Kidney transplantation or
renal transplantation is the
organ transplantOrgan transplantation is the moving of an organ from one body to another or from a donor site on the patient's own body, for the purpose of replacing the recipient's damaged or absent organ. The emerging field of regenerative medicine is allowing scientists and engineers to create organs to be...
of a
kidneyThe kidneys, organs with several functions, serve essential regulatory roles in most animals, including vertebrates and some invertebrates. They are essential in the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance, and...
into a patient with end-stage renal disease. Kidney transplantation is typically classified as deceased-donor (formerly known as cadaveric) or living-donor transplantation depending on the source of the donor organ. Living-donor renal transplants are further characterized as genetically related (living-related) or non-related (living-unrelated) transplants, depending on whether a biological relationship exists between the donor and recipient.
History
The first cadaveric kidney transplantation in the United States was performed June 17, 1950, on Ruth Tucker, a 44-year-old woman with
polycystic kidney diseaseAutosomal dominant polycystic kidney disease is an inherited systemic disorder that predominantly affects the kidneys, but may affect other organs including the liver, pancreas, brain, and arterial blood vessels...
, at
Little Company of Mary HospitalLittle Company of Mary Hospital is a hospital in Evergreen Park, Illinois, USA. The hospital was founded on January 19, 1930 by the Sisters of the Little Company of Mary .The first human organ transplant was performed here in 1950....
in Evergreen Park, Illinois. Although the donated kidney was rejected ten months later because no immunosuppressive therapy was available at the time—the development of effective antirejection drugs was years away—the intervening time gave Tucker's remaining kidney time to recover and she lived another five years.
The first kidney transplants between living patients were undertaken in 1954 in Boston and Paris. The Boston transplantation, performed on December 23, 1954, at Brigham Hospital was performed by
Joseph MurrayJoseph Edward Murray is a retired American plastic surgeon. He performed the first successful human kidney transplant on identical twins on December 23, 1954....
, J. Hartwell Harrison,
John P. MerrillJohn Putnam Merrill was an American physician and medical researcher. He led the team which performed the world's first successful kidney transplant...
and others. The procedure was done between identical twins to eliminate any problems of an
immuneAn immune system is a system of biological structures and processes within an organism that protects against disease by identifying and killing pathogens and tumor cells. It detects a wide variety of agents, from viruses to parasitic worms, and needs to distinguish them from the organism's own...
reaction. For this and later work, Dr. Murray received the
Nobel Prize for MedicineThe Nobel Prize in Physiology or Medicine administered by the Nobel Foundation, is awarded once a year for outstanding discoveries in the field of life science and medicine. It is one of five Nobel Prizes established in 1895 by Swedish chemist Alfred Nobel, the inventor of dynamite, in his will...
in 1990. The recipient died eight years after the transplantation.
The first kidney transplantation in the United Kingdom did not occur until 1960, when
Michael WoodruffSir Michael Francis Addison Woodruff, FRS, FRCS was an English surgeon and scientist principally remembered for his research into organ transplantation. Though born in London, Woodruff spent his youth in Australia, where he earned degrees in electrical engineering and medicine...
performed one between identical twins in Edinburgh. Until the routine use of medications to prevent and treat acute rejection, introduced in 1964, deceased donor transplantation was not performed. The kidney was the easiest organ to transplant:
tissue typingTissue typing is a procedure in which the tissues of a prospective donor and recipient are tested for compatibility prior to transplantation. An embryo can be tissue typed to ensure that the embryo implanted can be a cord-blood stem cell donor for a sick sibling.One technique of tissue typing,...
was simple, the organ was relatively easy to remove and implant, live donors could be used without difficulty, and in the event of failure, kidney dialysis was available from the 1940s. Tissue typing was essential to the success: early attempts in the 1950s on sufferers from
Bright's diseaseBright's disease is a historical classification of kidney diseases that would be described in modern medicine as acute or chronic nephritis. The term is no longer used, as diseases are now classified according to their more fully understood causes....
had been very unsuccessful.
The major barrier to organ transplantation between genetically non-identical patients lay in the recipient's immune system, which would treat a transplanted kidney as a "non-self" and immediately or chronically,
rejectTransplant rejection occurs when transplanted tissue is rejected by the recipient's immune system, which destroys the transplanted tissue. Transplant rejection can be lessened by determining the molecular similitude between donor and recipient and by use of immunosuppressant drugs after...
it. Thus, having medications to suppress the immune system was essential. However, suppressing an individual's immune system places that individual at greater risk of
infectionAn infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
and
cancerCancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
(particularly
skin cancerSkin neoplasms are skin growths with differing causes and varying degrees of malignancy. The three most common malignant skin cancers are basal cell cancer, squamous cell cancer, and melanoma, each of which is named after the type of skin cell from which it arises...
and
lymphomaLymphoma is a cancer in the lymphatic cells of the immune system. Typically, lymphomas present as a solid tumor of lymphoid cells. Treatment might involve chemotherapy and in some cases radiotherapy and/or bone marrow transplantation, and can be curable depending on the histology, type, and stage...
