Tag Archives: Kidney transplantation

Kidney transplant

Introduction:
A kidney transplant is an operation that places a healthy kidney in your body. The transplanted kidney takes over the work of the two kidneys that failed, and you no longer need dialysis.

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During a transplant, the surgeon places the new kidney in your lower abdomen and connects the artery and vein of the new kidney to your artery and vein. Often, the new kidney will start making urine as soon as your blood starts flowing through it. But sometimes it takes a few weeks to start working.

If you have advanced and permanent kidney failure, kidney transplantation may be the treatment option that allows you to live much like you lived before your kidneys failed. Since the 1950s, when the first kidney transplants were performed, much has been learned about how to prevent rejection and minimize the side effects of medicines.

But transplantation is not a cure; it’s an ongoing treatment that requires you to take medicines for the rest of your life. And the wait for a donated kidney can be years long.

Many transplanted kidneys come from donors who have died. Some come from a living family member. The wait for a new kidney can be long. People who have transplants must take drugs to keep their body from rejecting the new kidney for the rest of their lives.

A successful transplant takes a coordinated effort from your whole health care team, including your nephrologist, transplant surgeon, transplant coordinator, pharmacist, dietitian, and social worker. But the most important members of your health care team are you and your family. By learning about your treatment, you can work with your health care team to give yourself the best possible results, and you can lead a full, active life.

Around 40 per cent of patients with end-stage renal failure (ESRF) need a transplant which frees people from the need for dialysis treatments.

A successful kidney transplant has ten times the function of dialysis (for example ten times the ability to remove toxins and extra water from the blood). It means that transplant patients have a better quality of life, with more energy than they did on dialysis.

How transplants work:-
An assessment is necessary to determine whether your body will accept an available kidney. This may require several visits over four to six months, and all potential recipients must be healthy enough for surgery.

Although there is no age limit, few units will transplant patients over 70 years – unless very fit.

If a family member, partner or friend wants to donate a kidney, they will need to be evaluated for general health too.

If there is no potential living donor, you will need to register with hospital and be put on a national waiting list to receive a kidney from a deceased donor. but this varies considerably around the country. Kidneys can also be donated by strangers.

If there is a suitable living donor, the operation can be scheduled in advance, when it suits both sides. If you’re on a waiting list for a deceased donor kidney, as soon as it becomes available, you must go to the hospital quickly – where a test is carried out to check the kidney won’t be rejected. If it’s suitable, the transplant can proceed. The operation usually takes three to four hours.

A surgeon places the new kidney inside your lower abdomen and connects the artery and vein of the new kidney to your artery and vein. Your blood flows through the new kidney, which makes urine, just like your own kidneys did when they were healthy. Unless they are causing infection or high blood pressure, your own kidneys are left in place.

During the operation, the transplant kidney is inserted into the lower abdomen and connected to an artery and vein (to the leg). The blood flows through the new kidney, which makes urine, just like the old kidneys did when they were healthy. The old kidneys are usually left in place.

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Often the new kidney will start making urine as soon as blood starts flowing through it, but about one third of patients will require dialysis for around a week. Most patients leave hospital two weeks after the operation.

To prevent the immune system from seeing the new kidney as foreign and rejecting it, you’ll have to take drugs that turn off (or suppress) your immune response (immunosupressants). It’s important to understand the instructions for taking these medicines before leaving hospital, as missing the tablets for just 24 hours can cause rejection and the loss of the kidney.

Recovery From Surgery:-
As after any major surgery, you’ll probably feel sore and groggy when you wake up. However, many transplant recipients report feeling much better immediately after surgery. Even if you wake up feeling great, you’ll need to stay in the hospital for about a week to recover from surgery, and longer if you have any complications.

Posttransplant Care:-
Your body’s immune system is designed to keep you healthy by sensing “foreign invaders,” such as bacteria, and rejecting them. But your immune system will also sense that your new kidney is foreign. To keep your body from rejecting it, you’ll have to take drugs that turn off, or suppress, your immune response. You may have to take two or more of these immunosuppressant medicines, as well as medications to treat other health problems. Your health care team will help you learn what each pill is for and when to take it. Be sure that you understand the instructions for taking your medicines before you leave the hospital.

