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KIDNEY TRANSPLANT |
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KIDNEY TRANSPLANT
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Should you have a Kidney Transplant?
KIDNEY
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Although the degree of rehabilitation of some patients on dialysis is truly remarkable, most persons with a well-functioning transplanted kidney who are on small doses of medication, will generally feel better, look better, and be far healthier than most dialysis patients. |
After receiving a working kidney, many patients will describe their experience as “being reborn.” In many cases, an almost overnight rejuvenation takes place. |
Unfortunately, not all transplants are successful. “Successful” means that good kidney function is maintained for a sufficiently long period of time, minimum of one year. It is nearly meaningless to call a transplant successful after only a few days or weeks. Even though the surgery goes well, the real hurdles come afterward. Aside from the ever present possibility of rejection, there are numerous possible side effects from the toxicity of the drugs given to prevent rejection, as well as from the increased risk of infection. Some patients seem to have very mild side effects, while others are plagued by problems. This points up what is to many the biggest drawback of transplantation—uncertainty. |
After an initial period of adjustment (usually a few months), most dialysis patients settle into a relatively stable pattern in which they know how they nearly always feel during and between dialysis treatments, what their phycial capacities and limitations are, and what the quality of their lives will be. On the other hand, there is no way to predict with any certainty what the results of a transplant will be. |
You should discuss success and mortality rates with your physician and with physicians of your hospital’s transplant service. Some of the factors you should take into consideration and dtriscuss with your physician before deciding upon a transplant are the following: |
* Do you have additional medical problems that make it impossible or unwise for you to have a transplant? |
For some, this consideration will make further deliberation unnecessary. |
* Do you have a prospective, willing, living related donor? |
Information concerning success rates for both living donor and cadaveric kidneys should be obtained from the doctors at your center. |
How are you managing on dialysis? Are you extremely uncomfortable during treatments? Is your state of health (physically and/or mentally) poor? Or are you well-adjusted to dialysis and able to lead a nearly normal life between treatments? |
If you are doing quite well on dialysis you might want to consider waiting until further advances in transplant immunology or immunosuppressive therapy are developed. |
* What are the immunological factors which might favorably or unfavorably affect your particular case? |
| * Which modality of treatment (transplantation or dialysis) will best fit in with your vocational or other goals in life? |
Normal and Abnormal Kidney Functions
NORMAL AND ABNORMAL KIDNEY
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The kidneys are essential organs in the body which function to remove water and waste products. They also produce important hormones such as erythropoietin, Vitamin D, and renin. The kidneys are located in the back of the abdomen, one on each side of the spinal column, at about the level of the lower ribs. | The average weight of an adult human kidney is approximately one-quarter pound. Each kidney is approximately 4 inches long, 2.5 inches wide, and 1.5 inches thick. The kidney receives about 20 percent of the blood coming from the heart each time it beats. The rate of blood flow through both kidneys is approximately 1.2 liters per minute.
| The basic functioning unit of the kidney is called the nephron. The kidneys together comprise greater than 2 million nephrons, and each is capable of forming urine. The nephron’s function is to clean the blood of unwanted substances as it flows past. The nephron is composed of the glomeruli, through which the blood is filtered, and then the tubules, which receive and process the filtered fluid.
| Kidney function is estimated using the glomerular filtration rate or GFR. This is the amount of filtrate formed in all nephrons. The normally functioning kidney controls the concentration of body fluids. It accomplishes this by excreting excessive amounts of water in the urine if body fluids are too dilute or by excreting excessive solutes when body fluids are too concentrated. Despite large intakes of salt and water, almost no change in blood volume or concentration occurs.
| Another important function is acid-base balance. The body maintains a constant pH via several buffering mechanisms. The kidney plays a major role in this by the net excretion of hydrogen ions when the blood is too acidic and the net excretion of bicarbonate ions when the blood is too alkaline.