), in addition to the
side effectsIn medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
of the medications.
The basis for most immunosuppressive regimens is
prednisolonePrednisolone is the active metabolite of prednisone, which is also used as a drug.-Uses:Prednisolone is a corticosteroid drug with predominant glucocorticoid and low mineralocorticoid activity, making it useful for the treatment of a wide range of inflammatory and auto-immune conditions such as...
, a
corticosteroidCorticosteroids are a class of steroid hormones that are produced in the adrenal cortex. Corticosteroids are involved in a wide range of physiologic systems such as stress response, immune response and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte...
. Prednisolone suppresses the immune system, but its long-term use at high doses causes a multitude of side effects, including glucose intolerance and diabetes, weight gain,
osteoporosisOsteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered...
, muscle weakness,
hypercholesterolemiaHypercholesterolemia is the presence of high levels of cholesterol in the blood. It is not a disease but a metabolic derangement that can be caused by many diseases, notably cardiovascular disease...
, and
cataractA cataract is a clouding that develops in the crystalline lens of the eye or in its envelope, varying in degree from slight to complete opacity and obstructing the passage of light...
formation. Prednisolone alone is usually inadequate to prevent rejection of a transplanted kidney. Thus other, non-steroid immunosuppressive agents are needed, which also allow lower doses of prednisolone.
Indications
The indication for kidney transplantation is end-stage renal disease (ESRD), regardless of the primary cause. This is defined as a glomerular filtration rate <15ml/min/1.73 sq.m. Common diseases leading to ESRD include
malignant hypertensionMalignant hypertension or hypertensive emergency is severe hypertension with acute impairment of an organ system and the possibility of irreversible organ-damage...
,
infectionAn infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
s,
diabetes mellitusDiabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
, and
focal segmental glomerulosclerosisFocal segmental glomerulosclerosis is a cause of nephrotic syndrome in children and adolescents, as well as an important cause of kidney failure in adults.It is also known as "focal glomerular sclerosis" or "focal nodular glomerulosclerosis"....
; genetic causes include
polycystic kidney diseaseAutosomal dominant polycystic kidney disease is an inherited systemic disorder that predominantly affects the kidneys, but may affect other organs including the liver, pancreas, brain, and arterial blood vessels...
, a number of inborn errors of metabolism, and autoimmune conditions such as
lupusSystemic lupus erythematosus , often abbreviated to SLE or lupus, is a systemic autoimmune disease that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage...
and
Goodpasture's syndromeGoodpasture’s syndrome is a rare disease characterized by glomerulonephritis and hemorrhaging of the lungs...
. Diabetes is the most common cause of kidney transplantation, accounting for approximately 25% of those in the
USThe United States of America is a federal constitutional republic comprising fifty states and a federal district...
. The majority of renal transplant recipients are on some form of
peritoneal dialysisPeritoneal dialysis is a treatment for patients with severe chronic kidney disease. The process uses the patient's peritoneum in the abdomen as a membrane across which fluids and dissolved substances are exchanged from the blood...
, or the similar process of
hemofiltrationIn medicine, hemofiltration, also haemofiltration, is a renal replacement therapy similar to hemodialysis which is used almost exclusively in the intensive care setting...
—at the time of transplantation. However, individuals with chronic renal failure who have a living donor available may undergo pre-emptive transplantation before dialysis is needed.
Contraindications and requirements
Contraindications include both cardiac and pulmonary insufficiency, as well as hepatic disease. Concurrent tobacco use and morbid obesity are also among the indicators putting a patient at a higher risk for surgical complications.
Kidney transplant requirements vary from program to program and country to country. Many programs place limits on age (e.g. the person must be under a certain age to enter the waiting list) and require that one must be in good health (aside from the kidney disease). Significant
cardiovascular diseaseHeart disease or cardiovascular disease are the class of diseases that involve the heart or blood vessels . While the term technically refers to any disease that affects the cardiovascular system , it is usually used to refer to those related to atherosclerosis...
, incurable terminal infectious diseases and
cancerCancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
often are transplant exclusion criteria. In addition, candidates are typically screened to determine if they will be compliant with their medications, which is essential for survival of the transplant. People with mental illness and/or significant on-going
substance abuseA substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
issues may be excluded.
HIV was at one point considered to be a complete contraindication to transplantation. There was fear that immunosuppressing someone with a depleted immune system would result in the progression of the disease. However, some research seem to suggest that
immunosuppressive drugImmunosuppressive drugs or immunosuppressive agents are drugs that inhibit or prevent activity of the immune system. They are used in immunosuppressive therapy to:...
s and antiretrovirals may work synergistically to help both HIV viral loads/CD4 cell counts and prevent active rejection.
