A kidney transplant is a surgical procedure performed to place a new kidney from a donor to a patient (recipient) when both the kidneys fail to work. According to WHO, kidney transplantation is the most frequently carried out transplantation globally. Kidney transplantation is a classic example of allograft in which the kidney is transferred from human to human. Globally, patients diagnosed with end-stage kidney disease which need a renal transplant are estimated between 5 to 7 million in 2019. The global prevalence of chronic kidney disease (CKD) is 13.4% in 2019. There is a steady increase in the number of patients with CKD due to an increase in the prevalence of diabetes mellitus (DM), hypertension, obesity, and aging.
Table of Contents
Why Kidney Transplant?
In patients with kidney failure, he/she should undergo dialysis until a kidney transplant. Dialysis eliminates the waste products preventing the accumulation of the same. Patients cannot undergo lifetime dialysis because patients cannot live long in dialysis. So, kidney transplantation is the treatment of choice for kidney failure. More than 21000 kidney transplants have been done so far in India.
Even kidney failure is not an easy task, we will look at how it is performed in the upcoming sessions. A kidney transplant can extend the life span of chronic kidney disease/ kidney failure. As we all know Kidneys are involved in the excretion process, when kidneys stop working accumulation of water and waste products occur and ultimately lead to death when untreated. The major risk factors for kidney failure are diabetes mellitus and high blood pressure, which are the most uninvited guests worldwide
Diagnosis of kidney failure, which is not easy because symptoms appear only at the end-stage. Symptoms include itching, Muscle cramps, swelling of ankles and knees, and vomiting. As soon as the diagnosis of CKD, patients are advised to reduce their water intake, revise their current prescriptions, and suggest a good diet and exercises to keep their kidneys healthy. He/she should also have a look at his blood glucose and hypertension profile, which may pave the way to CKD.
How to Identify a Donor for Kidney Transplantation?
Initially, the recipient is evaluated to check whether he can accept kidney transplantation. Recipient parameters like blood group and HLA types etc. are analyzed and saved to check the donor compatibility. Indian society of organ transplantation has established an Indian transplant registry for the betterment of kidney failure patients. This includes a website in which recipients can fill their details and he/she will be on the waiting list until he/she gets an active and compatible donor. In 2014, 3000 new patients were added to the kidney waiting list each month and now it would be even more. So, according to a study every 14 minutes, a new patient was added to the waiting list in 2014.
The first compatibility checked between a donor and a recipient is the blood group. As we all know there are different blood groups available, the donor and the recipient should have the same blood group to avoid rejection. Rejection of graft is denoted as a failure of transplantation. The ABO blood grouping system is used to check the compatibility. This is based on the different cell surface antigens on RBC between individuals. AB positive is called a universal recipient because the individual has both A and B antigens along with a positive antigen. O negative is called a universal acceptor because the individual has no known antigen in the RBC surface. Even though O negative individuals can be universal donors, the same blood groups are only accepted.
Kidney Transplant Procedure
The new kidney is placed on the lower right or left side of the abdomen, and this newcomer does the job of the damaged kidneys. After identifying a compatible donor, the patient should get ready for transplant surgery. If your donor is live, the nephrologist can schedule your transplant surgery, whereas when your donor is deceased, you should rush to the hospital because the kidney should be transplanted before the cells die. Before a transplant, it is desirable to take a hepatitis B vaccine. A kidney transplant is done under general anesthesia, and an anesthesiologist will be present throughout the procedure to monitor the patient. Once you lose your consciousness and fall asleep the real procedure begins.
The kidney transplant surgeon cuts the recipient’s abdomen and places the donor’s kidney. Then they connect the renal arteries and veins from the damaged kidneys to your newcomer. The kidney transplant surgeon also attaches the new kidney’s ureter to your bladder so that you can urinate normally. Generally, the old kidneys are left in the recipient body itself unless it creates a problem like infection in the kidneys. After a kidney transplant, you will sleep until the anesthesia concentration goes down. You wake up with your new kidney, and you need to be concerned about the graft rejection. Not everything that we put in your bodysuits suits you, even if it is necessary. Your immune system may not have mercy on you by rejecting the new kidney. This is known as graft rejection. Immunosuppressants are prescribed to avoid this.
