Chronic kidney disease is a major concern for the health of the human body due to the difficulties it creates. When kidney function drops to a certain level, patients have end-stage kidney disease and need dialysis or a transplant to sustain their lives. Chronic kidney disease affects an average of about 8% of the population per year, and for our country this percentage is higher and reaches over 10%. Replacing a diseased kidney with a healthy donor is probably the most optimal and safe way to help in such a situation. The best time to perform this procedure is the transition between fourth and fifth degree chronic kidney disease. This avoids the complications of hemodialysis and sometimes increases the success of the procedure.
The kidneys are organs whose function is essential for sustaining life. Most people are born with two kidneys located on either side of the spine, behind the abdominal organs and below the ribs. The kidneys perform several basic functions to keep the body healthy.
Filtration of the blood to remove waste products from the body’s normal functions, transfer waste from the body such as urine and return water and chemicals back to the body.
Regulation of blood pressure by releasing several hormones.
Stimulating red blood cell production by releasing the hormone erythropoietin.
The normal anatomy of the kidneys includes two kidney-shaped organs that produce urine. The urine is then transferred to the bladder through the ureters. The bladder serves as a storehouse for urine. When the body feels that the bladder is full, urine is excreted from the bladder through the urethra.
When the kidneys stop functioning, kidney failure occurs. If this renal failure persists (chronically), the result of end-stage renal disease leads to the accumulation of toxic waste products in the body. In this case, either dialysis or transplantation is required.
– High blood pressure
– Polycystic kidney disease
– Severe anatomical problems of the urinary tract
Treatments of end-stage of kidney disease
Treatments for end-stage kidney disease are hemodialysis, a mechanical process of cleansing the blood of waste products; peritoneal dialysis, in which waste products are removed by passing chemical solutions through the abdominal cavity; and kidney transplantation.
Although none of these treatments treat end-stage kidney disease, transplantation offers the closest thing to normal life, as a transplanted kidney can replace a non-functioning kidney. However, it also includes a lifelong dependence on drugs to keep the new kidney healthy. Some of these drugs can have severe side effects.
Some kidney patients are considering a transplant after starting dialysis; others consider it before starting dialysis. In some circumstances, dialysis patients who also have severe medical problems such as cancer or active infections may not be suitable candidates for kidney transplantation.
Kidney transplants come from two different sources: a living donor or a deceased donor.
From a living donor
Sometimes family members, including siblings, parents, children (18 years or older), uncles, aunts, cousins, or a spouse or close friend may wish to donate a kidney. This person is called a “living donor”. The donor must be in good health, well informed about the transplant and be able to give informed consent. Any healthy person can donate a kidney safely.
From dead donor
A kidney from a deceased donor comes from a person who has suffered brain death. The unified law on anatomical gifts allows everyone to consent to the donation of organs for transplantation at the time of death and allows families to provide such permission. After granting permission to donate, the kidneys are removed and stored until the appropriate host organism is selected.
Transplant evaluation process
Regardless of the type of kidney transplant from a living donor or a deceased donor, special blood tests are needed to determine what type of blood and tissue there is. These test results help to compare the donor’s kidney with the recipient’s kidney.
Blood group tests
The first test determines the blood type. There are four blood groups: A, B, AB and 0. Each falls into one of these hereditary groups. The recipient and the donor must have the same or compatible blood type, unless they are participating in a special blood donation program.
- If the recipient’s blood type is A, the donor’s blood type should be A or 0;
- If the recipient’s blood type is B, the donor’s blood type must be B or 0;
- If the recipient’s blood type is 0, the donor’s blood type should be 0
- If the recipient’s blood type is AB, the donor’s blood type may be A, B, AB or 0
- The AB blood type is the easiest to compare because this individual accepts all other blood types.
Blood type 0 is the most difficult to match. Although people with blood type 0 can donate for all species, they can only receive kidneys from blood group 0 donors. For example, if a patient with blood type 0 receives a kidney from a blood type A donor, the body will recognize the donor’s kidney. as a stranger and will destroy it.
The second test, which is a blood test for human leukocyte antigens (HLA), is called tissue typing. Antigens are markers found in many cells of the body that distinguish each individual as unique. These markers are inherited from the parents. During the evaluation process, both recipients and all potential donors have tissue typing.
Obtaining a kidney in which all recipient markers and donor markers are the same is a “perfect match” kidney. Perfectly matched transplants have the best chance of working for many years. The most perfect kidney transplants come from siblings.