Sources of kidneys
Since medication to prevent rejection is so effective, donors do not need to be genetically similar to their recipient. Most donated kidneys come from deceased donors; however, the utilization of living donors in the United States is on the rise. In 2006, 47% of donated kidneys were from living donors. This varies by country: for example, only 3% of kidneys transplanted during 2006 in Spain came from living donors.
Living donors
More than one in three donations in the UK is now from a live donor and almost one in three in Israel. The percentage of transplants from living donors is increasing. Potential donors are carefully evaluated on medical and psychological grounds. This ensures that the donor is fit for surgery and has no disease which brings undue risk or likelihood of a poor outcome for either the donor or recipient. The psychological assessment is to ensure the donor gives informed consent and is not coerced. In countries where paying for organs is illegal, the authorities may also seek to ensure that a donation has not resulted from a financial transaction. In the UK, the
Human Tissue Act 2004The Human Tissue Act 2004 is an Act of the Parliament of the United Kingdom which consolidated previous legislation and created the Human Tissue Authority to "regulate the removal, storage, use and disposal of human bodies, organs and tissue."...
(HTA) dictated that donors must prove a familial or long-term relationship or enduring friendship, for instance by providing photographs of themselves together spread over a period of time or a birth or wedding certificate. Purely altruistic donation to strangers has recently been accepted by the
Human Tissue AuthorityThe Human Tissue Authority is a non-departmental public body in the United Kingdom that regulates the removal, storage, use and disposal of human bodies, organs and tissue for a number of scheduled purposes such as research, transplantation, and education and training.It was created by the Human...
in the United Kingdom, but as of December 2007 only four people had been given permission to do this under the HTA. The decision must be approved by a panel, whereas the typical donation based on relationship is required only to go through an executive. There is good evidence that kidney donation is not associated with long-term harm to the donor.
In some cases of male living donors a hydrocele may occur in the scrotum related to the side of the nephrectomy. As an example, a living donor who had a left side laproscopic nephrectomy, the left side of the scrotum can develop a hydrocele that envelopes the left testicle and enlargens the left side of the scrotum. This condition is typically non threatening and can disappear over time.
So called "daisy chain" transplants in the US involve one altruistic donor who donates a kidney to someone who has a family member willing to donate, who isn't a match. That family member then donates to a recipient who is a match. This "chain" can be continued with several more pairs of donors/recipients.
Traditionally, the donor procedure has been through a single incision of 4 –, but live donation is being increasingly performed by
laparoscopic surgeryLaparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...
. This reduces pain and accelerates recovery for the donor. Operative time and complications decreased significantly after a surgeon performed 150 cases. Live donor kidney grafts have higher long-term success rates than those from deceased donors. Since the increase in the use of laparoscopic surgery, the number of live donors has increased. Any advance which leads to a decrease in pain and scarring and swifter recovery has the potential to boost donor numbers. In January 2009, the first
all-roboticRobotic surgery, computer-assisted surgery, and robotically-assisted surgery are terms for technological developments that use robotic systems to aid in surgical procedures....
kidney transplant was performed at
Saint Barnabas Medical CenterSaint Barnabas Medical Center , an affiliate of the Barnabas Health , is a 597-bed non-profit major teaching hospital located in Livingston, New Jersey...
through a two-inch incision. In the following six months, the same team performed eight more robotic-assisted transplants.
In 2004 the FDA approved the Cedars-Sinai High Dose IVIG therapy which reduces the need for the living donor to be the same
blood typeA blood type is a classification of blood based on the presence or absence of inherited antigenic substances on the surface of red blood cells . These antigens may be proteins, carbohydrates, glycoproteins, or glycolipids, depending on the blood group system...
(ABO compatible) or even a tissue match. The therapy reduced the incidence of the recipient's immune system rejecting the donated kidney in highly sensitized patients.
In 2009 at the Johns Hopkins Medical Center, a healthy kidney was removed through the donor's vagina. Vaginal donations promise to speed recovery and reduce scarring. The first donor was chosen as she had previously had a
hysterectomyA hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...
. The extraction was performed using natural orifice transluminal endoscopic surgery, where an endoscope is inserted through an orifice, then through an internal incision, so that there is no external scar. The recent advance of
single port laparoscopySingle port laparoscopy , also known as single port access surgery , single port incisionless conventional equipment-utilizing surgery , single incision laparoscopic surgery , Single access endoscopic surgery , laparo-endoscopic single-site surgery , natural orifice transumbilical surgery , and one...
requiring only one entry point at the navel is another advance with potential for more frequent use.
Organ trade
In the developing world some people sell their organs. Such people are often in grave poverty or are exploited by salespersons. People traveling to make use of such kidneys, sometimes known as "transplant tourists," are not looked upon favorably by organizations such as the U.S.
National Kidney FoundationThe National Kidney Foundation, Inc. is a major voluntary health organization in the United States, headquartered in New York City...