Types of Kidney Transplant
Living Donor Kidney Transplant
Family members or friends can willingly donate their kidneys to the patient. In this type of transplant, the kidneys are taken from a live donor and placed in a kidney failure patient. A person can live with one kidney, so friends or family members with better compatibility can donate his kidney to the patient. As already stated, when compared to the waiting time and emergency surgery in the case of a deceased donor, this might be a scheduled procedure that avoids the start of the dialysis process. Living donor kidneys are said to function more quickly than kidneys donated by a deceased individual. A living-donor kidney transplant involves the recipient receiving a kidney from someone he or she knows, such as a relative.
Family members who are genetically related are more likely to be compatible living kidney donors. A non-directed living kidney donor is someone who is not known or genetically connected to the recipient. Paired donation is also a type of living donor kidney transplant. If you have a willing kidney donor whose organ is not compatible with you or does not match well for other reasons, you can choose a paired donation. Rather than donating a kidney to you, your donor may choose to donate a kidney to someone who is a better match for you. Then you receive a compatible kidney from the donor of that recipient.
Deceased donor kidney transplant
The kidney is acquired from a person who has recently died or has experienced brain death in a deceased donor kidney transplant surgery. The retrieved kidney will subsequently be transplanted into a kidney failure recipient. For the patients diagnosed with brain death, the organs are donated to different patients which require the organ. The kidney is taken with the deceased person’s family’s approval, and the procedure is completed within a few hours of the donor’s death. The donated kidney is kept in cold storage or attached to a machine until the surgery is performed to maintain the oxygen and nutrition supply intact. The recipient has to rush to the hospital because the kidney needs to be transplanted before kidney decay.
Preemptive kidney Transplant
It is a procedure for transplantation in which transplantation is performed before the initiation of dialysis. For adults with end-stage renal disease (ESRD), preemptive renal transplantation is well established as the best treatment but the benefits for children are less obvious. For grownups, renal transplant recipients have a higher chance of survival and a better quality of life compared to dialysis patients’ quality of life. It is highly effective in adults compared to the elderly.
Risks involved in Kidney Transplantation
A kidney transplant, like almost all major procedures, comes with many major risks and complications. The most terrifying complication that healthcare professionals look for is the body’s rejection of a transplanted kidney. A kidney transplant is full of dangers and problems. The rejection of a transplanted kidney by the body is the most terrifying condition.
The body’s immune system normally protects you from potentially hazardous things such as bacteria, toxins, and cancer cells. They do this by several mechanisms that mainly come under cell-mediated immunity and humoral immunity. Antigens are proteins that are present in the surfaces of the dangerous compounds which are detected by the immune system. The immune system recognizes them as foreign and starts to attack and eliminate them.
There are other complications after performing kidney transplantation, they are:
- Blood clots can occur in the blood arteries that are related to the donated kidney in rare circumstances.
- Urinary tract infections, colds, and flu are examples of minor infections caused by transplantation because they are exposed to the outside environment, and also immunosuppressants prescribed can add upon.
- Arterial stenosis is a narrowing of the artery that connects the donated kidney to the heart. This can happen months or even years after the transplant, and it might lead to an increase in blood pressure. To avoid additional narrowing, a stent may be inserted into the afflicted artery.
- After a kidney transplant, the ureter may get clogged, it is a tube that transports urine from the kidney to the urinary bladder. To unclog the ureter, a catheter is utilized, or surgery may be required. A routine check is always needed after transplantation
- After the first month of the kidney transplant, urine leakage may occur from the ureter and accumulate in the abdomen. An incision is usually made to leak out the urine accumulated.
