Kidney transplantation (KT) is the outcome of great advancement in
Kidney transplantation is the treatment of choice for end-stage kidney
disease (ESKD). Successful kidney transplantation may offer better
quality of life and longer patient survival compared with dialysis. Life
after successful kidney transplantation is almost normal.
Kidney transplantation is discussed in four parts:
- 1. Pre-Transplant Information
- 2. Transplant surgery
- 3. Post Transplant care
- 4. Deceased donor (Cadaveric) kidney transplant
1. Pre-Transplant Information
What is kidney transplantation?
Kidney transplantation is a surgical procedure in which a healthy kidney
(from a living donor or deceased - cadaver donor) is placed into the
body of a person suffering from end-stage kidney disease (recipient).
When is kidney transplant necessary?
Kidney transplantation is necessary for patients who are suffering from
ESKD who are on dialysis (hemodialysis or peritoneal dialysis) or who
are approaching ESKD but not yet on dialysis (pre-emptive KT).
When is kidney transplant not required in kidney failure?
A patient with acute kidney injury should not undergo KT. Kidney
transplantation is also not done in cases where only one kidney fails and the other kidney is still functioning. Transplantation should only be done if the renal failure is irreversible.
Discovery of kidney transplantation has been
a blessing for patients with chronic kidney failure.
Why is kidney transplant necessary in end-stage kidney
Dialysis replaces some degree of the filtration of waste products of the
kidneys. Other functions of the kidneys are not accomplished, some of
which are better addressed by transplantation. Hence, kidney
transplantation, when a suitable donor is available and when no
contraindications are present, offers the best treatment option for
complete rehabilitation of a patient with end-stage kidney failure. As
kidney transplantation saves lives and enables one to enjoy almost normal
life, it is referred to as the “Gift of Life”.
What are the advantages of kidney transplantation?
Major benefits of successful KT are:
- Better degree of replacement of renal function and better quality of
life: The patient may achieve an almost normal and active lifestyle
with more energy, stamina and productivity.
- Freedom from dialysis: Patients avoid the complications, cost, lost
time and inconveniences of dialysis treatment.
- Longer life expectancy: Transplant patients have a longer life
expectancy than risk-matched patients who remain on dialysis.
- Lesser dietary and fluid restrictions.
- Cost-effectiveness: Although the initial cost of a kidney transplant
may be high, the expenses decrease by the second to third year
post-transplant and by then, is usually less than that needed for
maintenance dialysis treatment.
- There is a reported improvement in sexual life and a higher chance
of fathering a child in males and becoming pregnant in females.
Successful kidney transplantation is the best treatment
option for CKD-ESKD as it offers almost normal life.
What are the disadvantages of kidney transplantation?
Kidney transplantation offers many benefits but also has disadvantages.
- Risk of major surgery. Kidney transplantation is a major surgical
procedure under general anesthesia that has potential risks both during
and after the surgery.
- Risk of rejection. There is no 100% guarantee that the body will
accept the transplanted kidney. But with the availability of newer
and better immunosuppressant drugs, rejections are less likely than
they were in the past.
- Regular medication. Transplant patients will need to take
immunosuppressive medicines regularly for as long as their donor
kidneys are functioning. Discontinuation, missing or not taking the
full dosage of immunosuppressant drugs, carries the risk of failure of
transplanted kidney due to rejection.
- Risks related to immunosuppressive drugs: Drugs that suppress the
immune response and rejection may lead to severe infections . Care
to avoid infections and screening for development of some forms of
cancer are part of post-transplant care. There are side effects for
drugs like high blood pressure, high blood cholesterol and sugar
- Stress. Waiting for a kidney donor before transplant, uncertainty of
success of transplant (the transplanted kidney may fail) and fear of losing function of the newly transplanted kidney after transplant, is stressful.
Kidney transplantation is not performed in CKD patients
with AIDS, cancer and other serious diseases.
What are the contraindications for a kidney transplant?
Kidney transplantation is not recommended if the ESKD patient has:
What is the age limit for a kidney transplant recipient?
- A serious active infection
- Active or untreated malignancy
- Severe psychological problems or mental retardation
- Unstable coronary artery disease
- Refractory congestive heart failure
- Severe peripheral vascular disease
- Antibodies against the donor kidney
- Other severe medical problems.
Although there is no fixed criteria for the age of a kidney transplant
recipient, it is usually recommended for persons from 5 to 65 years of
What are the likely sources of kidneys for transplantation?
There are three sources of kidneys for transplantation:
Who is the ideal kidney donor?
- Living related donors: blood relatives of the recipient up to the 4th
degree of consanguinity.