If you’ve been on hemodialysis, you’ll find that your posttransplant diet is much less restrictive. You can drink more fluids and eat many of the fruits and vegetables you were previously told to avoid. You may even need to gain a little weight, but be careful not to gain weight too quickly and avoid salty foods that can lead to high blood pressure

Rejection:-
You can help prevent rejection by taking your medicines and following your diet, but watching for signs of rejection—like fever or soreness in the area of the new kidney or a change in the amount of urine you make—is important. Report any such changes to your health care team.

Even if you do everything you’re supposed to do, your body may still reject the new kidney and you may need to go back on dialysis. Unless your health care team determines that you’re no longer a good candidate for transplantation, you can go back on the waiting list for another kidney.

Side Effects of Immunosuppressants:
Immunosuppressants can weaken your immune system, which can lead to infections. Some drugs may also change your appearance. Your face may get fuller; you may gain weight or develop acne or facial hair. Not all patients have these problems, though, and diet and makeup can help.

Immunosuppressants work by diminishing the ability of immune cells to function. In some patients, over long periods of time, this diminished immunity can increase the risk of developing cancer. Some immunosuppressants cause cataracts, diabetes, extra stomach acid, high blood pressure, and bone disease. When used over time, these drugs may also cause liver or kidney damage in a few patients.

Hope through Research:-
The NIDDK, through its Division of Kidney, Urologic, and Hematologic Diseases, supports several programs and studies devoted to improving treatment for patients with progressive kidney disease and permanent kidney failure, including patients who receive a transplanted kidney.

•The End-Stage Renal Disease Program promotes research to reduce medical problems from bone, blood, nervous system, metabolic, gastrointestinal, cardiovascular, and endocrine abnormalities in kidney failure and to improve the effectiveness of dialysis and transplantation. The program seeks to increase kidney graft and patient survival and to maximize quality of life.

•The NIH Organ/Tissue Transplant Center, located at the NIH Clinical Center in Bethesda, MD, is a collaborative project of NIH, the Walter Reed Army Medical Center, the Naval Medical Research Center, and the Diabetes Research Institute at the University of Miami. The site includes a state-of-the-art clinical transplant ward, operating facility, and outpatient clinic designed for the study of new drugs or techniques that may improve the success of organ and tissue transplants.

•The U.S. Renal Data System (USRDS) collects, analyzes, and distributes information about the use of dialysis and transplantation to treat kidney failure in the United States. The USRDS is funded directly by NIDDK in conjunction with the Centers for Medicare & Medicaid Services. The USRDS publishes an Annual Data Report, which characterizes the total population of people being treated for kidney failure; reports on incidence, prevalence, mortality rates, and trends over time; and develops data on the effects of various treatment modalities. The report also helps identify problems and opportunities for more focused special studies of renal research issues.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Resources:
http://www.topnews.in/health/kidney-transplant-patients-low-physical-activity-likely-die-early-211177
http://www.nlm.nih.gov/medlineplus/kidneytransplantation.html
http://www.kidney.niddk.nih.gov/kudiseases/pubs/transplant/
http://www.bbc.co.uk/health/physical_health/conditions/in_depth/kidneys/kidneys_transplant.shtml

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Urinalysis

Definition :
Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a number of tests to detect and measure various compounds that pass through the urine.

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It is a routine examination of the urine for cells, tiny structures, bacteria, and chemicals that suggest various illnesses. A urine culture attempts to grow large numbers of bacteria from a urine sample to diagnose a bacterial urine infection.


How the Test is Performed

A urine sample is needed. Your health care provider will tell you what type of urine sample is needed. For information on how to collect a urine sample, see:

*24-hour urine collection
*Clean catch urine specimen

There are three basic steps to a complete urinalysis:

1. Physical color and appearance:

*What does the urine look like to the naked eye?
*Is it clear or cloudy?
*Is it pale or dark yellow or another color?

The urine specific gravity test reveals how concentrated or dilute the urine is.

2.Microscopic appearance:

The urine sample is examined under a microscope. This is done to look at cells, urine crystals, mucus, and other substances, and to identify any bacteria or other microorganisms that might be present.

