Kidney transplantation or
renal transplantation is the
organ transplantOrgan transplant is the moving of an organ from one body to another , for the purpose of replacing the recipient's damaged or failing organ with a working one from the donor site. Organ donors can be living or deceased...
of a
kidneyThe kidneys are paired organs, which have the production of urine as their primary function. Kidneys are seen in many types of animals, including vertebrates and some invertebrates. They are part of the urinary system, but have several secondary functions concerned with homeostatic functions. ...
in 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 recipient 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 documented kidney transplant in the United States was performed June 17, 1950, on Ruth Tucker, a 44-year-old woman with
polycystic kidney diseaseThe autosomal dominant form of Polycystic kidney disease called ADPKD is much more common but less severe than autosomal recessive polycystic kidney. In 85% of patients, ADPKD is caused by mutations in the gene PKD1 on chromosome 16 ; in 15% of patients mutations in PKD2 are causative...
, 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 because no immunosuppressive therapy was available at the time—the development of effective antirejection drugs was years away—Tucker's remaining diseased kidney began working again and she lived another five years before dying of an unrelated illness.
Thereafter, successful kidney transplantations were undertaken in 1954 in Boston and Paris. The Boston transplantation 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 tumour cells. It detects a wide variety of agents, from viruses to parasitic worms, and needs to distinguish them from the organism's own...
reaction. The first kidney transplant 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 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 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. In 1954, at Brigham Hospital
Dr. Joseph E. MurrayJoseph Edward Murray is a retired American plastic surgeon. He performed the first successful human kidney transplant from an adult to his identical twin in 1954....
and Dr. J. Hartwell Harrison performed the world's first successful renal transplant between genetically identical patients, for which Dr. Murray received the
Nobel Prize for MedicineThe Nobel Prize in Physiology or Medicine is awarded once a year by the Swedish Karolinska Institute. It is one of the five Nobel Prizes established by the will of Alfred Nobel in 1895, awarded for outstanding contributions in Physics, Chemistry, Literature, Peace, and Physiology or Medicine...
in 1990. The donor is still alive as of 2005; the recipient died eight years after the transplantation.
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 a transplanted organ or tissue is not accepted by the body of the transplant recipient. This is explained by the concept that the immune system of the recipient attacks the transplanted organ or tissue...
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 detrimental colonization of a host organism by a foreign species. In an infection, the infecting organism seeks to utilize the host's resources to multiply, usually at the expense of the host. The infecting organism, or pathogen, interferes with the normal functioning of the...
and
cancerCancer is a class of diseases in which a group of cells display uncontrolled growth , invasion , and sometimes metastasis...
(particularly
skin cancerSkin cancer is a malignant growth on the skin which can have many causes. The most common skin cancers are basal cell cancer, squamous cell cancer, and melanoma. Skin cancer generally develops in the epidermis , so a tumor is usually clearly visible. This makes most skin cancers detectable in the...
and
lymphomaLymphoma is a cancer that begins in the lymphocytes of the immune system and presents as a solid tumor of lymphoid cells. They often originate like balls in lymph nodes, presenting as an enlargement of the node...
), 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, and may result from an unsuitable or incorrect dosage or...
of the medications.
The basis for most immunosuppressive regimens is
prednisolonePrednisolone is the active metabolite of prednisone.-Uses:Prednisolone is a corticosteroid drug with predominantly glucocorticoid and low mineralocorticoid activity, making it useful for the treatment of a wide range of inflammatory and auto-immune conditions such as asthma, uveitis, rheumatoid...
, 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 bone that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is disrupted, and the amount and variety of non-collagenous 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 secondary to many diseases and can contribute to many forms of disease, most 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 drop in the glomerular filtration rate (GFR) to 20–25% of normal. Common diseases leading to ESRD include
malignant hypertensionMalignant hypertension is a complication of hypertension characterized by very elevated blood pressure, and organ damage in the eyes, brain, lung and/or kidneys.It differs from other complications of hypertension in that it is accompanied by papilledema...
,
infectionAn infection is the detrimental colonization of a host organism by a foreign species. In an infection, the infecting organism seeks to utilize the host's resources to multiply, usually at the expense of the host. The infecting organism, or pathogen, interferes with the normal functioning of the...
s,
diabetes mellitusDiabetes mellitus —often referred to simply as diabetes—is a condition in which the body either does not produce enough, or does not properly respond to, insulin, a hormone produced in the pancreas. Insulin enables cells to absorb glucose in order to turn it into energy...
and
glomerulonephritisGlomerulonephritis, also known as glomerular nephritis, abbreviated GN, is a renal disease characterized by inflammation of the glomeruli, or small blood vessels in the kidneys. It may present with isolated hematuria and/or proteinuria ; or as a nephrotic syndrome, a nephritic syndrome, acute...