. These patients may have increased complications owing to poor infection control and lower medical and surgical standards. One surgeon has said that organ trade could be legalized in the UK to prevent such tourism, but this is not seen by the
National Kidney Research FundNational Kidney Research Fund is a British medical research charity, founded in 1961, dedicated to the curing of kidney diseases. The organization's priorities are to fund research into kidney disease, to provide financial support for the treatment of kidney disease, and to raise public awareness...
as the answer to a deficit in donors.
Deceased donors
Deceased donors can be divided in two groups:
- Brain-dead
Brain death is the irreversible end of all brain activity due to total necrosis of the cerebral neurons following loss of brain oxygenation. It should not be confused with a persistent vegetative state...
(BD) donors
- Donation after Cardiac Death
Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
(DCD) donors
Although brain-dead (or "beating heart") donors are considered dead, the donor's heart continues to pump and maintain the
circulationThe circulatory system is an organ system that passes nutrients , gases, hormones, blood cells, etc...
. This makes it possible for surgeons to start operating while the organs are still being
perfusedIn physiology, perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. The word is derived from the French verb "perfuser" meaning to "pour over or through."...
. During the operation, the
aortaThe aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries...
will be cannulated, after which the donor's blood will be replaced by an ice-cold storage solution, such as UW (
ViaspanViaspan, also known as University of Wisconsin solution , was the first solution thoughtfully designed for use in organ transplantation, and became the first intracellular-like preservation medium...
),
HTKHistidine-tryptophan-ketoglutarate, or Custodiol HTK solution is a high-flow, low-potassium preservation solution used for organ transplantation....
, or Perfadex. Depending on which organs are transplanted, more than one solution may be used simultaneously. Due to the temperature of the solution, and since large amounts of cold
NaClSodium chloride, also known as salt, common salt, table salt or halite, is an inorganic compound with the formula NaCl. Sodium chloride is the salt most responsible for the salinity of the ocean and of the extracellular fluid of many multicellular organisms...
-solution are poured over the organs for a rapid cooling, the heart will stop pumping.
"Donation after Cardiac Death" donors are patients who do not meet the brain-dead criteria but, due to the small chance of recovery, have elected via a living will or through family to withdraw support. In this procedure, treatment is discontinued (
mechanical ventilationIn medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be assisted by a physician, respiratory therapist or other suitable person compressing a bag or set of bellows...
is shut off). After a time of death has been pronounced, the patient is rushed to the operating room where the organs are recovered. Storage solution is flushed through the organs. Since the blood is no longer being circulated,
coagulationCoagulation is a complex process by which blood forms clots. It is an important part of hemostasis, the cessation of blood loss from a damaged vessel, wherein a damaged blood vessel wall is covered by a platelet and fibrin-containing clot to stop bleeding and begin repair of the damaged vessel...
must be prevented with large amounts of anti-coagulation agents such as
heparinHeparin , also known as unfractionated heparin, a highly sulfated glycosaminoglycan, is widely used as an injectable anticoagulant, and has the highest negative charge density of any known biological molecule...
. Several ethical and procedural guidelines must be followed; most importantly, the organ recovery team should not participate in the patient's care in any manner until after death has been declared.
Compatibility
If plasmapheresis or IVIG is not performed, the donor and recipient have to be
ABO blood groupA blood type is a classification of blood based on the presence or absence of inherited antigenic substances on the surface of red blood cells . These antigens may be proteins, carbohydrates, glycoproteins, or glycolipids, depending on the blood group system...
compatible. Also, they should ideally share as many
HLAThe human leukocyte antigen system is the name of the major histocompatibility complex in humans. The super locus contains a large number of genes related to immune system function in humans. This group of genes resides on chromosome 6, and encodes cell-surface antigen-presenting proteins and...
and "minor
antigenAn antigen is a foreign molecule that, when introduced into the body, triggers the production of an antibody by the immune system. The immune system will then kill or neutralize the antigen that is recognized as a foreign and potentially harmful invader. These invaders can be molecules such as...
s" as possible. This decreases the risk of
transplant rejectionTransplant rejection occurs when transplanted tissue is rejected by the recipient's immune system, which destroys the transplanted tissue. Transplant rejection can be lessened by determining the molecular similitude between donor and recipient and by use of immunosuppressant drugs after...
and the need for another transplant. The risk of rejection may be further reduced if the recipient is not already sensitized to potential donor HLA antigens, and if immunosuppressant levels are kept in an appropriate range. The level of sensitization to donor HLA antigens is determined by performing a
panel reactive antibodyPanel Reactive Antibody is a blood test that is routinely performed on patients waiting for kidney and heart transplants and measures anti-human antibodies in the blood. The PRA score is given as a percentage and can be from 0% to 99%. The PRA represents the percentage of the U.S...
test on the potential recipient. In the United States, up to 17% of all deceased donor kidney transplants have no HLA mismatch. However, HLA matching is a relatively minor predictor of transplant outcomes. In fact, living non-related donors are now almost as common as living (genetically)-related donors.