3,Chemical appearance:

A special stick (“dipstick”) tests for various substances in the urine. The stick contains little pads of chemicals that change color when they come in contact with the substances of interest.

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How to Prepare for the Test:
For a regular urinalysis, you are asked to urinate briefly into a plastic cup. When urine is collected for a urine culture, you must provide a “clean catch” sample – one that is not contaminated by skin cells and skin bacteria. This is so the doctor can obtain a sample of urine from inside your bladder, where normally there should be no bacteria. In contrast, there are many bacteria on the skin of a penis or in a vagina. The trick (harder for a woman than a man) is to pee directly into a sterile container without having the stream of urine first touch your skin or the nonsterile tissues of the vagina.

To collect a clean catch sample, you are given a sterile plastic container and asked to wipe off the area around your urethra (where urine exits) with an antiseptic cloth. For women, it’s also helpful to hold the two labia (outer walls) of the vagina apart with one hand when you urinate, so that the stream of urine passes directly into the sterile container. Since the first flow of urine is most likely to be contaminated by bacteria from around the opening of the urethra, first urinate for a moment into the toilet and then use the cup to collect the “middle” portion of your urine stream.

Certain medicines change the color of urine, but this is not a sign of disease. Your doctor may tell you to stop taking any medicines that can affect test results.

Medicines that can change your urine color include:

*Chloroquine
*Iron supplements
*Levodopa
*Nitrofurantoin
*Phenazopyridine
*Phenothiazines
*Phenytoin
*Riboflavin
*Triamterene

Why the Test is Performed :-

A urinalysis may be done:

As part of a routine medical exam to screen for early signs of disease
If you have signs of diabetes or kidney disease, or to monitor you if you are being treated for these conditions
To check for blood in the urine
To diagnose a urinary tract infection
Additional conditions under which the test may be performed:

*Acute bilateral obstructive uropathy
*Acute nephritic syndrome
*Acute tubular necrosis
*Acute unilateral obstructive uropathy
*Alkalosis
*Alport syndrome
*Analgesic nephropathy
*Anorexia nervosa
*Atheroembolic renal disease
*Atrial myxoma
*Bladder stones
*Chronic bilateral obstructive uropathy
*Chronic glomerulonephritis
*Chronic or recurrent urinary tract infection
*Chronic renal failure
*Chronic unilateral obstructive uropathy
*Chronic urethritis
*Complicated UTI (pyelonephritis)
*Congenital nephrotic syndrome
*Cystinuria
*Delirium
*Dementia
*Dementia due to metabolic causes
*Diabetes insipidus — central
*Diabetic nephropathy/sclerosis
*Enuresis
*Epididymitis
*Failure to thrive
*Focal segmental glomerulosclerosis
*Goodpasture’s syndrome
*Heart failure
*Hemolytic-uremic syndrome (HUS)
*Henoch-Schonlein purpura
*Insulin-dependent diabetes (IDD)
*IgA nephropathy (Berger’s disease)
*Injury of the kidney and ureter
*Interstitial nephritis
*Irritable bladder
*Left-sided heart failure
*Lupus nephritis
*Malignant hypertension (arteriolar nephrosclerosis)
*Medullary cystic kidney disease
*Membranoproliferative GN I
*Membranoproliferative GN II
*Membranous nephropathy
*Myelomeningocele (children)
*Necrotizing vasculitis
*Nephrotic syndrome
*Noninsulin-dependent diabetes (NIDD)
*Orchitis
*Ovarian cancer
*Paroxysmal nocturnal hemoglobinuria (PNH)
*Polycystic kidney disease
*Post-streptococcal GN
*Prerenal azotemia
*Primary amyloid
*Prostate cancer
*Prostatitis, acute
*Prostatitis, chronic
*Prostatitis, non-bacterial
*Pyelonephritis; acute
*Rapidly progressive (crescentic) glomerulonephritis
*Reflux nephropathy
*Renal papillary necrosis
*Renal tubular acidosis; distal
*Renal tubular acidosis; proximal
*Renal vein thrombosis
*Retrograde ejaculation
*Rhabdomyolysis
*Right-sided heart failure
*Secondary systemic amyloid
*Stress incontinence
*Systemic lupus erythematosus
*Systemic sclerosis (scleroderma)
*Thrombotic thrombocytopenic purpura
*Traumatic injury of the bladder and urethra
*Ureterocele
*Urethral stricture
*Urethritis
*Wegener’s granulomatosis
*Wilms’ tumor

RESULTS:

Normal Results
Normal urine may vary in color from almost colorless to dark yellow. Some foods (like beets and blackberries) may turn the urine a red color.