| The kidneys also have a hormonal role. They are in part responsible for the conversion of Vitamin D to its active metabolite, which is important in the absorption of calcium from the intestine. Erythropoietin is manufactured by the kidney and stimulates the bone marrow to produce red blood cells. With renal failure there is decreased production of this hormone and anemia results. With a decreased number of red blood cells and therefore fewer cells to carry oxygen to the tissues, patients may tire easily and become short of breath after only minimal activity. Often patients benefit by taking injections of synthetic erythropoietin to achieve and improved blood count. Renin is another kidney-produced hormone that is important in sodium and blood pressure control.
| Renal failure occurs from a variety of causes, and the time course and clinical symptoms vary from individual to individual. A person’s kidney failure may occur suddenly or progress slowly over a period of many years.
| As failure progresses the kidney is less able to maintain a steady volume and concentration of body fluids. For many, as fluid and salt become increasingly difficult to remove, high blood pressure occurs as well as edema or fluid in the tissues. Patients may have problems with swelling of their legs and shortness of breath from accumulation of fluid in the lungs (pulmonary edema). Medications may be necessary to control blood pressure and assist in fluid removal (diuretics). The kidneys also are no longer able to excrete the waste products of metabolism, and substances such as potassium and phosphorus can accumulate in the body.
| Elevated phosphorus levels cause calcium levels in the blood to fall and result in the stimulation of a hormone from the parathyroid glands. This hormone increases the release of calcium from bones and if not suppressed can result in bone pain and progress to weakened and demineralized bones.
| As failure progresses patients are required to modify their diets usually decreasing sodium, potassium, and phosphorus intake and ultimately restricting fluids. Patients will generally need to take phosphate binders as well as Vitamin D supplements.
| As waste products accumulate, patients may have problems with fatigue, headaches, nausea, vomiting, and decreased appetite resulting in weight loss. Itching may also be prominent if the body’s phosphorus levels are high. Patients may note a decreased ability to concentrate. Finally, there may be an increased tendency to bleed.
The decision to start hemodialysis is based on a combination of symptoms and laboratory data. Emergent indications to start are encephalopathy (change in mental status), seizures, and coma due to uremia, as well as severe hyperkalemia (elevated potassium), acidosis, pericarditis (or inflammation of the heart lining) from accumulated toxins, and pulmonary edema which no longer responds to medications.
| Most patients reach the need to initiate on hemodialysis gradually. The goal is to begin when a patient’s symptoms are no longer responsive to conservative management and before there are serious complications.
Practically speaking, most patients will start dialysis when the creatinine clearance (CRCI) is very low, 3–5 cc per minute (normal 100 cc per minute) and the serum creatinine is greater than 12–14 mg/dl (normal 1.0 mg/dl). These are not absolute numbers, however, and must be carefully interpreted for the individual patient. In a small person, a creatinine of 5 mg/dl may represent a level of function which requires dialysis. Fortunately, if your kidneys fail there is a choice of treatments to sustain your life.
Options available are hemodialysis, forms of peritoneal dialysis, and transplantation.
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Frequently Asked Questions Q. What is a kidney transplant? | | A kidney transplant is a surgical procedure in which a healthy kidney from one person is placed into another whose kidneys have stopped working. | Q. Who is a candidate for a kidney transplant? | | Any patient whose kidneys have permanently stopped working is a potential candidate for a kidney transplant. However, many factors must be considered in choosing between transplantation and chronic dialysis for a given individual. Among these factors are age, other medical problems, and personal considerations of work and lifestyle. You should discuss the options with your doctor and attempt to obtain as much information as possible in reaching your decision. | Q. Where do kidneys for transplantation come from? | | There are three sources of kidneys for transplantation: living related, living unrelated, and cadaver donors. Living donors are usually members of the recipient’s immediate family, such as siblings, parents or children. Only such close relatives are likely to have an acceptable tissue match, although recent data suggests that success with living unrelated kidneys is closer to that of related grafts than that of cadavers. This may be due to better state of the donor and less storage time. Cadaver donor kidneys are removed from victims of brain death, usually the result of an accident or a stroke. | Q. What are the chances my transplanted kidney will work? | The success rate following transplantation depends upon the closeness of the tissue match between donor and recipient. A kidney from a brother or sister with a “complete” match has a 95% chance of working at the end of one year. A kidney from a parent, child, or “half-matched” sibling has an 85% chance of working for at least one year. Finally, a cadaver donor kidney has an 80% change of working at least one year.