- Long term usage of immunosuppressants may invite other harmful guests like cancer, typhoid, etc.,
Kidney Transplantation Cost
The cost for the entire process of kidney transplantation costs around 7 to 8 lakhs INR in India. Whereas a dialysis routine would cost around 25000 INR per month for 7 to 8 sessions depending upon the severity. The cost for kidney transplantation includes organ recovery from the donor and transporting it to the recipient place usually a transplantation center where transplantation takes place, dialysis cost which is performed before transplantation, for the surgery itself since this is lifesaving and most importantly should be performed with at most expertise surgeons, for anesthesia, if the recipient has any comorbidities, stay and room costs in the hospitals, cross-matching and donor finding, recovery and rehabilitation of the recipient, pre-transplant evaluation and procedures and post-transplantation medicaments like immunosuppressant.
India being the most important country that receives patients from the world because of its decreased cost in the health care system with high facilities makes it one of the favorite sites for international medical tourism. But for a middle-class family in India 7 to 8 lakhs is a big amount, hence getting an organ is secondary but the organ is free but transplantation is not. Some private hospitals can cost even more than 10 lakhs for a kidney transplant. Several insurance schemes might help; people should be aware of the insurance schemes and make use of them. Also, the International Society of Organ Transplantation (ISOT) is trying to standardize the cost of transplants in India. Fortunately, in an unfortunate situation, kidney transplantation cost is less compared to other transplants like heart and liver which cost around more than 20 to 30 lakhs.
What to do after a Kidney Transplant?
The success of kidney transplantation may depend on many factors. Success transplantation comes from the result of
- Consulting nephrologist regularly and checking the transplanted kidney health regularly
- Good diet and exercise routine is recommended.
- Taking immunosuppressants shortly called anti-rejection medication on proper doses daily as prescribed by the nephrologist.
Mainly immunosuppressants should be taken to avoid rejection of the new kidney. Kidney rejection is difficult to diagnose initially. But once the immune system starts to detect it is difficult to stop. So, we need to cheat the immune system as soon as the transplant. The patient should never stop taking immunosuppressants, or never skip any dose that ultimately leads to rejection of the graft organ (kidney) from the host. Even the immunosuppressants also have some side effects which are usually manageable by the patient. Some of the common side effects are an increase in blood pressure, weight gain, and most importantly increased chances for infection and cancers. If the patient encounters any serious side effects, he/she can consult the nephrologist to change the medications. The patient should never stop taking immunosuppressants because the side effects, which cause rejection, lead to failure of the whole transplantation procedure.
Diet and Nutrition After Kidney Transplant
It is important to maintain your diet properly after transplantation surgery. It helps in maintaining your blood glucose level, blood pressure, and promotes the health of the patient. The diet should not contain high salt content rather should contain more fiber. A balanced diet is needed which includes fresh fruits and vegetables and a high amount of water. The patient should avoid low dairy intake. Since you are already immunocompromised due to the immunosuppressants, having a healthy diet is most important. You should also maintain your body’s cholesterol. So, a patient after transplant has to look for
- Blood sugar levels
- Blood pressure
- Total cholesterol
Tips for planning a diet in kidney transplant patients:
- Avoid raw and uncooked non veg items
- Avoid unpasteurized milk and dairy products
- Wash the vegetables and fruits
- Avoid grapes or pomegranate if you are taking cyclosporine (a common immunosuppressant)
Prednisolone is prescribed for many kidney patients, it can increase sodium and water levels in the body, which increases the blood pressure through the renin-angiotensin system. So, we need to limit sodium levels in the diet. Usually, NO SALT DIET is advised for kidney transplantation patients. Some immunosuppressants like cyclosporine can also increase the potassium levels, in such patients, there should be control of potassium in the blood. An increase in potassium can also trigger the renin-angiotensin system and can also result in cardiac complications. High potassium-rich foods include orange, tomatoes, bananas, green leafy vegetables, pumpkins, milk and dairy products, and chocolate.
The diet plan depends on your drug dose or the choice of the drug of your physician, so consult a nutritionist and pharmacist for your better diet plan.
