unrelated but make a good match may be able to donate one of their kidneys. This type of transplant is called a living transplant. Individuals who donate a kidney can live healthy lives with the remaining kidney.

A person receiving a transplant usually receives only one kidney, but, in rare situations, he or she may receive two kidneys from a deceased donor. In most cases, the diseased kidneys are left in place during the transplant procedure. The transplanted kidney is implanted in the lower abdomen on the front side of the body.

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Why is a kidney transplant recommended?

A kidney transplant is recommended for persons who have serious kidney dysfunction and will not be able to live without dialysis or a transplant. Some of the kidney diseases for which transplants are done include the following conditions. However, not all cases of the following diseases require kidney transplantation. Always consult your doctor for a diagnosis:

• Congenital renal obstructive disorders leading to hydronephrosis, including the following:

  • Ureteropelvic junction obstruction

  • Vesicoureteral reflux

  • Posterior urethral valves

  • Prune belly syndrome

  • Megaureter

• Congenital nephrotic syndrome

• Alport syndrome

• Nephropathic and juvenile cystinosis

• Polycystic kidney disease

• Nail-patella syndrome

• Glomerulonephritis

• Berger disease

• Henoch-Schönlein purpura

• Hemolytic uremic syndrome

• Wegener granulomatosis

• Goodpasture syndrome

• Diabetes

How many people in the United States need kidney transplants?

Visit United Network for Organ Sharing (UNOS) for statistics of patients awaiting a kidney transplant, and the number of patients who underwent a transplant this year.

Where do transplanted organs come from?

The majority of kidneys that are transplanted come from deceased organ donors. Organ donors are adults who have become critically ill and will not live as a result of their illness. Kidneys are harvested after these adults are pronounced dead. Parents or spouses can also agree to donate a relative's organs. Donors can come from any part of the United States. This type of transplant is called a cadaveric transplant.

A person receiving a transplant usually receives only one kidney, but, in rare situations, he or she may receive two from a cadaveric (deceased) donor. Some experimentation with splitting one kidney for two recipients is underway. Family members or individuals who are unrelated but make a good match may also be able to donate one of their kidneys. This type of transplant is called a living transplant (living donor). Individuals who donate a kidney can live healthy lives with the kidney that remains. A child older than two years can generally receive an adult kidney, as there is usually enough space in the belly for the new kidney to fit.

According to the latest statistics from the Organ Procurement and Transplantation Network, there were 16,519 kidney transplants performed in 2008. Of that total, 10,551 were from deceased donors and 5,968 were from living donors.

How are transplanted organs allocated?

UNOS is responsible for transplant organ distribution in the United States. UNOS oversees the allocation of many different types of transplants, including liver, kidney, pancreas, heart, lung, and cornea.

UNOS receives data from hospitals and medical centers throughout the country regarding adults and children who need organ transplants. The medical transplant team that currently follows you is responsible for sending the data to UNOS, and updating them as your condition changes.

Criteria have been developed to ensure that all people on the waiting list are judged fairly as to the severity of their illness and the urgency of receiving a transplant. Once UNOS receives the data from local hospitals, people waiting for a transplant are placed on a waiting list and given a "status" code. The people in most urgent need of a transplant are placed highest on the status list, and are given first priority when a donor kidney becomes available.

When a donor organ becomes available, a computer searches all the people on the waiting list for a kidney and sets aside those who are not good matches for the available kidney. A new list is made from the remaining candidates. The person at the top of the specialized list is considered for the transplant. If he/she is not a good candidate, for whatever reason, the next person is considered, and so forth. Some reasons that people lower on the list might be considered before a person at the top include the size of the donor organ and the geographic distance between the donor and the recipient.

How am I placed on the waiting list for a new kidney?

An extensive evaluation must be completed before you can be placed on the transplant list. Testing includes:

• Blood tests

• Diagnostic tests

• Psychological and social evaluation

Blood tests are done to gather information that will help determine how urgent it is that you are placed on the transplant list, as well as ensure that you receive a donor organ that is a good match. Some of the tests you may already be familiar with, since they evaluate the health of your kidney and other organs. These tests may include:

• Blood chemistries. These may include serum creatinine, electrolytes (such as sodium and potassium), cholesterol, and liver function tests.

• Clotting studies, such as prothrombin time (PT) and partial thromboplastin time (PTT). Tests that measure the time it takes for blood to clot.

Other blood tests will help improve the chances that the donor organ will not be rejected. They may include:

• Your blood type. Each person has a specific blood type: type A+, A-, B+, B-, AB+. AB-, O+, or O-. When receiving a transfusion, the blood received must be a compatible type with your own, or an allergic reaction will occur. The same allergic reaction will occur if the blood contained within a donor organ enters your body during a transplant. Allergic reactions can be avoided by matching the blood types of you and the donor.

• Human leukocyte antigens (HLA ) and panel reactive antibody (PRA). These tests help determine the likelihood of success of an organ transplant by checking for antibodies in your blood. Antibodies are made by the body's immune system in reaction to a foreign substance, such as a blood transfusion or a virus. Antibodies in the bloodstream will try to attack transplanted organs. Therefore, persons who receive a transplant will take medications that decrease this immune response. The higher your PRA, the more likely that an organ will be rejected.

