A person with permanent kidney failure (end stage renal disease, ESRD) needs renal replacement theray (RRT) to remove waste from their body. This could be achieved by hemodialysis, peritoneal dialysis or kidney (renal) transplantation (KTP). KTP is the solid organ transplant where a kidney from healthy donor is removed and transplanted into a patient with ESRD. Kidney transplantation is the best treatment option that allows him to live much like a normal person.

Kidney Transplantation is typically classified as

• Deceased-Donor (formerly known as cadaveric) where organ from brain dead individual is utilized.
• Living-donor transplantation organ from related (living-related) or non-related (living-unrelated) donor depending on whether a biological relationship exists between the donor and recipient is used.

Generally most patients with ESRD can undergo KTP but some people with kidney failure specially patient in older age and severe heart or vascular disease may be unfit to undergo kidney transplantation and are treated with long term dialysis. The conditions that prevent a person from being eligible for kidney transplantation include:

• Active or recently treated cancer.
• Active infection.
• A chronic illness that could lead to death within a few years.
• Dementia/Poorly controlled mental illness.
• Severe obesity (a body mass index greater than 40).
• Current drug or alcohol abuse.

A successful transplant takes a coordinated effort from the health care team which includes nephrologist, transplant surgeon, transplant coordinator, and dietitian. But the most important members are the patient and his family. By learning about the treatment, one can work along with the health care team to give the best possible results and the patient can lead a full, active life.

The Transplant Process

The transplantation process begins when the patient understands that his kidneys are failing and now he must start to consider the treatment options like maintainence dialysis or kidney transplantation. The healthcare team thoroughly evaluates the patient and then tells about his fitness for successful transplantation.

Medical Evaluation at a Transplant Centre

The patient medical evaluation is done to access fitness for undergoing transplantation. A detailed workup for transplantation is started. The patient blood is tested for blood type and other matching factors to determine whether the body will accept an available kidney. The medical and surgical team evaluate to see whether the patient is healthy enough to undergo the surgery. Cancer, a serious infection, or significant cardiovascular disease would make transplantation unlikely to succeed. At each step of evaluation the team want to make sure that the patient can understand the process and follow the schedule for taking medicines.

Kidney Recipient Evaluation

Suitability for kidney transplantation is basically depends on two factors:

• Blood group The recipient blood group (A, B, AB, or O) must be compatible with the donor's blood group.
• HLA factors HLA stands for human leukocyte antigen, a genetic marker located on the surface of white blood cells. Every individual inherit a set of three antigens from the mother and three from the father. A higher number of matching antigens increases the chance for the transplanted new kidney to last for a long time.
  If one is selected on the basis of the first two factors, a third is evaluated: Antibodies (Cross match) A person immune system may produce antibodies that act specifically against antigen in the donor's tissues. To see whether this is the case, a small sample of recipient blood is mixed with a small sample of the donor's blood in a tube. If no reaction occurs, this is described as negative cross-match. This suggests that one will be able to accept the particular donor kidney.

Donor Evaluation

Potential donor needs to be tested to make sure that donating a kidney will not endanger his health. First degree relative as a donor is always preferred over unrelated donor because of better match and improved success rate. Most people can donate a kidney with little risk. The donor undergoes a set of investigation which determines his medical fitness and vascular anatomy of the kidney.

Transplant Operation

In the living donor kidney transplantation, the operation is scheduled in advance. The recipient and the donor are operated on at the same time, usually in side-by-side operation theatre. One team of surgeons performs the donor nephrectomy that is the removal of the kidney from the donor, while another prepares the recipient pelvic vessels for placement of the donated kidney.

The recipient is given general anesthesia and the surgery takes 3 or 4 hours. The surgeon makes a small cut in the lower abdomen. The artery and vein from the new kidney are attached to the artery and vein of recipient. The ureter from the new kidney is connected to the urinary bladder. Most of the time, the new kidney will start making urine as soon as the blood starts flowing through it, but sometimes it may take few days to attain full function.

Recovery from Surgery

Most of the transplant recipients start feeling much better soon after surgery. The recipient need to stay in the hospital for about a week to recover from surgery.

Complications

2-5% of patients may develop complications after transplantation. Most of the time graft can be salvaged by timely intervention. Possible complications after kidney transplant are following

ATN (Acute Tubular Necrosis) Delayed establishment of good urine output and renal function Vascular Blood clotting in new connected blood vessels Parigraft hematoma Collection of blood around transplanted kidney Infection chest infection, wound infection Urine leak leak of urine from ureter anastomosis site.

Post transplant Care

A person body's immune system is designed to keep him healthy by sensing "foreign invaders," such as bacteria, and rejecting them. So the immune system will also sense this new kidney as foreign. To prevent the body from rejecting new kidney, the recipient has to take two or more of immunosuppressant medicines, as well as medications to treat other health problems. The health care team helps to learn what each pill is for and when to take it. The patient should clearly understand the instructions for taking the medicines before discharge from the hospital.

Rejection

The recipient should be regular and cautious while taking the medicines and following the diet. They should keep watch for signs of rejection like fever or soreness in the area of the new kidney or a change in the amount of urine.

Even if one does everything which he is supposed to do, the body may still reject the new kidney and one may need to go back on dialysis. Unless the health care team determines that one is no longer a good candidate for transplantation, he or she can go back for another kidney.

Renal transplantation at Jaypee Hospital

At Jaypee Hospital, we have done more than 250 successful Kidney Transplant in last 2 years since it's inception. The department of Kidney transplant have state of art operation theatre, transplant ICU for post operative care. This also provides supportive care to critically ill patients who might be in need of special dialysis called CRRT Continuous Renal Replacement Therapy. Only few centres in India have this specialized form of dialysis.