Kidney transplant

Overview

A kidney transplant is a surgery to place a healthy kidney from a living or deceased donor into a person whose kidneys no longer function properly.

The kidneys are two bean-shaped organs located on each side of the spine just below the rib cage. Each is about the size of a fist. Their main function is to filter and remove waste, minerals and fluid from the blood by producing urine.

When kidneys lose this filtering ability, harmful levels of fluid and waste accumulate in the body, which can raise blood pressure and result in kidney failure (end-stage renal disease). End-stage renal disease occurs when the kidneys have lost about 90% of their ability to function normally. End-stage renal disease occurs when the kidneys have lost about 90% of their ability to function normally.

Common causes of end-stage kidney disease include:

• Diabetes
• Chronic, uncontrolled high blood pressure
• Chronic glomerulonephritis — an inflammation and eventual scarring of the tiny filters within the kidneys
• Polycystic kidney disease

People with end-stage renal disease need to have waste removed from their bloodstream via a machine (dialysis) or a kidney transplant to stay alive.

Why it's done

A kidney transplant is often the treatment of choice for kidney failure, compared with a lifetime on dialysis. A kidney transplant can treat chronic kidney disease or end-stage renal disease to help you feel better and live longer.

Compared with dialysis, kidney transplant is associated with:

• Better quality of life
• Lower risk of death
• Fewer dietary restrictions
• Lower treatment cost

Some people may also benefit from receiving a kidney transplant before needing to go on dialysis, a procedure known as preemptive kidney transplant.

But for certain people with kidney failure, a kidney transplant may be riskier than dialysis. Conditions that may prevent you from being eligible for a kidney transplant include:

• Advanced age
• Severe heart disease
• Active or recently treated cancer
• Dementia or poorly controlled mental illness
• Alcohol or drug abuse
• Any other factor that could affect the ability to safely undergo the procedure and take the medications needed after a transplant to prevent organ rejection

Only one donated kidney is needed to replace two failed kidneys, making living-donor kidney transplantation an option.

If a compatible living donor isn't available, your name may be placed on a kidney transplant waiting list to receive a kidney from a deceased donor.

How long you have to wait for a deceased donor organ depends on the degree of matching or compatibility between you and the donor, time on dialysis and on the transplant waitlist, and expected survival post-transplant. Some people get a match within several months, and others may wait several years.

Risks

Kidney transplantation can treat advanced kidney disease and kidney failure, but the surgery isn't a cure. Some forms of kidney disease may return after a transplant.

The health risks associated with a kidney transplant include those associated directly with the surgery and rejection of the donor organ. Risks also include the side effects of taking anti-rejection medications (immunosuppressants) needed to prevent the body from rejecting the donated kidney.

Deciding whether a kidney transplant is right for you is a personal decision that deserves careful thought and consideration of the serious risks and benefits. Talk through your decision with your family, friends and other trusted advisers.

Complications of the procedure

Kidney transplant surgery carries a risk of significant complications, including:

• Blood clots and bleeding
• Leaking from or blockage of the tube that links the kidney to the bladder (ureter)
• Infection
• Failure or rejection of the donated kidney
• An infection or cancer that can be passed on from the donated kidney
• Death, heart attack and stroke

Anti-rejection medication side effects

After a kidney transplant, you'll take medications to help prevent your body from rejecting the donor kidney. These medications can cause a variety of side effects, including:

• Bone thinning and bone damage
• Diabetes
• Excessive hair growth or hair loss
• High blood pressure
• High cholesterol

Other side effects may include:

• Increased risk of cancer, particularly skin cancer and lymphoma
• Infection
• Puffiness
• Weight gain
• Acne

How you prepare

Choosing a transplant center

If your doctor recommends a kidney transplant, you'll be referred to a transplant center. You're also free to select a transplant center on your own or choose a center from your insurance company's list of preferred providers.

When you consider transplant centers, you may want to:

• Learn about the number and type of transplants the center performs each year
• Ask about the transplant center's kidney transplant survival rates
• Compare transplant center statistics through the database maintained by the Scientific Registry of Transplant Recipients
• Find out if the center offers different donation programs that might increase your chances of receiving a living-donor kidney

You may also consider:

• Costs that will be incurred before, during and after the transplant. Costs will include tests, organ procurement, surgery, hospital stays, and transportation to and from the center for the procedure and follow-up appointments.
• Other services provided by the transplant center, such as support groups, travel arrangements, local housing during the recovery period and referrals to other resources.
• The center's commitment to keeping up with the latest transplant technology and techniques, which indicates that the program is growing.

Evaluation

After you've selected a transplant center, you'll be evaluated to determine whether you meet the center's eligibility requirements for a kidney transplant.

The team at the transplant center will assess whether you:

• Are healthy enough to have surgery and tolerate lifelong post-transplant medications
• Have any medical conditions that would interfere with transplant success
• Are willing and able to take medications as directed and follow the suggestions of the transplant team

The evaluation process may take several days and includes:

• A thorough physical exam
• Imaging studies, such as X-ray, MRI or CT scans
• Blood tests
• Psychological evaluation
• Any other necessary testing as determined by your doctor

After your evaluation, your transplant team will discuss the results with you and tell you whether you've been accepted as a kidney transplant candidate. Each transplant center has its own eligibility criteria. If you aren't accepted at one transplant center, you may apply to others.

What you can expect

Before the procedure

Finding a match

A kidney donor can be living or deceased, related or unrelated to you. Your transplant team will consider several factors when evaluating whether a donor kidney will be a good match for you.

Tests to determine whether a donated kidney may be suitable for you include:

• Blood typing. It's preferable to get a kidney from a donor whose blood type matches or is compatible with your own.