In the 1980s, experimental protocols were developed for ABO-incompatible transplants using increased
immunosuppressionImmunosuppression involves an act that reduces the activation or efficacy of the immune system. Some portions of the immune system itself have immuno-suppressive effects on other parts of the immune system, and immunosuppression may occur as an adverse reaction to treatment of other...
and
plasmapheresisPlasmapheresis is the removal, treatment, and return of blood plasma from blood circulation. It is thus an extracorporeal therapy...
. Through the 1990s these techniques were improved and an important study of long-term outcomes in Japan was published (
http://www.centerspan.org/pubs/transplantation/1998/0127/tr029800224o.pdf). Now, a number of programs around the world are routinely performing ABO-incompatible transplants.
Procedure
In most cases the barely functioning existing kidneys are not removed, as this has been shown to increase the rates of surgical morbidities. Therefore, the kidney is usually placed in a location different from the original kidney, often in the
iliac fossaThe iliac fossa is a large, smooth, concave surface located on the internal surface of the ilium...
, so it is often necessary to use a different blood supply:
- The renal artery
The renal arteries normally arise off the side of the abdominal aorta, immediately below the superior mesenteric artery, and supply the kidneys with blood. Each is directed across the crus of the diaphragm, so as to form nearly a right angle with the aorta....
of the kidney, previously branching from the abdominal aortaThe abdominal aorta is the largest artery in the abdominal cavity. As part of the aorta, it is a direct continuation of the descending aorta .-Path:...
in the donor, is often connected to the external iliac arteryThe external iliac arteries are two major arteries which bifurcate off the common iliac arteries anterior to the sacroiliac joint of the pelvis. They proceed anterior and inferior along the medial border of the psoas major muscles...
in the recipient.
- The renal vein
The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava.It is usually singular to each kidney, except in the condition "multiple renal veins".It also divides into 2 divisions upon entering the kidney:...
of the new kidney, previously draining to the inferior vena cavaThe inferior vena cava , also known as the posterior vena cava, is the large vein that carries de-oxygenated blood from the lower half of the body into the right atrium of the heart....
in the donor, is often connected to the external iliac veinThe external iliac veins are large veins that connect the femoral veins to the common iliac veins. Their origin is at the inferior margin of the inguinal ligaments and they terminate when they join the internal iliac veins ....
in the recipient.
There is disagreement in surgical textbooks regarding which side of the recipient’s pelvis to use in receiving the transplant. Campbell's Urology (2002) recommends placing the donor kidney in the recipient’s contralateral side (i.e. a left sided kidney would be transplanted in the recipient's right side) to ensure the renal pelvis and ureter are anterior in the event that future surgeries are required. In an instance where there is doubt over whether there is enough space in the recipient’s pelvis for the donor's kidney the textbook recommends using the right side because the right side has a wider choice of arteries and veins for reconstruction. Smith's Urology (2004) states that either side of the recipient's pelvis is acceptable, however the right vessels are “more horizontal” with respect to each other and therefore easier to use in the anastomoses. It is unclear what is meant by the words “more horizontal”. Glen's Urological Surgery (2004) recommends putting the kidney in the contralateral side in all circumstances. No reason is explicitly put forth; however, one can assume the rationale is similar to that of Campbell's—to ensure that the renal pelvis and ureter are most anterior in the event that future surgical correction becomes necessary.
Kidney-pancreas transplant
Occasionally, the kidney is transplanted together with the
pancreasThe pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin, as well as a digestive organ, secreting pancreatic juice containing digestive enzymes that assist...
. This is done in patients with
diabetes mellitus type 1Diabetes mellitus type 1 is a form of diabetes mellitus that results from autoimmune destruction of insulin-producing beta cells of the pancreas. The subsequent lack of insulin leads to increased blood and urine glucose...
, in whom the diabetes is due to destruction of the
beta cellBeta cells are a type of cell in the pancreas located in the so-called islets of Langerhans. They make up 65-80% of the cells in the islets.-Function:...
s of the pancreas and in whom the diabetes has caused renal failure (
diabetic nephropathyDiabetic nephropathy , also known as Kimmelstiel-Wilson syndrome, or nodular diabetic glomerulosclerosis and intercapillary glomerulonephritis, is a progressive kidney disease caused by angiopathy of capillaries in the kidney glomeruli. It is characterized by nephrotic syndrome and diffuse...
). This is almost always a deceased donor transplant. Only a few living donor (partial) pancreas transplants have been done. For individuals with diabetes and renal failure, the advantages of earlier transplant from a living donor (if available) are far superior to the risks of continued dialysis until a combined kidney and pancreas are available from a deceased donor. A patient can either receive a living kidney followed by a donor pancreas at a later date (PAK, or pancreas-after-kidney) or a combined kidney-pancreas from a donor (SKP, simultaneous kidney-pancreas).