; genetic causes include
polycystic kidney diseaseThe autosomal dominant form of Polycystic kidney disease called ADPKD is much more common but less severe than autosomal recessive polycystic kidney. In 85% of patients, ADPKD is caused by mutations in the gene PKD1 on chromosome 16 ; in 15% of patients mutations in PKD2 are causative...
, a number of inborn errors of metabolism, and autoimmune conditions such as
lupusSystemic lupus erythematosus is a chronic autoimmune connective tissue disease that can affect any part of the body...
and
Goodpasture's syndromeGoodpasture’s syndrome is a rare condition characterized by glomerulonephritis and hemorrhaging of the lungs...
. Diabetes is the most common cause of kidney transplant, accounting for approximately 25% of those in the US. The majority of renal transplant recipients are on some form of
dialysisIn medicine, dialysis is primarily used to provide an artificial replacement for lost kidney function due to renal failure...
—
hemodialysisIn medicine, hemodialysis is a method for removing waste products such as potassium and urea, as well as free water from the blood when the kidneys are in renal failure. Hemodialysis is one of three renal replacement therapies .Hemodialysis can be an outpatient or inpatient therapy...
,
peritoneal dialysisPeritoneal dialysis is a treatment for patients with severe chronic kidney failure. 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 diseaseCardiovascular disease or cardiovascular diseases is the class of diseases that involve the heart or blood vessels ....
, incurable terminal infectious diseases and
cancerCancer is a class of diseases in which a group of cells display uncontrolled growth , invasion , and sometimes metastasis...
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 abuseAlthough the term substance can refer to any physical matter, substance abuse has come to refer to the overindulgence in and dependence of a drug or other chemical leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others.]The disorder is...
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, current research does not bear out this fear; in fact there are findings that immunosuppressive drugs 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 need not 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 of 2004 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 Authority in the United Kingdom, and 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.
Traditionally, the donor procedure has been through a single incision of , but live donation is being increasingly performed by
laparoscopic surgeryLaparoscopic surgery, also called minimally invasive surgery , bandaid surgery, keyhole surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions as compared to larger incisions needed in traditional surgical procedures.Practicioners of "open"...
. 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 tend to perform better than those from deceased donors. Since the increase in the use of laparascopic 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 is the use of robots in performing surgery. Three major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Some major advantages of robotic surgery are precision, miniaturization, smaller incisions, decreased blood loss,...
kidney transplant was performed at
Saint Barnabas Medical CenterSaint Barnabas Medical Center , an affiliate of the Saint Barnabas Health Care System, 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 tranplants.
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...
(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 access surgerySingle port access surgery, also known as laparo endoscopic single-site surgery , single incision laparoscopic surgery or one port umbilical surgery or single port incisionless conventional equipment-utilizing surgery or natural orifice transumbilical surgery , is an advanced minimally invasive...
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 exploited by salespersons. People travelling to make use of such kidneys, sometimes known as "transplant tourists", are not looked upon favorably by organizations such as the US
National Kidney FoundationThe National Kidney Foundation, Inc. is a major voluntary health organization in the United States. Its mission is to prevent kidney and urinary tract diseases, improve the health and well-being of individuals and families affected by these diseases, and increase the availability of all organs...
. These patients may have increased complications due to poor infection control and lower medical and surgical standards. One surgeon has said 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 a legal definition of death that refers to the irreversible end of all brain activity due to total necrosis of the cerebral neurons following loss of blood flow and oxygenation. It should not be confused with a persistent vegetative state...
(BD) donors
- Donation after Cardiac Death
A cardiac arrest, also known as cardiopulmonary arrest or circulatory arrest, is the abrupt cessation of normal circulation of the blood due to failure of the heart to contract effectively during systole....
(DCD) donors
Although brain-dead (or "heart-beating") donors are considered dead, the donor's heart continues to pump and maintain the
circulation- [Headline text]--75.137.171.242 01:21, 21 October 2009 :bThe circulatory system is an organ system that passes nutrients , gases, hormones, blood cells, nitrogen waste products, etc. to and from cells in the body to help fight diseases and help stabilize body temperature and pHb to maintain...
. 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 bringing oxygenated blood to all parts of the body in the systemic circulation....
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 ionic 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 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 , 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, a highly-sulfated glycosaminoglycan, is widely used as an injectable anticoagulant, and has the highest negative charge density of any known biological molecule. It can also be used to form an inner anticoagulant surface on various experimental and medical devices such as test tubes and...
