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If you have advanced Chronic Kidney Disease (CKD), you will soon require kidney replacement therapy. Kidney replacement therapy can be in the form of dialysis - either hemodialysis, peritoneal dialysis, or kidney transplantation. Patients who are healthy enough to undergo a transplant are strongly encouraged to pursue this option over life-long dialysis. This is because transplanted patients live longer and healthier lives than patients who remain on dialysis. A living donor kidney transplant usually lasts for about 15 years. If your transplanted kidney fails, you can be considered for a second kidney transplant.
Synopsis
Kidney Transplantation for Advanced Chronic Kidney Disease
A patient with advanced CKD may receive a kidney from either a living donor or a deceased donor. If the patient does not have any known healthy donors, then they can register for a deceased donor through the government list. They can do this once they have started dialysis via the assistance of the Transplant Coordinator at their dialysis centre. Once registered on the list, it may take a few years to receive a kidney - during this period, the patient will need to continue on regular dialysis.
Pre-transplantation Evaluation for Living-donor Transplantation
Until the time of transplantation, the patient may need to continue regular dialysis. It is possible to undergo a ‘pre-emptive’ kidney transplantation – in this situation, the patient may have advanced CKD but may be stable enough that they do not require dialysis. These patients can be closely monitored and directly transplanted without dialysis.
To undergo a kidney transplant, patients will need to find a donor. The kidney donor is usually someone preferably within the family who is willing to donate one of their kidneys. The Nephrologist with evaluate the donor to ensure he or she is healthy enough to donate. There are several tests the donor has to undergo as part of this evaluation. Likewise, the recipient will also have a battery of tests to ensure he or she is healthy enough to undergo a transplant.
A blood group-matched donor is always preferable, however, in some cases, a donor and recipient may not have compatible blood groups and an ABO-incompatible transplant can be conducted. The outcomes of these transplants are also very good. The Nephrologist and Transplant surgeon will explain in detail the medical and surgical risks of transplantation to both the donor as well as the recipient.
Kidney Transplantation Surgery
- For the Donor
The donor surgery is usually done laparoscopically to allow for quick recovery times, fewer complications, and smaller scars. Very rarely, the Surgeon may have to convert a laparoscopic surgery to an open procedure (which will result in a larger scar) if there are any complications during the surgery. Donors are often up and walking the day after surgery and are discharged usually in 3-4 days.
- For the Recipient
The surgery and immediate post-transplant course for the recipient is much more complicated than for the donor. The recipient will need to complete a dialysis session before transplantation. They will need to start on anti-rejection medications before surgery. Post-surgery, the patient will continue on these anti-rejection medications to ensure that the body accepts the new kidney. Usually, the new kidney will work immediately and the patient will start making large volumes of urine and will not require further dialysis. They will be monitored closely after surgery to ensure they are adequately hydrated and to ensure that the new kidney is functioning well. Many medications will be new to the recipient and patients may have reactions to these medications. Often these reactions can be easily managed and medications can be adjusted accordingly.
Rarely, the new kidney does not function immediately and the patient will have to continue dialysis until the kidney functions. In these cases, or in cases in which the new kidney is not working as well as expected, a kidney biopsy may be required. This procedure if done carefully is low risk and will guide treatment to improve the transplanted kidney’s function.
It is also very rare that a transplanted patient has to be taken back to the operating room for a surgical problem - this may be required if there is intra-abdominal bleeding or if there is leakage from any of the surgical stitch sites. In the majority of cases where there are no complications, recipients are discharged 5-6 days after surgery.
Post-Kidney Transplantation
For the Donor:
The post-kidney transplant course for the donor is usually quite simple. They will have to come in for one follow-up with the Surgeon and the Nephrologist if their surgical course was uneventful. They usually do not require any new medications but should follow up intermittently as recommended by the Nephrologist.
They will be instructed to avoid certain medications which may be harmful to kidney health such as non-steroid anti-inflammatory painkillers. They will be advised to maintain a healthy lifestyle to avoid developing Diabetes or Hypertension in the future.
For the Recipient:
Of course, for the recipient, the immediate post-kidney transplant course is more complex. The recipient will have to follow up with their Nephrologist frequently after transplant. They will need to take their medications on time without missing doses. Blood tests with be monitored at frequent intervals and medications may be adjusted often. Medications will include anti-rejection drugs as well as a few anti-infective drugs.
The Nephrologist will instruct the patient to avoid any medications that may be harmful to the new kidney. Additionally, the Nephrologist should always be immediately notified of any new medications added by other doctors or of any over-the-counter medications the patient wants to take. This is because many medications may interact with the anti-rejection medication levels which may put the new kidney at risk.
Anti-rejection medications, also known as immunosuppressive medications, have to be taken for the entire life of the transplanted kidney. This is because there is always a risk of rejection. Conversely, the chronic use of these immunosuppressive medications will increase the risk of infections.
To balance the risk of rejection and infection, transplanted patients will need to follow up at regular intervals with their Nephrologist. If the Nephrologist notices that the function of the transplanted kidney has worsened, a transplant biopsy may be advised. The results of the biopsy, as explained earlier, will provide a diagnosis for the dysfunction and guide treatment to improve function.
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