- Living non-related donors: like friends, spouses or relatives.
- Deceased (cadaver) donors: from victims of brain death.
An identical twin is an ideal kidney donor with the best chances of
survival after transplantation.
Kidney donated by family member donors results
in most successful kidney transplantation.
84. Save Your Kidneys
Who can donate a kidney?
A healthy person with two kidneys can donate one kidney as long as
the blood group, tissue type and tissue crossmatching are compatible
with the receipient. Generally, donors should be between the ages of
18 and 65 years.
How does blood group determine the selection of a kidney
Blood group compatibility is important in KT. The recipient and donor
must have either the same blood group or compatible groups . Just like
in blood transfusions, a donor with blood group O is considered a
“universal” donor. (see table below)
Who cannot donate a kidney?
|Recipient’s blood group
||Donor’s blood group
||A or O
||B or O
||AB,A, B or O
A living donor should be thoroughly evaluated medically and
psychologically to ensure that it is safe for him or her to donate a kidney.
A person cannot donate kidney if he or she has diabetes mellitus, cancer,
HIV, kidney disease, high blood pressure or any major medical or
What are the potential risks to a living kidney donor?
A potential donor is evaluated thoroughly to ensure that it is safe for him
or her to donate a kidney. With a single kidney, most donors live a
normal healthy life. After kidney donation sexual life is not affected. A
woman can have children and a male donor can father a child.
Potential risks of kidney donation surgery are the same as those with
any other major surgery. Risk of contracting kidney disease in kidney
donors is not any higher just because they have only one kidney.
Kidney donation is safe and
saves lives of CKD patients.
Paired kidney donation & Pre-emptive kidney transplant
85. CHP. 14. Kidney Transplantation
What is paired kidney donation?
Living donor kidney transplantation has several advantages over
deceased donor kidney transplantation or dialysis. Many patients with
end-stage kidney disease have healthy and willing potential kidney
donors but the hurdle is blood group or cross match incompatibility.
Paired kidney donation (also known as “live donor kidney exchange”,
“living donor swap” or “kidney swap”) is the strategy which allows the
exchange of living donor kidneys between two incompatible donor/
recipient pairs to create two compatible pairs. This can be done if the
second donor is suitable for the first recipient, and the first donor is
suitable for the second recipient (as shown above). By exchanging the
donated kidneys between the two incompatible pairs, two compatible
transplants can be performed.
What is pre-emptive kidney transplant?
Kidney transplantation usually takes place after a variable period of
dialysis therapy. Kidney transplantation may be done before the initiation
of maintenance dialysis when the renal function is less than 20 ml/min.
This is called a pre-emptive KT.
Pre-emptive KT is considered the best option for kidney replacement
therapy in medically suitable patients with end stage kidney disease
(ESKD) because it not only avoids the risks, cost, and inconvenience
of dialysis, but also is associated with better graft survival than
transplantation performed after initiating dialysis. Because of its benefits,
one is strongly advised to consider a pre-emptive transplantation in
ESKD, if a suitable donor is available.
86. Save Your Kidneys
2. Transplant Surgery
How is a kidney transplanted?
- Before surgery, medical, psychological and social evaluation is done
to ensure fitness and safety of both the recipient and the donor (in
living-kidney donor transplant). Testing also ensures proper blood
group and HLA matching and tissue crossmatching.
- Kidney transplantation is a teamwork of the nephrologists, transplant
surgeon, pathologist, anesthesiologist and supporting medical
(cardiologist, endocrinologist, etc) and nursing staff as well as
- After a thorough explanation of the procedure a careful reading of
the consent form, consent of both the recipient and the donor (in
living kidney donation) is obtained.
- In living-kidney donor transplant surgery, both the recipient and the
donor are operated on simultaneously.
- This major surgery lasts from three to five hours and is performed
under general anesthesia.
- In living-kidney donor transplant surgery, usually the left kidney is
removed from the donor either by open surgery or by laparoscopy.
After removal, the kidney is washed with a special cold solution and
subsequently placed into the right lower (pelvic) part of the abdomen
of the recipient.
- In most cases, the old diseased kidneys of the recipient are not
- When the source of kidney is a living donor, the transplanted kidney
usually begins functioning immediately. However, when the source of the kidney is a deceased (cadaver) kidney donor, the transplanted
kidney may take a few days or weeks to begin functioning. The
recipient with delayed functioning transplanted kidney needs dialysis
until kidney function becomes adequate.
- After the transplant, the nephrologist supervises the monitoring and
medications of the recipient. Living donors should also be screened
and monitored regularly for any health issues that may develop.