Although tissue typing is performed partially or absent HLA match with some degree of “mismatch” between recipient and donor.
Throughout life, the body produces substances called antibodies that act to destroy foreign matter. Individuals can make antibodies whenever there is an infection, during pregnancy, a blood transfusion, or a kidney transplant. If there are antibodies to the donor’s kidney, the body can destroy the kidney. Therefore, when a donor kidney is present, a cross-matching test is performed to ensure that the recipient has no pre-formed antibodies against the donor.
Cross-linking is performed by mixing the recipient’s blood with donor cells. If the cross-match is positive, it means that there are antibodies against the donor. The recipient should not receive this particular kidney unless special pre-transplant treatment is given to reduce antibody levels. If the cross-match is negative, it means that the recipient has no antibodies to the donor and that they are possible and suitable for that kidney.
Cross-links are performed several times during preparation for transplantation of a living donor and final cross-linking is performed within 48 hours before this type of transplantation.
A test is also performed for viruses such as HIV (human immunodeficiency virus), hepatitis and CMV (cytomegalovirus) to select appropriate post-transplant prevention drugs. These viruses are tested in each potential donor to prevent the disease from spreading to the recipient.
- Period before transplantation
- General health support: general metabolic laboratory tests, coagulation tests, complete blood count, colonoscopy, uterine smear and mammography (women) and prostate (men)
- Cardiovascular assessment: electrocardiogram, stress test, echocardiogram, cardiac catheterization
- Pulmonary assessment: chest X-ray, spirometry
- Unregulated cardiovascular disease
- History of metastatic cancer or ongoing chemotherapy
- Active systemic infections
- Uncontrollable psychiatric illness
- Current drug abuse
- Ongoing neurological impairment with significant cognitive impairment and no surrogate decision making
- Transplant surgery
Kidney transplantation is performed under general anesthesia. The operation usually takes 2-4 hours. This type of surgery is a heterotopic transplant, which means that the kidney is placed in a different place from the existing kidneys. (Liver and heart transplants are orthotopic transplants in which the diseased organ is removed and the transplanted organ is placed in the same place.) A kidney transplant is placed in the front of the lower abdomen, in the pelvis.
Kidneys are not usually removed unless they cause severe problems such as uncontrollable high blood pressure, frequent kidney infections, or are significantly enlarged. The artery that carries blood to the kidney and the vein that carries blood is surgically connected to the artery and vein that already exist in the recipient’s pelvis. The ureter, or tube that carries urine from the kidney, is connected to the bladder. Recovery in the hospital is usually 3-7 days.
Complications can occur with any surgery. The following complications are uncommon, but may include:
Problems with bleeding, infection or wound healing.
Difficulty with blood circulation to the kidneys or a problem with the flow of urine from the kidneys. These complications may require another operation to correct them.
- Period after transplantation
The post-transplant period requires careful monitoring of renal function, early signs of rejection, adjustments to various medications, and vigilance for an increased incidence of immunosuppressive effects such as infections and cancer.
Just as the body fights the bacteria and viruses (microbes) that cause disease, it can also fight the transplanted organ because it is a “foreign organ.” When the body fights the transplanted kidney, rejection occurs.
Rejection is an expected side effect of transplantation, and up to 30% of people who receive a kidney transplant will experience some degree of rejection. Most rejections occur within six months of the transplant, but can occur at any time, even years later. Prompt treatment can reverse rejection in most cases.
Anti-rejection drugs, also known as immunosuppressive agents, help prevent and treat rejection. They are necessary for the “life” of the transplant. If these drugs are stopped, rejection may occur and the kidney transplant may fail.
- Better long-term results. There is no need to wait in the waiting list for a kidney transplant from a deceased donor.
- Surgery can be scheduled at a time convenient to both the donor and recipient.
- Lower risk of complications or rejection and better early kidney transplant function.
- Any healthy person can donate a kidney. When a living person donates a kidney, the remaining kidney will expand slightly as it takes on the work of two kidneys. Donors do not need medication or special diets after they recover from surgery. As with any major surgery, complications are likely, but kidney donors have the same life expectancy, general health, and kidney function as most others. Kidney loss does not interfere with a woman’s ability to have children.