Exercise After Kidney Transplantation
Exercise is needed to reduce blood pressure, reduce weight gain, improve sleep schedule, and increase cardiac functions. The frequency of your exercise plan is very important. You should work out for at least 30 minutes 4 times per week.
Do’s for your exercise routine:
- Remember to have a good time. Pick an activity that you enjoy. Exercising should be enjoyable rather than work. If you appreciate what you’re doing, you’ll be more inclined to remain with it.
- Before exercising, wait at least 112 hours after having a meal.
- Remember, if you’re on a fluid restriction, follow your fluid restriction rules when drinking liquids during exercise.
- Dress appropriately for the weather and use appropriate footwear.
- Increase your exercise level gradually, particularly if you haven’t been exercising consistently.
- Before any cardiovascular activity, give yourself a five-minute warm-up that includes stretching exercises.
- Make fitness a part of your everyday regimen. Make it a habit to exercise at the same time each day (such as in the mornings when you have more energy). To avoid boredom, include a range of workouts.
- Don’t give up. If you exercise regularly, it will quickly become a habit. Make exercise a lifelong habit.
Don’t for your exercise routine:
- If your medications have changed, check with your nephrologist to see if you can resume your regular exercise routine. New medications may alter your response to physical activity.
- Large lifting and pushing heavy things should all be avoided. When lifting anything, exhale as you lift.
- Avoiding short periods of bed rest after exercise should be avoided because it diminishes exercise tolerance.
- When it’s too chilly, hot, or humid outside, don’t exercise.
- If your exercise routine has been interrupted for a few days, reduce your activity level.
- If you’re not feeling well or have a fever, don’t exercise
The main thing to be noted is NOT TO IGNORE PAIN
Do not continue the activity if you feel chest pain or pain elsewhere in your body. You may harm your joints if you engage in an activity while in discomfort. Specific instructions might be obtained from your nephrologist.
If you’re experiencing any of the following symptoms, you should stop exercising and rest and consult a nephrologist immediately.
- Chest pain
- Feeling shaky, dizzy, or lightheaded?
- Unexplained swelling
- Pain or discomfort in your, neck, arm, or shoulder
- Any other symptoms that cause discomfort
Different patients should have a different exercise routine based on each medical profile, medications, and associated conditions, consult physician and physiotherapist for planning their exercise routine.
How to Control Blood Pressure After a Kidney Transplant?
Hypertension is the most common condition encountered after kidney transplantation that is 80% to 90% of patients get affected. Hypertension is a condition in which the blood pressure (more than 140/90 mm/Hg) (both systolic and diastolic) gets higher. This may be due to the presence of damaged kidneys, immunosuppressant drugs, and other risk factors like salt intake, diabetes mellitus, obesity, and smoking.
There is a relationship between kidney rejection and systolic blood pressure. Patients with high blood pressure have a high probability of kidney rejection. This may also result from the interaction between immunological and non-immunological factors. The blood pressure can also be due to diet. The patient should take care of his/her diet so as to maintain normal blood pressure. If the patient is already hypertensive, the regimen used for the therapy should be revised. After a kidney transplant, the blood pressure should be checked frequently, if blood pressure is found increasing, preferred antihypertensive drugs are prescribed. The preferred blood pressure for kidney transplantation is to be below 130/80 mm/Hg (systolic/diastolic).
How Long can you Live After Kidney Transplantation?
Life expectancy for a patient undergoing dialysis will vary on the patient’s medical conditions and the way a patient follows your treatment set up. The average life expectancy is 5-10 years for patients undergoing dialysis. Whereas for kidney transplanted patients it is higher. The survival rate depends upon the type of transplantation his/her undergoes. If the kidney is transplanted from a live donor, the patient is requested to survive for 12 to 20 years. Patients who received a kidney from a deceased donor have less life expectancy compared to living donor transplantation.
