Kidney transplantation

A kidney transplantation is the treatment of choice for patients of end stage renal disease. Kidneys come from living donors or brain dead or recently cadaveric donors. The term "brain death" means death of the cerebrum. All patients at end stage kidney disease are theoretically eligible for kidney transplantation. Although a relatively simple operation, a kidney transplantation is not a simple task, neither for the recipient nor for the medical team.

After transplantation, the patient must be submitted to strong immunosuppressive treatment (e.g., steroids, cyclosporine, azathioprine, mycophenolate, tacrolimus, rapamycin, antibody treatment). To avoid complications, the kidney transplant recipient must be evaluated by the medical team prior to the operation to ensure eligibility for this procedure. Further to the detailed medical history of the potential recipient, a detailed clinical examination is also necessary along with an extensive lab and radiological evaluation. The existence of any mental disease must also be excluded. Same applies for rectal bleeding and coronary heart disease.

Men over the age of 40 should have their prostate examined. Women must undergo a Pap test, pelvic examination and, when over 40 years of age, they must also have a mammography performed. Smokers should quit smoking.

The lower urinary tract should be sterilized prior to transplantation, as confirmed by a complete urinalysis and urine culture. A cystography and urodynamic testing must be performed in case of suspected genetic abnormalities.Vesicoureteral reflux should be corrected prior to transplantation.

Also before transplantation, patients must be submitted to surgical procedures necessary for treating the following cases:

  • Nephrectomy: Large polycystic kidneys (contralateral), chronic parenchymal inflammation, chronic inflammatory reflux, severe proteinuria, uncontrolled hypertension, inflammatory nephrolithiasis
  • Splenectomy: Donor/ recipient blood group incompatibility (ABO)
  • Cholecystectomy: Cholelithiasis
  • Colectomy: History of diverticulitis
  • Prostatectomy: Prostatic hypertrophy, which can cause obstructive uropathy to the graft
  • Coronary revascularization: Coronary disease

Contraindications for kidney transplantation:

  • Cirrhosis (except in combined liver-kidney transplantation)
  • Chronic respiratory failure (risk during general anesthesia)
  • Severe peripheral vascular disease
  • Active peptic ulcer (until treated, with medication or surgery)
  • Coronary artery disease (treatment before transplantation with angioplasty or CABG)
  • Irreversible congestive heart failure (unless a combined kidney-heart transplantation is performed)
  • Active systemic lupus erythematosus
  • Active human immunodeficiency virus (HIV) infection
  • Active chronic inflammation (osteomyelitis, gravitational ulcers in diabetics, active tuberculosis, recurrent urinary tract infections, peritonitis)
  • Patients positive for hepatitis B (increased risk of death due to resurgence of viremia after transplantation due to immunosuppression)
  • Uncontrolled cancer
  • Psychiatric disorders
  • Non-compliance to previous treatment (high-risk patients for graft loss due to poor treatment compliance)
  • Blood group incompatibility (ABO) (increased risk of accelerated or hyperacute rejection)
  • HLA incompatibility (the better the compatibility antigens HLA-A, HLA-B, HLA-DR between donor and recipient, the better the outcome of transplantation)
  • Cross-compatibility (cross-matching) when positive transplantation is not permitted due to increased risk of vascular and hyperacute rejection in the early post-transplant period.

A man can live a normal life with one kidney. However, after a kidney transplant strict adherence to treatment is necessary. Regular laboratory tests for monitoring the functioning of the transplanted kidney and the levels of various drugs are necessary to avoid unwanted complications.

Complications following a transplant are divided into early and late.

Early complications involve poor kidney function, possibly because of acute rejection, cyclosporine toxicity, ischemia prior to kidney revascularization due to prerenal and postrenal problems, cytomegalovirus or Ebstein-Barr infection.

Late complications involve the loss of kidney function as a result of chronic rejection or recurrence of primary disease in the graft, hypertension, hyperlipidemia, osteoporosis, skin cancer, lymphomas, Kaposi’s sarcoma, genital tract tumors, peptic ulcer, psychiatric disorders, diabetes mellitus, cardiovascular problems and others conditions.

In the past the most appropriate time for transplantation from a living donor was after the patient’s start the renal function replacement therapy. Lately, patients are advised to proceed to kidney transplantation before starting renal function replacement therapy . Namely, when creatinine clearance is equal to 10 ml/min or 15 ml/min for children and diabetics.

This means when the patient’s overall health condition is still good, but their kidney function is poor enough to require transplantation.

As to potential transplant recipients from living or cadaveric donors, and in order to ensure best outcome of a future kidney transplantation, strict adherence to medication and adequate renal function replacement therapy is advised (hemodialysis or peritoneal dialysis)