- Age <18 years, unless emancipated minor
- Uncontrollable hypertension
- History of pulmonary embolism or recurrent thrombosis
- Bleeding disorders
- Uncontrollable psychiatric illness
- Morbid obesity
- Uncontrollable cardiovascular disease
- Chronic lung disease with impaired oxygenation or ventilation
- History of melanoma
- History of metastatic cancer
- Bilateral or recurrent nephrolithiasis (kidney stones)
- Chronic kidney disease (CKD) stage 3 or less
- Proteinuria> 300 mg / d except postural proteinuria
- HIV infection
- Reduced need for strong pain medications
- Shorter recovery time in hospital
- Faster return to normal activities
- Very low complication rate
- The operation takes 2-3 hours. The recovery time in the hospital is usually 1-3 days. Donors are often able to return to work immediately 2-3 weeks after the procedure.
Although laparoscopy is increasingly used in open surgery, from time to time the surgeon may choose to perform an open procedure when individual anatomical differences in the donor suggest that this will be a better surgical approach.
The quality and function of the kidneys, restored with any technique, work equally well. Regardless of the technique, all donors will be required to monitor their overall health, blood pressure and renal function throughout their lives.
Many patients have relatives or non-relatives who wish to donate a kidney but are unable to do so because their blood type or tissue type does not match. In such cases, the donor and recipient are said to be “incompatible”.
This is a program that allows patients to receive a kidney from a living donor who has an incompatible blood type. In order to receive such a kidney, patients must undergo several treatments before and after transplantation to remove harmful antibodies that may lead to kidney transplant rejection.
A special process called plasmapheresis, which is similar to dialysis, is used to remove these harmful antibodies from the patient’s blood.
Patients need multiple treatments with plasmapheresis before transplantation and may need several more after transplantation to keep their antibody levels lower. Some patients may also need to have their spleens removed during transplant surgery to reduce the number of cells that produce antibodies. The spleen, a fungal organ the size of a man’s fist, produces blood cells. Located in the upper left part of the abdomen below the ribs, the spleen can be removed laparoscopically.
This program allows kidney transplants to be performed on patients who have developed antibodies against their kidney donors, a situation known as a “positive cross-circle.”
The process is similar to that of incompatible kidney transplants. Patients receive antibody-lowering drugs or may undergo plasmapheresis treatment to remove harmful antibodies from their blood. If antibody levels against their donors are successfully reduced, they can move on with transplants.
Incompatible with kidney transplantation kidney transplants and positive cross / sensitized kidney kidney transplants are very successful internationally. The success rate is close to that for transplants from compatible living donors and is better than the success rate for transplants of deceased donors.
Kidney transplantation from deceased donors
When a person does not have a living donor but is an acceptable transplant candidate, he / she will be placed on a waiting list.
Most kidneys from deceased donors are transplanted to recipients in the same service area as the deceased donor. Although there are recommended guidelines for organ allocation, it may request a “deviation” to meet the special needs of patients awaiting kidney transplantation in their service area.
Unfortunately, many more patients are medically fit for transplants than the available organs. Waiting hours are many years and increase longer. Many patients develop medical and surgical complications while waiting, which may prevent them from receiving a kidney transplant from a deceased donor in the future.
Kidney transplant success rate
The success rate of a kidney transplant varies depending on whether the donated organ is from a living donor or a deceased donor, as well as the medical circumstances of the recipient. Kidneys from living donors usually last longer. Most kidney losses are due to rejection, but infections, circulatory problems, cancer and the return of the original kidney disease can also cause kidney loss.
With short organ supplies and long waits, patients travel abroad to receive a kidney transplant. Commercialism and poor legal regulation in the country where the transplant is performed can undermine the true nature of the transplant and endanger the patient’s life.
Lifelong immunosuppression is a huge burden for patients. Tolerance or the body’s ability to “accept” an organ without a daily anti-rejection drug is the “Holy Grail” of transplantation. Many animal models, as well as isolated reports of patients withdrawing from these drugs, are encouraging.
Most of the successful models involve intensive treatment during transplantation with bone marrow infusions from the donor who delivered the organ. The recipient involves the bone marrow cells, becomes “chimeric” and the new bone marrow cells “re-educate” the recipient to accept the organ. There are many issues that need to be addressed in transplantation, but scientists and experts are working together to eliminate the need for lifelong immunosuppression.
Continuous progress in our understanding of the mechanisms involved in accepting kidney transplants has led to new and exciting drugs. After testing the new drugs in animals, these drugs go into clinical trials in humans. The great success of transplantation has been achieved as a result of basic research, careful testing of innovative drugs and the willingness of patients to participate in controlled trials of new drugs. Even tolerance protocols will require short-term administration of new immunosuppressive drugs. Patient collaboration and participation in clinical trials is essential for the development of kidney transplantation.
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