TransplantingIslet transplantation is the transplantation of isolated islets from a donor pancreas and into another person. It is an experimental treatment for type 1 diabetes mellitus. Once transplanted, the islets begin to produce insulin, actively regulating the level of glucose in the blood.Islets are...
just the
islet cellsThe islets of Langerhans are the regions of the pancreas that contain its endocrine cells. Discovered in 1869 by German pathological anatomist Paul Langerhans at the age of 22, the islets of Langerhans constitute approximately 1 to 2% of the mass of the pancreas...
from the pancreas is still in the experimental stage, but shows promise. This involves taking a deceased donor pancreas, breaking it down, and extracting the islet cells that make
insulinInsulin is a hormone central to regulating carbohydrate and fat metabolism in the body. Insulin causes cells in the liver, muscle, and fat tissue to take up glucose from the blood, storing it as glycogen in the liver and muscle....
. The cells are then injected through a catheter into the recipient and they generally lodge in the liver. The recipient still needs to take
immunosuppressantsImmunosuppressive drugs or immunosuppressive agents are drugs that inhibit or prevent activity of the immune system. They are used in immunosuppressive therapy to:...
to avoid
rejectionTransplant rejection occurs when transplanted tissue is rejected by the recipient's immune system, which destroys the transplanted tissue. Transplant rejection can be lessened by determining the molecular similitude between donor and recipient and by use of immunosuppressant drugs after...
, but no surgery is required. Most people need two or three such injections, and many are not completely insulin-free.
Post operation
The transplant surgery takes about three hours. The donor kidney will be placed in the lower abdomen and its blood vessels connected to arteries and veins in the recipient's body. When this is complete, blood will be allowed to flow through the kidney again. The final step is connecting the ureter from the donor kidney to the bladder. In most cases, the kidney will soon start producing urine.
Depending on its quality, the new kidney usually begins functioning immediately. Living donor kidneys normally require 3–5 days to reach normal functioning levels, while cadaveric donations stretch that interval to 7–15 days. Hospital stay is typically for 4–7 days. If complications arise, additional medications (diuretics) may be administered to help the kidney produce urine.
Immunosuppressant drugs are used to suppress the immune system from rejecting the donor kidney. These medicines must be taken for the rest of the patient's life. The most common medication regimen today is a cocktail of
tacrolimusTacrolimus is an immunosuppressive drug that is mainly used after allogeneic organ transplant to reduce the activity of the patient's immune system and so lower the risk of organ rejection...
,
mycophenolateMycophenolic acid INN or mycophenolate is an immunosuppressant drug used to prevent rejection in organ transplantation. It inhibits an enzyme needed for the growth of T cells and B cells. It was initially marketed as the prodrug mycophenolate mofetil to improve oral bioavailability. More...
, and
prednisonePrednisone is a synthetic corticosteroid drug that is particularly effective as an immunosuppressant drug. It is used to treat certain inflammatory diseases and some types of cancer, but has significant adverse effects...
. Some patients may instead take cyclosporine,
sirolimusSirolimus , also known as rapamycin, is an immunosuppressant drug used to prevent rejection in organ transplantation; it is especially useful in kidney transplants. A macrolide, sirolimus was first discovered as a product of the bacterium Streptomyces hygroscopicus in a soil sample from Easter...
, or
azathioprineAzathioprine is a purine analogue immunosuppressive drug. It is used to prevent organ rejection following organ transplantation and to treat a vast array of autoimmune diseases, including rheumatoid arthritis, pemphigus, inflammatory bowel disease , multiple sclerosis, autoimmune hepatitis, atopic...
. Cyclosporine, considered a breakthrough immunosuppressive when first discovered in the 1980s, ironically causes
nephrotoxicityNephrotoxicity is a poisonous effect of some substances, both toxic chemicals and medication, on the kidneys. There are various forms of toxicity. Nephrotoxicity should not be confused with the fact that some medications have a predominantly renal excretion and need their dose adjusted for the...
and can result in iatrogenic damage to the newly transplanted kidney. Blood levels must be monitored closely and if the patient seems to have declining renal function, a biopsy may be necessary to determine whether this is due to rejection or cyclosporine intoxication.
Postoperative diet
Kidney transplant recipients are discouraged from consuming grapefruit, pomegranate and green tea products. These food products are known to interact with the transplant medications, specifically tacrolimus, cyclosporin and sirolimus; the blood levels of these drugs may be lowered, potentially leading to a rejection episode.
Acute
rejectionTransplant rejection occurs when transplanted tissue is rejected by the recipient's immune system, which destroys the transplanted tissue. Transplant rejection can be lessened by determining the molecular similitude between donor and recipient and by use of immunosuppressant drugs after...
occurs in 10–25% of people after transplant during the first 60 days. Rejection does not necessarily mean loss of the organ, but it may necessitate additional treatment and medication adjustments.