Usually, glucose, ketones, protein, bilirubin, are not detectable in urine. The following are not normally found in urine:

*Hemoglobin
*Nitrites
*Red blood cells
*White blood cells
Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific test results.

What Abnormal Results Mean
For specific results, see the individual test article:

*Bilirubin – urine
*Glucose – urine
*Protein – urine
*Red blood cells in urine test
*Urine ketones
*Urine pH
*Urine protein
*Urine specific gravity

How long is it before the result of the test is known?
Your doctor might be able to do a urinalysis in his or her office and can give you the results within 10-15 minutes. If the urine is sent to a separate laboratory, it usually takes several hours to get results, so you may not hear from your doctor until the next day. A urine culture takes 24 to 72 hours to complete, so you may not hear results for several days.

Resources:
https://www.health.harvard.edu/fhg/diagnostics/urinalysis.shtml
http://www.nlm.nih.gov/medlineplus/ency/article/003579.htm

http://www.hallvet.com.au/services/urinalysis.html

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Radionuclide Scan of the Kidneys

Definition
A radionuclide scan of the kidneys shows a picture of your kidneys while they are at work making urine.A kidney radionuclide scan, also called a kidney scan or renal scan, is a diagnostic imaging test that involves administering a small amount of radionuclide, also called a radioactive tracer, into the body and then imaging the kidneys with a gamma camera. The images obtained can help in the diagnosis and treatment of various kidney diseases and conditions. This test can be useful to evaluate infection, blockages, injury to the kidneys, and some causes of high blood pressure.

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Precautions
A kidney scan requires the use of a radioactive material; therefore, patients who are pregnant or suspect they may be pregnant are cautioned not to have the test unless the benefits outweigh the risks. Women should inform their doctor if they are breast feeding. The doctor will recommend the woman stop breast feeding for a specified period of time, depending on the particular tracer and dose used.

Description
Kidney scans are performed either in a hospital nuclear medicine department or in an outpatient radiology or nuclear medicine facility. The patient is positioned in front of, or under, a gamma camera—a special piece of equipment that detects the radiation emitted from the body and produces an image. An intravenous injection of the radionuclide is administered. Immediately after the injection imaging begins, and, in most studies, the flow of blood to each kidney is evaluated. Serial images of the kidneys are obtained over a specified period of time, depending upon the particular radiopharmaceutical used. Kidney scans may be performed to determine the rate at which the kidneys are filtering a patient’s blood. These studies use a radiopharmaceutical called technetium DTPA (Tc99m DTPA). This radiopharmaceutical also can identify obstruction in the renal collecting system. To establish the function of the renal tubules, the radiopharmaceutical Technetium DMSA (Tc99m DMSA) is used.

A kidney scan ranges from 45 minutes to three hours in length, depending upon the goals of the test, but the test typically takes about an hour to an hour and a half. It is important to understand that kidney scans can reveal an abnormality, but they do not always identify the specific problem. They are very useful in providing information about how the various parts of the kidneys function, which, in turn, can assist in making a diagnosis.

Typically, posterior images are obtained but images are also obtained at oblique angles. If indicated, the patient may be positioned so that mobility of the kidney is demonstrated by sitting up or lying down for the images. If obstruction or renal function is being evaluated, a diuretic (drug to induce urination), such as Lasix, may be injected. If hypertension or renal artery sterosis is being evaluated, Captopril or Enalapril (ACE inhibitors) may be injected.
Preparation
No special preparation is necessary for a kidney scan. In some instances the patient may be required to drink additional liquids and to empty their bladder before the exam. If another nuclear medicine study was recently performed, the patient may have to wait for a specified period to avoid any interference from residual radioactivity in the body. The patient is instructed to remove metal items from the area to be scanned.