All of these statistics assume this is your first transplant, and that you will be taking the anti-rejection drugs. If you are having a repeat transplant, the success rate will be 10%-15% less.
These kidneys are not immortal, however, with 50% of cadaver kidneys declining over 6 – 10 years, a rate faster than the relatively stable success of related kidneys. | Q. What are some of the factors which would increase the risk of transplantation? | Advanced age is a significant risk factor. Generally, patients over the age of 60 have done less well than younger patients. Significant heart disease, particularly a history of angina or prior heart attacks, will also increase the risk.
Because of the high incidence of heart disease in diabetic patients, all diabetics must undergo an exercise stress test before being accepted for transplantation. Chronic lung disease increases the risk of pneumonia after transplantation.
Smoking will also increase this risk, and all potential transplant patients are urged not to smoke. Patients who are significantly overweight are more likely to have complications in any surgical procedure, and should attempt to reduce before transplantation. A history of other systemic diseases such as cancer or hepatitis may also affect the risk; indeed, many patients with a history of cancer or abnormal liver enzymes secondary to hepatitis may not be accepted for transplantation. All of these factors vary in importance in different individuals, and should be discussed with your doctor, as well as with the transplant surgeon when you have your transplant evaluation. | Q. Will my own kidneys be removed? | | It is rarely necessary to remove your own kidneys prior to transplantation. This may be required if you have severe high blood pressure uncontrollable by medication and dialysis, or if your kidneys are chronically infected. However, whenever possible, your own kidneys will be left alone. Even if not functioning normally, they continue to make erythropoietin, a hormone your body requires to make red blood cells, and they may make some urine. This is particularly important if your transplant should fail. | Q. What is rejection? | | The body has a normal defense mechanism, called the immune system, which protects it from foreign substances, such as bacteria and viruses. The body sees a kidney transplant as foreign and attacks it to get rid of it. This process is called rejection, and is a normal response of the body’s immune system. Even though rejection may be prevented by medication, the possibility of rejection never goes away. The body will not adapt to the kidney, nor will the kidney change to accommodate the body, although after the first 3 – 6 months, rejection is less of a problem. | Q. How is rejection prevented? | To prevent rejection patients are given drugs, called immunosuppressive medications. These drugs work by lowering the body’s immune response, making it incapable of destroying the kidney. There are now several immunosuppressive medications available, giving transplant physicians new flexibility in treating recipients. Most patients will receive a combination of drugs. The newest of these medications is called cyclosporine, a highly effective drug which has considerably improved the results of transplants of all sorts.
Cyclosporine works by interfering with the ability of your lymphocytes to cooperate normally in attacking the transplant. It is now given in pill form in combination with prednisone, a steroid medication with anti-inflammatory properties. The combination of cyclosporine, Imuran (an older drug), and prednisone, all in low doses, is used currently for all recipients of unrelated kidney transplants, and for all living related donor transplants that are not perfectly matched.
The additional immunosuppressive drug mentioned above is azathioprine or Imuran. Occasionally, patients are switched from cyclosporine to Imuran several months after transplant to avoid some potential side effects of long term cyclosporine administration. Your doctor will advise you if this is necessary. | Q. How long will I have to take these drugs? | | It will be necessary for you to take some immunosuppressive medication for as long as you have the transplant. Because the body never accepts the kidney as part of itself, rejection can occur even years later, particularly if you stop your medicines. However, it will be possible to reduce the dosage of medications gradually over time, as the risk of rejection lessens with time. | Q. How is the operation done? | | General anesthesia is most frequently used for kidney transplantation, although occasionally a spinal or epidural technique may be recommended by the anesthesiologist. Antibiotics are given to prevent infection, and a catheter is placed in your bladder after anesthesia has been given. The transplanted kidney is placed in the pelvis just above the pelvic bone, on either the right or the left side. The kidney’s artery and vein are sewn to your iliac artery and vein, which are the large blood vessels leading to your leg. The ureter is connected directly to the bladder. The operation normally takes about three hours. | Q. Is the operation risky? | The kidney transplant operation itself is quite safe. The technique is well established, and technical complications are rare. Nevertheless, as with any operation, difficulties may arise.