Complications
Problems after a transplant may include:
- Transplant rejection (hyperacute, acute or chronic)
- Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
s and sepsisSepsis is a potentially deadly medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues...
due to the immunosuppressantAn immunosuppressant is any substance that performs immunosuppression of the immune system. They may be either exogenous, as immunosuppressive drugs, or endogenous, as ,e. g., testosterone...
drugs that are required to decrease risk of rejection
- Post-transplant lymphoproliferative disorder
Post-transplant lymphoproliferative disorder is the name given to a B-cell proliferation due to therapeutic immunosupression after organ transplantation. These patients may develop infectious mononucleosis-like lesions or polyclonal polymorphic B-cell hyperplasia...
(a form of lymphomaLymphoma is a cancer in the lymphatic cells of the immune system. Typically, lymphomas present as a solid tumor of lymphoid cells. Treatment might involve chemotherapy and in some cases radiotherapy and/or bone marrow transplantation, and can be curable depending on the histology, type, and stage...
due to the immune suppressants)
- Imbalances in electrolytes including calcium and phosphate which can lead to bone problems among other things
- Other side effects of medications including gastrointestinal inflammation and ulceration of the stomach and esophagus, hirsutism
Hirsutism or frazonism is the excessive hairiness on women in those parts of the body where terminal hair does not normally occur or is minimal - for example, a beard or chest hair. It refers to a male pattern of body hair and it is therefore primarily of cosmetic and psychological concern...
(excessive hair growth in a male-pattern distribution), hair loss, obesityObesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
, acneAcne vulgaris is a common human skin disease, characterized by areas of skin with seborrhea , comedones , papules , pustules , Nodules and possibly scarring...
, diabetes mellitus type 2Diabetes mellitus type 2formerly non-insulin-dependent diabetes mellitus or adult-onset diabetesis a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. Diabetes is often initially managed by increasing exercise and...
, hypercholesterolemiaHypercholesterolemia is the presence of high levels of cholesterol in the blood. It is not a disease but a metabolic derangement that can be caused by many diseases, notably cardiovascular disease...
.
A patient's age and health condition before transplantation affect the risk of complications. Different transplant centers have different success at managing complications and therefore, complication rates are different from center to center.
The average lifetime for a donated kidney is ten to fifteen years. When a transplant fails, a patient may opt for a second transplant, and may have to return to dialysis for some intermediary time.
Infections due to the immunosuppressant drugs used in people with kidney transplants most commonly occurs in mucocutaneous areas (41%), the urinary tract (17%) and the respiratory tract (14%). The most common infective agents are bacterial (46%), viral (41%), fungal (13%), and protozoan (1%). Of the viral illnesses, he most common agents are
HCMV (human cytomegalovirus)Human cytomegalovirus is a species of virus that belongs to the viral family known as Herpesviridae or herpesviruses. It is typically abbreviated as HCMV and is alternatively known as human herpesvirus-5 ...
(31.5%),
herpes simplexHerpes simplex is a viral disease caused by both Herpes simplex virus type 1 and type 2 . Infection with the herpes virus is categorized into one of several distinct disorders based on the site of infection. Oral herpes, the visible symptoms of which are colloquially called cold sores or fever...
(23.4%), and
herpes zosterHerpes zoster , commonly known as shingles and also known as zona, is a viral disease characterized by a painful skin rash with blisters in a limited area on one side of the body, often in a stripe...
(23.4%). Infection is the cause of death in about one third of people with renal transplants, and
pneumoniaPneumonia is an inflammatory condition of the lung—especially affecting the microscopic air sacs —associated with fever, chest symptoms, and a lack of air space on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes...
s account for 50% of the patient deaths from infection.
Prognosis
Kidney transplantation is a life-extending procedure. The typical patient will live 10 to 15 years longer with a kidney transplant than if kept on dialysis. The increase in longevity is greater for younger patients, but even 75-year-old recipients (the oldest group for which there is data) gain an average four more years of life. People generally have more energy, a less restricted diet, and fewer complications with a kidney transplant than if they stay on conventional dialysis.
Some studies seem to suggest that the longer a patient is on dialysis before the transplant, the less time the kidney will last. It is not clear why this occurs, but it underscores the need for rapid referral to a transplant program. Ideally, a kidney transplant should be preemptive, i.e., take place before the patient begins dialysis.
At least four professional athletes have made a comeback to their sport after receiving a transplant: New Zealand
rugby unionRugby union, often simply referred to as rugby, is a full contact team sport which originated in England in the early 19th century. One of the two codes of rugby football, it is based on running with the ball in hand...
player
Jonah LomuJonah Tali Lomu, MNZM is a New Zealand rugby union player. He had sixty-three caps as an All Black after debuting in 1994. He is generally regarded as the first true global superstar of rugby union. He has had a huge impact on the game...
, German-Croatian Soccer Player
Ivan KlasnićIvan Klasnić is a Croatian footballer who plays for Bolton Wanderers of the Premier League. He is a Croatian international. In 2007, Klasnić underwent a kidney transplant, and became the first player to participate in a major tournament after a transplant.-St. Pauli:Klasnić started his...