Let your doctor know if you could be pregnant or if you are breast-feeding a baby. The medicine used in this test would expose your baby to radiation.

What happens when the test is performed.
You have an IV (intravenous) line placed into a vein. A slightly radioactive version of a substance called sodium pertechnetate is injected through the IV. This substance helps your kidneys and urine show up on pictures.

A camera that is specially designed to detect radioactivity is placed against your back or abdomen. A number of pictures are taken over time. The camera itself does not expose you to any additional radiation, so the number of pictures is not harmful in any way. The test is usually completed within an hour.

Risk Factors:
Many people worry when they hear that the medicine used in this test is slightly radioactive. In truth, this test exposes you to a very small amount of radiation-no greater than that of routine xrays.

Moreover, Nuclear medicine procedures are very safe. Unlike some of the dyes that may be used in x-ray studies, radioactive tracers rarely cause side effects. There are no long-lasting effects of the tracers themselves, because they have no functional effects on the body’s tissues. If pharmaceuticals are injected these can temporarily raise or lower blood pressure, or cause one to urinate.

Aftercare
Patients can resume their normal daily activities immediately after the test. Most radioactive tracers are excreted through the urinary system, so drinking fluids after a kidney scan can help flush the tracer out of the body more quickly.

Results
The scan should reveal normal kidney function for the patient’s age and medical status, as well as show normal relative position, size, configuration, and location of the kidneys. Initial blood flow images should reflect that blood circulation to both kidneys is equal. Patients whose images suggest a space-occupying lesion or obstruction may require other imaging procedures, such as CT or ultrasound, to provide more information. Also, if the kidneys appear to be abnormal in size, have an unusual contour, or are unusually positioned, other imaging procedures may be required.

Resources:
https://www.health.harvard.edu/fhg/diagnostics/radionuclide-scan-of-the-kidneys.shtml
http://www.enotes.com/nursing-encyclopedia/kidney-radionuclide-scan

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Kidney Donation is Safe

Kidney location after transplantation.

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People who decide to donate a kidney to their near and dear ones need not fear any long term implications as donation has no negative impact on donor’s general health, say experts. Donors can lead a perfectly normal life and, on the contrary, are benefitted psychologically, having the satisfaction of saving a life, they add. Similar observations have been made by a study done in puerto rico which has been reported in the transplantion proceedings . People with one normal kidney can lead a perfectly nomal life and in fact one in 1,000 people are born with single kidney, Dr. S.   C. Tiwari, professor at the department of nephrology at aiims, said. Hence, mortality for donors is same as for normal people with there being hardly any chance of death because of complications arising out of donation, he said. Tiwari said the institute, where on an average two kidney transplants are performed in a week, did not have a policy of keeping a track of kidney donors.

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However, recipients, who usually come for health follow up regularly, are enquired about the health of donors, generaly related to them. The only difference a donation makes for donors is that their remaining kidney is under more pressure as it has to work for the whole body. thus, donors are asked to live a regulated life and control their diet, blood pressure and physical activity so that work load on kidney does not exceed, Tiwari said. till three months after donation, donors’ single kidney remains hypertrophy, which reflects that it is coping with entire body’s load, and then it adjusts, Tiwari said.

During these three months, the donors are supposed to take special care. One significant outcome of kidney donaiton is that donors have a sense of “eternal satisfaction” for contributing to the life of a relative, he added. The opinion on kidney donation is strengthened by the study, carried out under the puerto rico renal transplant programme, an academic programme based in an affiliated community hospital, in puerto rico.

The study, based on a documentation of the long-term health of live kindney donors, said that in general the health after many years of donation reflects more or less the health of the general population, stressing that kidney donation is a relatively safe procedure with little morbidity and no mortality in the majority of cases. Risk of mortality is estimated to be 0.03 per cent while acute complication rates vary and are relatively low at eight per cent in places with vast experience in living donation, it said. the puerto rico study involved follow up of the health of 20 donors who had donated their kidney 20 years ago or more.