During the operation, you may require a blood transfusion, particularly if you are already anemic. After surgery, the most common complication is a urine leak, occurring about 5% of the time. This may occur because of damage to the ureter during harvesting of the donor kidney that was not recognizable at the time of the transplant. The problem is almost always correctable, but may require a second operation. Wound infections are very uncommon, thanks to modern antibiotics. | Q. How long will I be in the hospital? | | Most patients will remain in the hospital for one to two weeks following transplantation. Recovery from the surgery itself is generally rapid. Patients are encouraged to be out of bed on the day following surgery, and many are eating solid food within two or three days. However, the possibility that the kidney may not work right away, and the risk of rejection, may prolong your hospitalization. | Q. How long will I be out of work? | Most patients return to work after six to eight weeks. This will vary with each individual, depending upon your response to the transplant, any complications which develop, the type of work you do, and most importantly, how you feel. Because close follow up is particularly important during the first three months after transplantation, you should plan on frequent visits to the transplant clinic and your own physician during this period.
However, transplantation is intended to return you to as normal a lifestyle as is possible, and you will be encouraged to return to your usual activities as soon as you are able. | Q. Will my new kidney work right away? | | About half of cadaver donor kidney transplants do not make urine right away. During the process of removing the kidney, storing it as long as one or two days, and placing it in the recipient, some damage may occur. This damage is called acute tubular necrosis (ATN), and is almost always reversible. It may be one to three or more weeks before the kidney begins to make urine. During this time you will require dialysis. ATN can also occur after living related donor transplantation, but it is much less common. | Q. Should I have a living related or cadaver donor transplant? | A number of factors enter into this decision, including success rates following transplantation and the availability of donors. The best results following transplantation are obtained with HLA-identical (6 antigen matched) living related donors, which almost always come from a sibling, rarely from a cadaver. As noted before, the available results on living unrelated donor kidneys show them to be better than those for cadavers.
A major advantage of living donor transplants is the ready availability of the donor. This allows the transplant to be performed without a long waiting period, as there are currently more potential recipients than available cadaver donors. For this reason, we encourage living related donation whenever the family situation is appropriate, and, if circumstances are correct, donations for spouses. | Q. How is a living related donor chosen? | Potential living related donors usually are identified in discussions with your family and your doctor. Tissue typing is then scheduled; the required tests include blood group typing, HLA typing, and a mixed lymphocyte culture. Based on these tests it is frequently possible to identify the donor most likely to result in a successful transplant. Choosing the donor is best done in consultation with your doctor and the transplant team.
The selected donor is then scheduled for admission to the hospital for a donor evaluation. This evaluation is primarily on an out-patient basis and involves a wide variety of tests to ensure the health of the donor. Included in these tests is an arteriogram, an x-ray procedure in which dye is injected into the arteries supplying the kidney. This test allows the surgeon to decide which kidney would be best to remove. After completion of all tests, the physician responsible for the donor evaluation, who is not a member of the transplant team, will discuss the results with the potential donor privately. Only donors who are healthy and have two completely normal kidneys will be accepted. | Q. Are there any risks to the donor? | The short term risks of donation are those associated with major surgery, including the risks of general anesthesia, wound infection, and the possible need for a blood transfusion. These risks are very small in healthy people. The donor evaluation process is designed to identify any special factors which would place a donor at increased risk; such donors would not be accepted. The longer term risks are slightly more uncertain. Some studies of donors 10 – 15 years following donation have suggested a slightly higher incidence of mild high blood pressure and protein in the urine; although these changes are not particularly different from the general aging population.