. 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...
compatible. Also, they should ideally share as many
HLAThe human leukocyte antigen system is the name of the major histocompatibility complex in humans. The superlocus contains a large number of genes related to immune system function in humans. This group of genes resides on chromosome 6, and encode cell-surface antigen-presenting proteins and many...
and "minor
antigenAn antigen is a substance that prompts the generation of antibodies and can cause an immune response. "Self" antigens are usually tolerated by the immune system; whereas "Non-self" antigens are identified as intruders and attacked by the immune system...
s" as possible. This decreases the risk of
transplant rejectionTransplant rejection occurs when a transplanted organ or tissue is not accepted by the body of the transplant recipient. This is explained by the concept that the immune system of the recipient attacks the transplanted organ or tissue...
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. 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 immunosuppression and plasmapheresis. 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 descending aorta.-Path:...
in the donor, is often connected to the external iliac arteryThe external iliac artery is a large artery in the pelvic region that carries blood to the lower limb.The external iliac artery is a paired artery, meaning there is one on each side of the body: a right external iliac artery and left external iliac artery.The external iliac artery is accompanied by...
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 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.
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 an exocrine gland, secreting pancreatic juice containing digestive enzymes that pass to...
. This is done in patients with
diabetes mellitusDiabetes mellitus —often referred to simply as diabetes—is a condition in which the body either does not produce enough, or does not properly respond to, insulin, a hormone produced in the pancreas. Insulin enables cells to absorb glucose in order to turn it into energy...
type I, in whom the diabetes is due to destruction of the
beta cellright|thumbnail|300px|A porcine islet of Langerhans. The left image is a brightfield image created using [[hematoxylin]] stain; nuclei are dark circles and the [[acinar]] pancreatic tissue is darker than the islet tissue...
s of the pancreas and in whom the diabetes has caused renal failure (
diabetic nephropathyDiabetic nephropathy , also known as Kimmelstiel-Wilson syndrome 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 glomerulosclerosis...
). 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, 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 that has extensive effects on metabolism and other body functions, such as vascular compliance. 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, and stopping use of fat as an energy...
. 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 a transplanted organ or tissue is not accepted by the body of the transplant recipient. This is explained by the concept that the immune system of the recipient attacks the transplanted organ or tissue...
, 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 lasts five hours on average. 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 4–7days. 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 whose main use is after allogeneic organ transplant to reduce the activity of the patient's immune system and so lower the risk of organ rejection. It reduces T-cell and interleukin-2 activity...
,
mycophenolateMycophenolic acid or mycophenolate is an immunosuppressant drug used to prevent rejection in organ transplantation. It was initially marketed as the prodrug mycophenolate mofetil to improve oral bioavailability. More recently, the salt mycophenolate sodium has also been introduced...
, and
prednisonePrednisone is a synthetic corticosteroid drug that is particularly effective as an immunosuppressant, and affects virtually all of the immune system. It is used to treat certain inflammatory diseases and cancers, but has significant adverse effects. It is usually taken orally but can be delivered...
. Some patients may instead take cyclosporine,
rapamycinSirolimus , 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 drug that suppresses the immune system.Azathioprine is used in organ transplantation and autoimmune disease. Some of the autoimmune diseases are rheumatoid arthritis, pemphigus, Inflammatory Bowel Disease , multiple sclerosis, autoimmune hepatitis and restrictive lung...
. 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 kidney. 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.
Acute
rejectionTransplant rejection occurs when a transplanted organ or tissue is not accepted by the body of the transplant recipient. This is explained by the concept that the immune system of the recipient attacks the transplanted organ or tissue...
occurs in 10–25% of people after transplant during the first sixty days. Rejection does not necessarily mean loss of the organ, but may require additional treatment and medication adjustments.
Complications
Problems after a transplant may include:
- Transplant rejection (hyperacute, acute or chronic)
- Infection
An infection is the detrimental colonization of a host organism by a foreign species. In an infection, the infecting organism seeks to utilize the host's resources to multiply, usually at the expense of the host. The infecting organism, or pathogen, interferes with the normal functioning of the...
s and sepsisSepsis is a serious medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection.
due to the immunosuppressantAn immunosuppressant is any substance that performs immunosuppression of the immune system. They may either be 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 group of B cell lymphomas occurring in immunosuppressed patients following organ transplant.-Incidence/prevalence:...
(a form of lymphomaLymphoma is a cancer that begins in the lymphocytes of the immune system and presents as a solid tumor of lymphoid cells. They often originate like balls in lymph nodes, presenting as an enlargement of the node...
due to the immune suppressants)
- Imbalances in electrolytes including calcium and phosphate which can lead to bone problems amongst other things
- Other side effects of medications including gastrointestinal inflammation and ulceration of the stomach and esophagus, hirsutism
Hirsutism is excessive and increased hair growth on female humans in locations where the occurrence of terminal hair normally is minimal or absent. 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 skin condition, caused by changes in pilosebaceous units, skin structures consisting of a hair follicle and its associated sebaceous gland, via androgen stimulation. It is characterized by noninflammatory follicular papules or comedones and by inflammatory papules,...