The donors were interviewed and subjected to a complete history and physical examination, including blood pressure and urine analysis, the report said. of the 20 donors, 12 were females and eight males. the donors were in the mean age of 61 years. Significantly all the donors expressed happiness over donation, the report said. in terms of health parameters, the donors had normal urine analyses, excluding one, a 73-year-old woman who had donated kidney to her daughter, who had persence of protein in urine (proteinuria), the report said adding the woman had developed de novo diabetes. Five of the 20 donors developed de novo hypertension at least 10 years after the donation.However, all of them had a strong family history of hypertension, it said. however, donors had elevated levels of creatinin, a product of muscle breakdown, in their serum and lower creatinin clearance by kidneys.

The report said that though it indicated reduced kidney function, the increase in serum creatinin was not significant. Tiwari said that at aiims he had not seen any donor having a creatinin level, which has caused any problem. Dr. D. S. Rana, a nephrologist at the ganga ram hospital, said that creatinin level sometimes increases in marginal donors – donor who are aged (above 65), or have mild hypertension, or have slightly abnormal kidney function. All these are contraindicaitons for kidney donation, but such people are sometimes accepted as donors when no other suitable donor is available, rana said, adding even such donors do not carry any major risk. If raised levels of creatinin are observed, patients are asked to avoid high protein diet, rana said. during the donation surgery also, donors are not at an additional risk. The risks are same as in any other surgery.

Sources: The Times Of India

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Kidney Transplantation

Kidney location after transplantation.

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Alternative Names:Renal transplant; Transplant – kidney

Definition:

A kidney transplant is surgery to place a healthy kidney into a person with kidney failure. Kidney transplantation or renal transplantation is the organ transplant of a kidney 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.

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Description :
Kidney transplants are one of the most common transplant operations in the United States.

A donated kidney is needed to perform a kidney transplant.

The donated kidney may be from:

*Living related donor — related to the recipient, such as a parent, sibling, or child
*Living unrelated donor — such as a friend or spouse

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 hypertension, infections, diabetes mellitus and glomerulonephritis; genetic causes include polycystic kidney disease as well as a number of inborn errors of metabolism as well as autoimmune conditions including lupus and Goodpasture’s syndrome. 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 dialysis – hemodialysis, peritoneal dialysis, or the similar process of hemofiltration – at the time of transplantation. However, individuals with chronic renal failure who have a living donor available often elect to undergo transplantation before dialysis is needed.

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, with some coming from living donors. However, the utilization of living donors in the United States is on the rise. In the year 2006, 47% of donated kidneys were actually from living donors (Organ Procurement and Transplantation Network, 2007). It is important to note that this varies by country: for example, only 3% of transplanted kidneys during 2006 in Spain came from living donors (Organización Nacional de Transplantes (ONT), 2007).

Living donors:
Potential donors are carefully evaluated on medical and psychological grounds. This ensures that the donor is fit for surgery and has no kidney disease whilst confirming that the donor is purely altruistic. Traditionally, the donor procedure has been through a single, 4-7 inch incision but live donation is being increasingly performed by laparoscopic surgery. This reduces pain and accelerates recovery for the donor. Excellent results have been demonstrated with laparoscopic donor nephrectomy, for both donor and recipient outcomes. Overall, recipients of kidneys from live donors do extremely well, in comparison to deceased donor recipients.

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 type (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

PROCEDURE FOR A LIVING KIDNEY DONOR:-
If you are donating a kidney, you will be placed under general anesthesia before surgery. This means you will be asleep and pain-free. The surgeon makes a cut in the side of your abdomen, removes the proper kidney, and then closes the wound. The procedure used to require a long surgical cut. However, today surgeons can use a short surgical cut (mini-nephrectomy) or laparoscopic techniques.

Deceased donors:-
Deceased donors can be divided in two groups:

Brain-dead (BD) donors
Donation after Cardiac Death (DCD) donors
Although brain-dead (or “heart-beating”) donors are considered dead, the donor’s heart continues to pump and maintain the circulation. This makes it possible for surgeons to start operating while the organs are still being perfused. During the operation, the aorta will be cannulated, after which the donor’s blood will be replaced by an ice-cold storage solution, such as UW (Viaspan), HTK, 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 NaCl-solution are poured over the organs for a rapid cooling of the organs), 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 ventilation is shut off). Usually, a certain amount of minutes after death has been pronounced, the patient is rushed to the operating theatre, where the organs are recovered, after which the storage solution is flushed through the organs itself. Since the blood is no longer being circulated, coagulation must be prevented with relatively large amounts of anti-coagulation agents, such as heparin. It is important to note that several ethical and procedural guidelines must be followed, chief of which is that the organ recovery team should not participate in the patient’s care in any manner until after death has been declared.