In kidney transplantation, kidney is transplanted in lower
abdomen of the recipient without disturbing old kidneys.
Post-transplant Care & Drugs
88. Save Your Kidneys
3. Post-Transplant Care
What are the likely post-transplant complications?
The common possible complications after transplantation include
rejection, infection, medication side effects and post-operative
complications. Major considerations in post-transplant care are:
Post-transplant Medications and Kidney Rejection
How does post-surgical management of kidney
transplantation differ from other routine surgery?
- Post-transplant medications and kidney rejection.
- Precautions to keep the transplanted kidney healthy and to prevent
In most cases of routine surgery, post-surgical medications and care
are needed for about 7-10 days. However, after kidney transplantation,
lifelong regular medications and meticulous care are mandatory.
What is kidney rejection?
The immune system of the body is designed to recognize and destroy
foreign proteins and antigens like harmful bacteria and viruses. When
the recipient’s immune system recognizes that the transplanted kidney
is not ‘its own,’ it attacks the transplanted kidney and tries to destroy it.
89. CHP. 14. Kidney Transplantation
This attack by the body’s natural defense on a transplanted kidney is
known as rejection. Rejection occurs when the transplanted kidney is
not accepted by the body of the transplant recipient.
Major post-transplant complications are kidney
rejection, infection and side effects of drugs.
When does kidney rejection occur and what is its effect?
Rejection of the kidney can occur at any time after the transplant, most
commonly in the first six months. The severity of rejection varies from
patient to patient. Most rejections are mild and easily treated by proper
immunosuppressant therapy. In a few patients however, rejection may
be severe not responding to therapy and eventually destroying the kidney.
What medications should a patient take after transplant to
- Because of the immune system of the body, there is always a risk of
rejection of the transplanted kidney.
- If the immune system of the body is suppressed the risk of rejection
is decreased. However, the patient becomes prone to life-threatening
- Special drugs are given to patients after kidney transplantation to
selectively alter the immune system and prevent rejection, but
minimally impair the ability of the patient to fight infections.
Such special drugs are known as immunosuppressant drugs.
At present, the most widely used immunosuppressant drugs are
tacrolimus/cyclosporine, mycophenolate mofetil (MMF), sirolimus/
everolimus and prednisolone.
How long does the patient need to continue
immunosuppressant drugs after kidney transplant?
Immunosuppressant medications have to be given throughout life, for as long as the kidney graft is functioning. In the immediate post transplant period, several drugs are given but their numbers and dosages are gradually reduced over time.
After kidney transplantation lifelong drug therapy
is mandatory to prevent kidney rejection.
Does the patient need any other medication after kidney
Yes. After kidney transplant, in addition to immunosuppressant drugs,
antihypertensive drugs, calcium, and medications to treat or prevent
infection and anti-peptic ulcer medications may be prescribed.
What are the common side effects of immunosuppressant
Common side effects of immunosuppressant drugs are summarized in
the following table.
What happens if transplanted kidney fails?
When a transplanted kidney fails, the patient may either undergo a second
transplant or undergo dialysis.
If a transplanted kidney fails, initiation of dialysis and a
second transplant are two treatment options.
Precautions after Kidney Transplant
91. CHP. 14. Kidney Transplantation
Precautions after kidney transplant
Successful kidney transplant provides a new, normal, healthy and
independent life. However, the recipient must live a disciplined lifestyle
and follow precautions to protect the transplanted kidney and prevent
infections. The patient has to be compliant and take prescribed
medications regularly and without fail.
General guidelines to keep transplanted kidney healthy
- Never stop taking medication or modify its dosage. Remember that
irregularity, modification or discontinuation of medications are some
of the most common reasons for transplant failure.
- Always keep a list of medications and maintain adequate stock. Do
not take any over-the-counter drugs or herbal therapies.
- Blood pressure, volume of urine, weight and blood sugar (if advised
by the doctor) every day.
- Regular follow up with a doctor and laboratory tests as advised, is
- Get blood tested in reputed laboratories only. If laboratory reports
are not satisfactory, rather than changing the laboratory, it is advisable
to consult your doctor at the earliest.
- In an emergency, if you need to consult a doctor who is unaware
about your disease, do not fail to inform him that you are a transplant
recipient and brief him about the medications.
- There are less dietary restrictions after transplantation. Meals should be taken regularly. One should eat a well-balanced diet with adequate calories and proteins as prescribed. Eat foods low in salt, sugar, and fat and high in fiber to avoid weight gain.
Keys for success in post-transplant period are
regularity, precautions and watchfulness.
- Water intake should be adequate to avoid dehydration. Patients
may require up to more than three liters of water a day.