, diabetes mellitusDiabetes mellitus —often referred to simply as diabetes—is a condition in which the body either does not produce enough, or does not properly respond to, insulin, a hormone produced in the pancreas. Insulin enables cells to absorb glucose in order to turn it into energy...
(type 2), hypercholesterolemiaHypercholesterolemia is the presence of high levels of cholesterol in the blood. It is not a disease but a metabolic derangement that can be secondary to many diseases and can contribute to many forms of disease, most notably cardiovascular disease...
, and others.
The average lifetime for a donor 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.
Prognosis
Kidney transplantation is a life-extending procedure. The typical patient will live ten to fifteen years longer with a kidney transplant than if kept on dialysis. The years of life gained 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' 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 pre-emptive, 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 is a full contact team sport, a form of football which originated in England in the early 19th century. One of the codes of rugby football, it is based on running with the ball in hand. It is played with an oval-shaped ball, outdoors on a level field, usually with a grass surface, 100 m...
player Jonah LomuJonah Tali Lomu, MNZM is a New Zealand rugby union footballer. 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. One of the sport's most intimidating players on the field, he has had a huge impact on the game...
, German-Croatian Soccer Player Ivan KlasnićIvan Klasnić is a Croatian footballer who currently plays for English Premier League side Bolton Wanderers on loan from FC Nantes, and the Croatian national team.-St. Pauli:...
, and NBAThe National Basketball Association is a professional basketball league, composed of thirty teams in North America . It is an active member of USA Basketball , which is recognized by the International Basketball Federation as the National Governing Body for basketball in the United States...
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 Brichta Elementary School in Tucson, Arizona...
and Alonzo MourningAlonzo Harding Mourning, Jr. is a retired American professional basketball player, who played most of his 16-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 country occupying most of northern North America, extending from the Atlantic Ocean in the east to the Pacific Ocean in the west and northward into the Arctic Ocean...
|
2000 |
724 |
388 |
|
FranceFrance , officially the French Republic , is a country located in Western Europe, with several overseas islands and territories located on other continents. Metropolitan France extends from the Mediterranean Sea to the English Channel and the North Sea, and from the Rhine to the Atlantic Ocean...
|
2003 |
| 136 |
|
ItalyItaly , officially the Italian Republic , is a country located on the Italian Peninsula in Southern Europe and on the two largest islands in the Mediterranean Sea, Sicily and Sardinia. Italy shares its northern, Alpine boundary with France, Switzerland, Austria and Slovenia...
|
2003 |
| 135 |
|
SpainSpain , officially the Kingdom of Spain , is a country located in southwestern Europe on the Iberian Peninsula. [The Spanish constitution does not establish any official denomination of the country, even though España , Estado español and Nación española are used interchangeably...]
|
2003 |
| 60 |
|
United KingdomThe United Kingdom of Great Britain and Northern Ireland is a sovereign state located off the northwestern coast of continental Europe. It is an island country, spanning an archipelago including Great Britain, the northeastern part of Ireland, and many small islands...
|
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 country located at the crossroads of South Asia, the Middle East, and Central Asia...
- SIUT |
2008 |
|
|
|
- Australian Aboriginal activist Charles Perkins is the longest surviving Australian receiver of a kidney transplant, living twenty-eight years on his donor organ.
- Denice Lombard of Washington, D.C., received her father's kidney on August 30, 1967, aged 13 and is still alive and healthy forty years later.
In the US health system
The major barrier to individuals being accepted by a kidney transplant program in the United States is lack of employer based insurance. 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. Therefore, as of 2009, no kidney transplant center in the US will accept patients who cannot guarantee they can pay for their drugs after Medicare support ceases. This is because transplant teams believe it wastes a donated kidney when patients without insurance cannot afford drug bills and reject the kidney. 75% of patients with end-stage renal disease only have Medicare coverage.
The 1999 law passed against the specific recommendations of the Institute of Medicine study Congress had ordered, which states in the publication "Kidney failure and the federal government" that patients who want a transplant should be covered to the same extent that dialysis patients are covered—100%—since maintaining a dialysis patient at $72,000 a year for basic dialysis plus that much again to treat these critically ill patients with, on average, two hospitalizations a year from infections from their access to the machines and strokes, heart attacks and other complications of dialysis for a total cost to Medicare per dialysis patient of $150,000 a year is much more expensive than $17,000 a year to maintain a patient after transplant.
In March of 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 radical 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 andCherry McKay in 1975. It has operated under several...
– An Australian religious group, many of whose members have donated a kidney to a stranger
- Donald Wilford - An American surgeon who has performed many kidney transplants
External links