Kidneys from brain-dead donors are generally of a superior quality, since they have not been exposed to warm ischemia (the time between the heart stopping and the kidney being cooled).

Compatibility:
If plasmapheresis or IVIG is not performed, the donor and recipient have to be ABO blood group compatible. Also, they should ideally share as many HLA and “minor antigens” as possible. This decreases the risk of transplant rejection 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, it is important to note that 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. . Now, a number of programs around the world are routinely performing ABO-incompatible transplants.

In 2004 the FDA approved the Cedars-Sinai High Dose IVIG protocol which eliminates the need for the donor to be the same blood type.

Procedure:
Since in most cases the barely functioning existing kidneys are not removed because this has been shown to increase the rates of surgical morbidities, the kidney is usually placed in a location different from the original kidney (often in the iliac fossa), and as a result it is often necessary to use a different blood supply:

*The renal artery of the kidney, previously branching from the abdominal aorta in the donor, is often connected to the external iliac artery in the recipient.

*The renal vein of the new kidney, previously draining to the inferior vena cava in the donor, is often connected to the external iliac vein in the recipient.

Why the Procedure is Performed :

A kidney transplant may be recommended if you have kidney failure caused by:

*Diabetes
*Glomerulonephritis
*Severe, uncontrollable high blood pressure
*Certain infections

A kidney transplant alone may NOT be recommended if you have:

*Certain infections, such as TB or osteomyelitis
*Difficulty taking medications several times each day for the rest of your life
*Heart, lung, or liver disease
*Other life-threatening diseases

Risks  Factor:

The risks for any anesthesia are:

*Problems breathing
*Reactions to medications

The risks for any surgery are:
*Bleeding
*Infection

Other risks include:
Infection due to medications that suppress the immune response that must be taken to prevent transplant rejections

Post operation:
The transplant surgery lasts about three hours. 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, so the ischemia time is minimized. In most cases, the kidney will soon start producing urine. Since urine is sterile, this has no effect on the operation. The final step is connecting the ureter from the donor kidney to the bladder.

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 four to seven days. If complications arise, additional medicines may be administered to help the kidney produce urine.

Medicines 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 : tacrolimus, mycophenolate, and prednisone. Some patients may instead take cyclosporine, rapamycin, or azathioprine. Cyclosporine, considered a breakthrough immunosuppressive when first discovered in the 1980’s, ironically causes nephrotoxicity and can result in iatrogenic damage to the newly transplanted kidney. Blood levels must be monitored closely and if the patient seems to have a declining renal function, a biopsy may be necessary to determine if this is due to rejection or cyclosporine intoxication.

Acute rejection occurs in 10% to 25% of people after transplant during the first sixty days. Rejection does not necessarily mean loss of the organ, but may require additional treatment.

Complications:
Problems after a transplant may include:

*Transplant rejection (hyperacute, acute or chronic)

*Infections and sepsis due to the immunosuppressant drugs that are required to decrease risk of rejection

*Post-transplant lymphoproliferative disorder (a form of lymphoma 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 (excessive hair growth in a male-pattern distribution), hair loss, obesity, acne, diabetes mellitus (type 2), hypercholesterolemia, 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 starts on dialysis.

At least three professional athletes have made a comeback to their sport after receiving a transplant: NBA players Sean Elliott and Alonzo Mourning; and New Zealand rugby union player Jonah Lomu as well as the German-Croatian Soccer Player Ivan Klasni?.

Recovery
The recovery period is 4 – 6 weeks for people who donate a kidney. If you’ve done so, you should avoid heavy activity during this time. Your doctor removes the stitches after a week or so.

If you received a donated kidney, you will need to stay in the hospital for about a week. Afterwards, you will need close follow-up by a doctor and regular blood tests.

Resources:
http://en.wikipedia.org/wiki/Kidney_transplantation
http://www.nlm.nih.gov/medlineplus/ency/article/003005.htm

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