The life expectancy for a patient who received a transplant from a deceased donor is 8 to 12 years. In conclusion, the patient survives more than the dialysis period. Graft survival is less in deceased transplantation than compared to living organ transplantation. But most of the time after a kidney transplant, the patient can live a normal life compared to spending time on a dialysis unit 15 hours a week. Also, the patient’s economic status improves after the kidney transplant. He/she should take medications properly and undergo routine checkups to save his /her life longer. The patient should not stop taking medication, it is not a fever, that you take medications to cure it and move on. You should take your medicines lifelong. You should take care of the newcomer who helped you in saving your life even though you destroyed your own.
Precautions after a kidney transplantation
A kidney transplant might feel like obtaining a second chance at life for many people. There are numerous advantages to receiving a kidney transplant, including having more time in the day and more independence. There are numerous factors to consider in your life after a kidney transplant, including how to care for your new kidney.
The following are precautions are to be noted
- Take your immunosuppressant’s and other medications exactly as prescribed by your nephrologist.
- If you see any signs of infection or suspected kidney rejection, call your transplant team immediately.
- Avoid being in the company of unwell individuals.
- Stay hydrated by drinking plenty of water.
- Consume low-salt, low-fat, and low-cholesterol foods (see diet section).
- Start an activity plan, such as walking or biking, once your nephrologist has approved you.
You should undergo several lifestyle changes that can make you feel better and keep in mind some of them.
If you plan to return to work after your transplant, your transplant team may advise you to wait three to six weeks. You may be limited in what you can perform at work, at least at first.
You might want to go on a trip now that you’re feeling better and have more energy. Before making a journey plan, consult your transplant team and it may advise you to wait 2 to 3 months after surgery. Talk to your nephrologist about anything you should think about before going on vacation, such as getting enough immunosuppressant refills to carry and what to do in any emergency cases.
Your transplant team may ask that you avoid having intercourse for 4 to 6 weeks following your surgery, or until the surgical site is completely healed. Women who have received a kidney transplant may have regular menstrual cycles, and as a result, they are more likely to become pregnant. Your nephrologist will advise you to wait for a year following your transplant for getting pregnant.
You should wait for at least 2 to 4 weeks for driving.
How to Lose weight After Kidney Transplantation?
Obesity is a typical long-term problem for transplant recipients. Obesity is a major risk factor linked to high blood pressure, high cholesterol, and diabetes. As a result, keeping a healthy weight before and after transplantation is critical to your general health. The recipient is to consume fewer calories than he/she expend. Low-calorie diets, physical activity, behavior therapy, are just a few of the weight-loss options. But, in the end, it’s the calories you expend that matter. If you don’t exercise, you should consume 1400-1500 calories a day, regardless of what you eat. Have a good diet routine (see the previous sections diet and exercise after kidney transplantation).
Diabetes After Kidney Transplantation
NODAT: New-onset diabetes after transplant
This is a condition in which recipients can develop diabetes mellitus after the transplantation, which can be caused due to immunosuppression therapy. So, after transplantation, one must look for a blood sugar profile.
Whole foods high in potassium and phosphorus will be available again after the surgery, you must balance with a heart healthy diet that gives you healthy body weight. If you are having trouble meeting this balance, you might want to end with a condition called metabolic syndrome. Metabolic syndrome is a disorder in which you have multiple metabolic issues that all arise at the same time. You must have at least three of the following criteria to be diagnosed with metabolic syndrome: high blood pressure, high blood sugar, a high triglyceride level, a low HDL cholesterol level, or extra fat in and around the belly. Any one of these diseases can put your health at risk, but the combination can be riskier and can cost your life. When you have metabolic syndrome, your chances of having heart disease and type 2 diabetes increase. It may also increase the probability of kidney rejection. The only prevention is to make lifestyle changes like changing diet and employing exercise. Remember lifestyle changes can save your life.
Most frequent questions and answers
The native kidneys are not usually removed during kidney transplants unless they are causing problems. This is done because it can leave an anatomical space that can cause discomfort to the patient. Also, the kidneys can degenerate hence the load decreases.
The success rate depends upon the type of transplantation. Live donor transplantation has an increased success rate. Transplantation from deceased donors is 85% to 90% for the first year. Live donor transplantation has 90% to 95%.