• Viral studies. These tests determine if you have viruses that may increase the likelihood of rejecting the donor organ, such as cytomegalovirus (CMV).

Diagnostic tests that are performed are necessary to understand your complete medical status. The following are some of the other tests that may be performed, although many of the tests are decided on an individual basis:

• Renal ultrasound. A noninvasive test in which a transducer is passed over the kidney producing sound waves which bounce off of the kidney, transmitting a picture of the organ on a video screen. The test is used to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.

• Kidney biopsy. A procedure in which tissue samples are removed (with a needle or during surgery) from the kidney for examination under a microscope; to determine if cancer or other abnormal cells are present.

• Intravenous pyelogram (IVP). A series of X-rays of the kidney, ureters, and bladder with the injection of a contrast dye into the vein to detect tumors, abnormalities, kidney stones, or any obstructions, and to assess renal blood flow.

The transplant team will consider all information from interviews, your medical history, physical examination, and diagnostic tests in determining whether you can be a candidate for kidney transplantation. After the evaluation and you have been accepted to have a kidney transplant, you will be placed on the United Network for Organ Sharing (UNOS) list.

If you are receiving a kidney donated by a living donor, the donor will undergo a similar evaluation. 

The transplant team

During the evaluation process, you will be interviewed by many members of the transplant team. The following are some of the members of the team:

• Transplant surgeons. Doctors who specialize in transplants and who will be performing the surgery.

• Nephrologist. A doctor who specializes in disorders of the kidneys. Nephrologists will help manage your condition before and after the surgery.

• Transplant nurse coordinator. A nurse who organizes all aspects of care provided to you before and after the transplant. The nurse coordinator will provide patient education, and coordinates the diagnostic testing and follow-up care.

• Social workers. Professionals who will help your family deal with many issues that may arise including lodging and transportation, finances, and legal issues.

• Dietitians. Professionals who will help you meet your nutritional needs before and after the transplant.

• Physical therapists. Professionals who will help you become strong and independent with movement and endurance after the transplantation.

• Pastoral care. Chaplains who provide spiritual care and support.

• Other team members. Several other team members will evaluate you before transplantation and will make recommendations to the team. These include, but are not limited to, the following:

  • Anesthesiologist

  • Hematologist

  • Infectious disease specialist

  • Psychologist

How long will it take to get a new kidney?

There is no definite answer to this question. Sometimes, people wait only a few days or weeks before receiving a donor organ. If no living-related donor is available, it may take months or years on the waiting list before a suitable donor organ is available. During this time, you will receive close follow-up with your doctors and the transplant team. Various support groups are also available to assist you during this waiting time.

How am I notified when a kidney is available?

Each transplant team has its own specific guidelines regarding waiting on the transplant list and being notified when a donor organ is available. In most instances, you will be notified by phone or pager that an organ is available. You will be told to come to the hospital immediately so that you can be prepared for the transplant.

What is rejection?

Rejection is a normal reaction of the body to a foreign object. When a new kidney is placed in a person's body, the body sees the transplanted organ as a threat and tries to attack it. The immune system makes antibodies to try to kill the new organ, not realizing that the transplanted kidney is beneficial. To allow the organ to successfully live in a new body, medications must be given to trick the immune system into accepting the transplant and not thinking it is a foreign object.

What is done to prevent rejection?

Medications must be given for the rest of your life to fight rejection. Each person is individual, and each transplant team has preferences for different medications. The anti-rejection medications most commonly used singly or in combination include:

• Cyclosporine

• Tacrolimus

• Azathioprine

• Mycophenolate mofetil

• Prednisone

• OKT3

• Antithymocyte Ig (ATGAM)

New anti-rejection medications are continually being approved. Doctors tailor drug regimes to meet the needs of each individual patient.

Usually several anti-rejection medications are given initially. The doses of these medications may change frequently as your response to them changes. Because anti-rejection medications affect the immune system, persons who receive a transplant will be at higher risk for infections. A balance must be maintained between preventing rejection and making you very susceptible to infection. Blood tests to measure the amount of medication in the body are done periodically to make sure you do not get too much or too little of the medications. White blood cells are also an important indicator of how much medication you need.

This risk of infection is especially great in the first few months because higher doses of anti-rejection medications are given during this time. You will most likely need to take medications to prevent other infections from occurring.

What are the signs of rejection?

The following are some of the most common symptoms of rejection. However, each individual may experience symptoms differently. Symptoms may include:

• Fever

• Tenderness over the kidney

• Elevated blood creatinine level

• High blood pressure

Your transplant team will instruct you on who to call immediately if any of these symptoms occur.

Long-term outlook for a person after a kidney transplant

Living with a transplant is a life-long process. Medications must be given that trick the immune system so it will not attack the transplanted organ. Other medications must be given to prevent side effects of the anti-rejection medications, such as infection. Frequent visits to and contact with the transplant team are essential. Knowing the signs of organ rejection and watching for them on a daily basis are critical.

Every person is different and every transplant is different. The new anti-rejection medications that are being approved are very exciting. Results improve continually as doctors and scientists learn more about how the body deals with transplanted organs and search for ways to improve the success of transplantation.