, and
NBAThe National Basketball Association is the pre-eminent men's professional basketball league in North America. It consists of thirty franchised member clubs, of which twenty-nine are located in the United States and one in Canada...
basketballers
Sean ElliottSean Michael Elliott is a retired American professional basketball player in the NBA.-Early life:Elliott was born in Tucson, Arizona and was youngest of three boys. He was a very intelligent boy growing up and attended the G.A.T.E. program at Toleson Elementary School in Tucson, Arizona...
and
Alonzo MourningAlonzo Harding Mourning, Jr. is a former American professional basketball player, who played most of his 15-year NBA career for the Miami Heat....
.
Statistics
Statistics by country, year and donor type
| Country | Year | Cadaveric donor | Living donor | Total transplants |
CanadaCanada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...
|
2000 |
724 |
388 |
|
FranceThe French Republic , The French Republic , The French Republic , (commonly known as France , is a unitary semi-presidential republic in Western Europe with several overseas territories and islands located on other continents and in the Indian, Pacific, and Atlantic oceans. Metropolitan France...
|
2003 |
|
136 |
|
ItalyItaly , officially the Italian Republic languages]] under the European Charter for Regional or Minority Languages. In each of these, Italy's official name is as follows:;;;;;;;;), is a unitary parliamentary republic in South-Central Europe. To the north it borders France, Switzerland, Austria and...
|
2003 |
|
135 |
|
SpainSpain , officially the Kingdom of Spain languages]] under the European Charter for Regional or Minority Languages. In each of these, Spain's official name is as follows:;;;;;;), is a country and member state of the European Union located in southwestern Europe on the Iberian Peninsula...
|
2003 |
|
60 |
|
United KingdomThe United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
|
2003 |
|
439 |
|
United StatesThe United States of America is a federal constitutional republic comprising fifty states and a federal district...
|
2008 |
|
|
|
PakistanPakistan , officially the Islamic Republic of Pakistan is a sovereign state in South Asia. It has a coastline along the Arabian Sea and the Gulf of Oman in the south and is bordered by Afghanistan and Iran in the west, India in the east and China in the far northeast. In the north, Tajikistan...
- SIUTThe Sindh Institute of Urology and Transplantation is a dialysis & kidney transplant centre located in Pakistan.SIUT was founded by Dr. Adeebul Hasan Rizvi and it is Pakistan's largest kidney disease center, as well as Parkistan's largest public sector health organisation...
|
2008 |
|
|
|
- Bill Thompson is the longest-surviving American kidney recipient, having received his kidney in 1966 at age 15; it has survived over 40 years.
- Denice Lombard of Washington, D.C., received her father's kidney on August 30, 1967, at age 13 and is still alive and healthy forty years later.
- John Dan of Nairobi, Kenya, is the known longest-surviving kidney recipient in East Africa. He received a kidney from his brother in 1984 and is still alive 26 years later.
- Chakravarthy from chennai, India, received kidney from his brother on 2nd May 1983 at the age of 29, is still alive and healthy 27 years later.
- Annemarie Grosskopf of Johannesburg, South Africa, received a kidney from a deceased donor in 1981 at the age of 21, and is alive and healthy 30 years later.
In addition to nationality, transplantation rates differ based on race, sex, and income. A study done with patients beginning long-term dialysis showed that the sociodemographic barriers to renal transplantation present themselves even before patients are on the transplant list. For example, different groups express definite interest and complete pretransplant workup at different rates. Previous efforts to create fair transplantation policies had focused on patients currently on the transplantation waiting list.
In the US health system
Transplant recipients must take immunosuppressive anti-rejection drugs for as long as the transplanted kidney functions. For the routine immunosuppressives Prograf, Cellcept and prednisone, these drugs cost US$1,500 per month. In 1999 Congress passed a law that restricts Medicare from paying for more than three years for these drugs, unless the patient is otherwise Medicare eligible. Transplant programs may not transplant a patient unless the patient has a reasonable plan to pay for medication after the medicare expires, however, patients are almost never turned down for financial reasons alone. 50% of patients with end-stage renal disease only have Medicare coverage.
In March 2009 a bill was introduced in the Senate, 565 and in the House, H.R. 1458 that will extend Medicare coverage of the drugs for as long as the patient has a functioning transplant. This means that patients who have lost their jobs and insurance will not also lose their kidney and be forced back on dialysis. Dialysis is currently using up $17 billion yearly of Medicare funds and total care of these patients amounts to over 10% of the entire Medicare budget.
See also
- Gurgaon kidney scandal
The multi-billion rupee Gurgaon kidney scandal came to light in January 2008 when police arrested several people for running a kidney transplant racket in Gurgaon, an industrial township near New Delhi, India...
- Jesus Christians
Jesus Christians is a small Christian group that practices communal living and distributes Bible-based comics and books.-History:The group was started in New South Wales, Australia, by Dave and...
– An Australian religious group, many of whose members have donated a kidney to a stranger
External links