The significance of these studies is unknown, and there is no evidence of renal failure in prior donors. The remaining kidney expands and takes over the function previously performed by two. Because most kidney diseases affect both kidneys simultaneously, the donor is not at increased risk of kidney failure should he or she contract such a disease. Donors are cautioned to avoid contact sports or other activities which could cause major trauma to the remaining kidney. We believe that donors will lead perfectly normal lives. It is fair to state, however, that possible consequences of donation after more than twenty years are unknown, primarily because transplantation of kidneys in significant numbers only began about twenty years ago. |
Certificate of Registration for Kidney Transplantation
| | The Kidney Transplant program at Patel Hospital is dedicated to providing comprehensive perioperative care to patients with chronic renal disease, including end–stage renal disease. Our team consists of Physician and Surgeon-specialists and Nurse co-ordinators whose purpose is the efficient pre-transplant evaluation and management and a smooth transition into the transplant phase. Following Kidney Transplantation, care will be coordinated by the transplant coordinator and depends on consistent communication between the transplant physicians, the patient and the referring doctor. Within the scope of our program exist the necessary services to provide comprehensive evaluation and management of patients before and after the transplant event. The Kidney Transplant procedure is performed at the Patel Hospital. |
KIDNEY TRANSPLANT TEAM
| 1. Dr. SWAPAN SOOD (Transplant Surgeon)
2. Dr. RAJEEV BHATIA (Nephrology)
3. Dr. S.K.SHARMA (Surgeon)
4. Dr. DEEPAK CHAWLA (Surgeon)
5. Dr. ABHISHEK GUPTA (Critical Care)
6. M/s. PALLAVI KHANNA (Psychology-Counselling)
7. M/s. CHARANJEET KAUR (Transplant co-ordinator)
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Kidney transplant is a team affair. Each member of the team is crucial to the success of the transplant. As a procedure the transplant neither starts nor ends with the transplant.
From preoperative care of the patient, the transplant operation to the postoperative care and 5 years after the transplant, each part of transplant management is important. An experienced well trained and well oiled teams is an asset to any transplant programme. With belief in GOD the kidney transplantation team at Patel Hospital endeavours comprehensive, compassionate, dedicated and efficient patient care with latest health care techniques. |
FULL SCOPE OF SERVICES | Expanded surgical techniques, improved anti-rejection protocols and high-quality patient care characterize the Patel Hospital transplant program and are critical factors in current success in kidney transplantation. Candidates for kidney transplantation are individuals with chronic kidney failure related to:- - DIABETES.
- HYPERTENSION.
- GLOMERULONEPHRITIS (chronic kidney inflammation with failure).
- POLYCYSTIC KIDNEYS.
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FAMILY INVOLVEMENT |
Kidney transplantation is a family affair, especially if the recipient is receiving a kidney donation from a living relative. For this reason, family members are intricately involved in the care process, including decision making and follow-up lifestyle changes. The Patel Hospital transplant team help kidney patients and their families communicate and learn about what is happening. They are available 24 hours a day to answer emergency questions. Through their commitment and dedication, patients and family members experience a true continuity of care from admission into the program through post-transplant follow-up. |
A DEDICATION TO EDUCATION |
The kidney transplant program at Patel Hospital is dedicated to both patient and physician education. We provide continuing medical education for outside physician & dialysis center staff by providing information on topics related to pre-transplant and post-transplant management issues and physician access. |
PATIENT EDUCATION |
The complexity of kidney transplantation requires intensive education for patients, living donors and family members. The program has produced brochures in English and Hindi regarding all aspects of the transplant process. In addition, recipients and donors receive extensive one–on-one instruction and education by members of the multidisciplinary transplant team. |
PHYSICIAN EDUCATION |
Member of the kidney transplant program regularly attend local and national meetings to discuss the latest advances in the field of end-stage disease and kidney transplantation. In addition, our physicians are available for telephone consultations and invite colleagues to call for discussions about complex cases. |
OUR UNIQUE FEATURES
Laparoscopic Donor Nephrectomy
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Laparoscopic live donor Nephrectomy has become the gold standard in live donor Nephrectomy by cutting down on donor morbidity especially post operative pain. Laparoscopic donor Nephrectomy is as safe as open surgery. |
Complete in House Support | - Angiography.
- Colour Doppler.
- CT Scan.
- Digital X-ray.
- Nuclear Medicine.
- Critical Care Unit.
- Blood Bank & Component Therapy.
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Who is an Eligible Kidney Donor ? | - Age below 70 years.
- No Co morbid disease.
- Blood group matching with recipient
‘O’ group is universal donor - AB group is universal recipient
- Kidney function should be normal
- Blood relation of a recipient
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