  Transplants involving a donor and recipient with incompatible blood types are also possible but require additional medical treatment before and after transplant to reduce the risk of organ rejection. These are known as ABO incompatible kidney transplants.

• Tissue typing. If your blood type is compatible, the next step is a tissue typing test called human leukocyte antigen (HLA) typing. This test compares genetic markers that increase the likelihood the transplanted kidney will last a long time. A good match means it's less likely that your body will reject the organ.

• Crossmatch. The third and final matching test involves mixing a small sample of your blood with the donor's blood in the lab. The test determines whether antibodies in your blood will react against specific antigens in the donor's blood.

  A negative crossmatch means they are compatible and your body isn't as likely to reject the donor kidney. Positive crossmatch kidney transplants also are possible but require additional medical treatment before and after the transplant to reduce the risk of your antibodies reacting to the donor organ.

Additional factors your transplant team may consider in finding the most appropriate donor kidney for you include matching age, kidney size and infection exposure.

Living kidney donation

Finding a willing living kidney donor is an alternative to waiting for a compatible deceased-donor kidney to become available.

Family members are often the most likely to be compatible living kidney donors. But successful living-donor transplants are also common with kidneys donated from unrelated people, such as friends, co-workers or religious congregation members.

Paired donation is another type of living kidney donation if you have a willing kidney donor whose organ isn't compatible with you or doesn't match well for other reasons. Rather than donating a kidney directly to you, your donor may give a kidney to someone who may be a better match. Then you receive a compatible kidney from that recipient's donor.

In some cases, more than two pairs of donors and recipients may be linked with a living kidney donor who hasn't named a specific person to receive the kidney. They form a donation chain with several recipients benefiting from the nondirected donor's gift.

If a compatible living donor isn't available, your name will be placed on a waiting list for a deceased-donor kidney. Because there are fewer available kidneys than there are people waiting for a transplant, the waiting list continues to grow. The waiting time for a deceased-donor kidney is usually a few years.

Staying healthy

Whether you're waiting for a donated kidney or your transplant surgery is already scheduled, work to stay healthy. Being healthy and as active as you're able can make it more likely you'll be ready for the transplant surgery when the time comes. It may also help speed your recovery from surgery. Work to:

• Take your medications as prescribed.
• Follow your diet and exercise guidelines.
• Don't smoke. If you need help quitting, talk to your doctor.
• Keep all appointments with your health care team.
• Stay involved in healthy activities, including relaxing and spending time with family and friends.

Stay in touch with your transplant team and let your team know of any significant changes in your health. If you're waiting for a donated kidney, make sure the transplant team knows how to reach you at all times. Keep your packed hospital bag ready and make arrangements for transportation to the transplant center.

During the procedure

Kidney transplants are performed with general anesthesia, so you're not awake during the procedure. The surgical team monitors your heart rate, blood pressure and blood oxygen level throughout the procedure.

During the surgery:

• The surgeon makes an incision in the lower part of one side of the abdomen and places the new kidney into the body. Unless your own kidneys are causing complications such as high blood pressure, kidney stones, pain or infection, they are left in place.
• The blood vessels of the new kidney are attached to blood vessels in the lower part of the abdomen, just above one of your legs.
• The new kidney's ureter — the tube that links the kidney to the bladder — is connected to the bladder.

After the procedure

After a kidney transplant, you can expect to:

• Spend several days to a week in the hospital. Doctors and nurses monitor your condition in the hospital's transplant recovery area to watch for signs of complications.

  Your new kidney will make urine like your own kidneys did when they were healthy. Often this starts immediately. In other people, it may take several days, and you may need temporary dialysis until your new kidneys begin to function properly.

  Expect soreness or pain around the incision site while you're healing. Most kidney transplant recipients can return to work and other normal activities within eight weeks after transplant. Avoid lifting objects weighing more than 10 pounds or exercising other than walking until the wound has healed (usually about six weeks after surgery).

• Have frequent checkups as you continue recovering. After you leave the hospital, close monitoring is necessary for a few weeks to check how well your new kidney is working and to make sure your body is not rejecting it.

  You may need to have blood tests several times a week and have your medications adjusted in the weeks following your transplant. During this time, if you live in another town, you may need to make arrangements to stay near the transplant center.

• Take medications the rest of your life. You'll take a number of medications after your kidney transplant. Immunosuppressant drugs help keep your immune system from attacking and rejecting your new kidney. Additional drugs help reduce the risk of other complications, such as infection, after your transplant.

Results

After a successful kidney transplant, your new kidney will filter your blood, and you will no longer need dialysis.

To prevent your body from rejecting your donor kidney, you'll need medications to suppress your immune system. Because these anti-rejection medications make your body more vulnerable to infection, your doctor may also prescribe antibacterial, antiviral and antifungal medications.

It is important to take all your medicines as your doctor prescribes. Your body may reject your new kidney if you skip your medications even for a short period of time. Contact your transplant team immediately if you are having side effects that prevent you from taking the medications.

After the transplant, be sure to perform skin self-checks and get checkups with a dermatologist to screen for skin cancer. Also, staying up to date with other cancer screening is strongly advised.

Kidney transplant success rates

Survival rates among kidney transplant recipients in U.S. transplant centers can be found online at the Scientific Registry of Transplant Recipients website.

If your new kidney fails, you can resume dialysis or consider a second transplant. You may also choose to discontinue treatment. If you decide to discontinue treatment, your doctor can give you medicines to help relieve your symptoms. This decision depends on your current health, your ability to withstand surgery and your expectations for maintaining a certain quality of life.