- Exercise regularly and keep weight under control. Avoid heavy
physical activity and contact sports e.g. boxing, football.
- Safe sexual activities can be resumed after about two months, after
consulting the doctor.
- Avoid smoking and alcohol intake.
- Stay away from crowded places such as cinemas, shopping malls,
public transportation and people who have infections.
- Always wear a face mask in public places and high-risk areas such
as construction sites dust-laden environments, excavation sites,
caves, animal care settings, farms, gardens, etc.
- Always wash your hands with soap and water before you eat, before
preparing or taking medications and after using the bathroom.
- Drink filtered boiled water.
- Eat fresh home-cooked cooked food in clean utensils. Avoid eating
meals cooked outside the home and raw, uncooked foods. Avoid
raw fruits and vegetables for the first 3 months after transplant.
- Maintain proper cleanliness at home.
- Take good care of teeth by brushing twice a day.
- Do not neglect any cuts, abrasions or scrapes. Promptly clean them
with soap and water cover them with clean dressing.
Immediately consulting a doctor and promptly treating any new
or unusual problem are mandatory to protect the kidney.
93. CHP. 14. Kidney Transplantation
Consult or call the doctor or transplant clinic in case of:
Why are only a few patients with kidney failure able to get
- Fever over 100 F or 37.8 C and flu-like symptoms such as chills,
body aches or persistent headache.
- Pain or redness over or around the transplanted kidney.
- Significant decrease in urine output, fluid retention (swelling) or rapid
weight gain (more than 1 kg in a day).
- Blood in the urine or burning sensation during urination.
- Cough, breathlessness, vomiting or diarrhea.
- Development of any new or unusual symptoms.
- Immediately contacting the doctor and promptly treating any new or
unusual problem are mandatory to protect the kidney.
A kidney transplant is the most effective and best treatment option for
patients with chronic kidney disease - end stage kidney failure. There is
a large number of patients who need or wish to obtain a kidney transplant.
There are three important reasons for the limited feasibility of the
- 1. Unavailability of kidney:Only a few patients are luckyto obtain
either living (related or non-related) or deceased (cadaveric) kidney
donors. Major problems are the limited availability of living donors
and the long waiting list for deceased donors.
- 2. Cost:The cost of transplant surgery and the post-transplant lifelong
medications is very high. This is a major hurdle for a large number
of patients in developing countries.
- 3. Lack of facilities: In many developing countries, facilities for kidney
transplantation are not readily or easily available.
The scarcity of kidney donors is a major hurdle which
deprives patients from the benefits of a transplant.
Deceased (Cadaveric) kidney transplantation
94. Save Your Kidneys
4. Deceased (Cadaveric) Kidney Transplantation
What is deceased kidney transplantation?
Deceased (cadaver) transplantation involves transplanting a healthy
kidney from a patient who is “brain dead” into a patient with CKD. The
deceased kidney comes from a person who has been declared “brain
dead” with the desire to donate organs having been expressed either
by the family or by the patient previously, at the event of his/her death.
Why are deceased kidney transplants necessary?
Due to the shortage of living donors, many CKD patients, though keen
to have a transplant, have to remain on maintenance dialysis. The only
hope for such patients is a kidney from deceased or cadaver donors.
The most noble human service is being able to save the lives of others
after death by donating organs. A deceased kidney transplant also
helps eliminate illegal organ trade and is the most ethical form of kidney
What is “Brain Death”?
“Brain death” is the complete and irreversible cessation (stopping) of
all brain functions that leads to death. The diagnosis of “brain death” is
made by doctors in hospitalized unconscious patients on ventilator
In “Brain Death” damage is irreversible with no chances
of improvement by any medical or surgical treatment.
Criteria for diagnosis of brain death are:
- 1. The patient must be in a state of coma and the cause of the coma
(e.g. head trauma, brain hemorrhage etc) is firmly established by
history, clinical examination, laboratory testing, and neuroimaging.
Certain medications (e.g. sedatives, anticonvulsants, muscle relaxants,
95. CHP. 14. Kidney Transplantation
anti-depressants, hypnotics and narcotics), metabolic and endocrine
causes can lead to an unconscious state that can mimic brain death.
Such causes have to be excluded before confirming the diagnosis of
brain death. The doctor should correct low blood pressure, low
body temperature and low body oxygen before considering brain
What is the difference between brain death and
- 2. Persistent deep coma in spite of proper treatment under care of
experts for an adequate period to “exclude the possibility of
- 3. No spontaneous breathing, patient is on ventilator support.
- 4. Respiration, blood pressure and blood circulation is maintained with
ventilator and other life support devices.
An unconscious patient may or may not need the support of a ventilator
and is likely to recover after proper treatment. In a patient with “Brain
Death,” the brain damage is severe and irreversible and is not expected
to recover despite any medical or surgical treatment. In a patient with
“Brain Death”, as soon as the ventilator is switched off, respiration
stops and the heart stops beating. It is important to remember that the
patient is already legally dead and removing the ventilator is not the
cause of death. Patients with “Brain Death” cannot remain on ventilator
support indefinitely, as their heart will stop relatively soon.
Is it possible to donate a kidney after dying?
No. Death occurs after the heart and respiration stop irreversibly and
permanently. Like corneal donation, after death, kidney donation is
not possible. When the heart stops, the blood supply to the kidney
also stops, leading to severe and irreversible damage to the kidney,
preventing its use for kidney transplantation.
In “Brain Death” the body’s respiration and blood
circulation are artificially maintained after death.
What are the common causes for “Brain Death?”
Common causes of brain death are head injuries (i.e. falls or vehicular
accidents), intracranial brain hemorrhage, brain infarct and brain tumor.
When and how is “Brain Death” diagnosed? Who diagnoses
When a deeply comatose patient kept on ventilator and other life
supporting devices for an adequate period does not show any
improvement on clinical and neurological examination, the possibility of
“Brain Death” is considered. Diagnosis of brain death is made by a
team of doctors who are not involved in kidney transplantation This
team includes the attending physician, neurologist or neurosurgeon, who,
after independent examinations of the patient, declare “brain death.”
By detailed clinical examination, various laboratory tests, special EEG
test for brain and other investigations, all possibilities of recovery from
brain damage are explored. When no chance of any recovery is
confirmed, “brain death” is declared.
What are the contraindications for kidney donation from a
patient with “Brain Death?”
Under the following conditions a kidney cannot be accepted from a
donor with brain death:
- 1. A patient with active infections.
- 2. A patient suffering from HIV or hepatitis B or C.
- 3. A patient with long standing hypertension, diabetes mellitus, kidney
disease or presence of kidney failure.
- 4. Cancer patient (except brain tumor).
One deceased donor can save the lives of two CKD
patients as he donates both his kidneys.
Which other organs can be donated by cadaver donors?
Cadaver donors can donate both kidneys and save lives of two patients.
Besides kidney, other organs which can be donated are eye, heart,
liver, skin, pancreas etc.
Who comprise the team for deceased kidney transplantation?
For deceased (cadaveric) kidney transplantation proper team work is
necessary. The team ncludes:
How is deceased kidney transplantation performed?
- Relatives of the deceased kidney donor for legal consent.
- Attending physician of the donor.
- Cadaver transplant coordinator, who explains and helps the relatives
of the patient for kidney donation.
- Neurologist who diagnoses the brain death.
- Nephrologist, urologist, transplant surgeon and team.
These are essential aspects of deceased kidney transplantation.
- A proper diagnosis of brain death is mandatory.
- The donor kidneys should be confirmed to be reasonably healthy
and the donor should have no systemic disease that would
- Consent to donation should be given by a relative or person who is
legally allowed to do so.
- Donor is kept on ventilator and other life-supporting devices to
maintain respiration, heart beat and blood pressure until both kidneys
are removed from the body.
After kidney transplantation the patient can
enjoy a normal and active lifestyle.
98. Save Your Kidneys
Is there any payment made given to the donor’s family?
- After removal, the kidney is processed properly with a special cold
fluid and is preserved in ice.
One deceased donor can donate both kidneys, so two recipients
can be given the gift of life.
- Appropriate recipients are selected from a waiting list of patients
following a protocol based on blood group, HLA matching and tissue
cross matching compatibility.
- Better outcomes are expected the earlier the harvested kidneys are
transplanted. They should ideally be transplanted within 24 hours of
harvest. Beyond a certain length of time, they may not be viable for
- The surgical procedure on the recipient is the same for both living or
deceased kidney donation.
- During the period of time between harvest and transplantation, the
donor kidney sustains some damage due to lack of oxygen, lack of
blood supply and cold exposure from storage in ice. Because of
such injury, the kidney may not function immediately after
transplantation and on occasion, short term dialysis support may be
necessary while waiting for the donor kidney to recover and regain
None. Giving another person a new lease on life is an invaluable gift.
Being a donation, the donor or the donor’s family should not expect to
receive any payment in exchange for the donated kidney, neither does
the recipient need to pay anyone. The joy and satisfaction for this
humanitarian gesture should be enough compensation for the donor or
Organ donation is a spiritual act.
What can be more sacred than saving a life?