Renal transplant is the commonest among all major organ transplants. Word Transplant is derived by joining the words Transfer and Implant. Transplant remains the best therapeutic option for patients with advanced chronic kidney disease. The first successful kidney transplant was done in 1962 at Brigham hospital in Boston between twin brothers. Since then thousands of transplantation are done with much improved outcome thanks to advancement in modern medicine.
What is Kidney transplant?
Addition of one kidney in a patient suffering from permanent kidney disease where the residual function is less than 10 ml/min, not sufficient to lead healthy life without dialysis.
What is the source of Kidney donation?
Living or Brain dead (Cadaver)
Living donor can be Related or Unrelated.
Living Related donors: By law only first degree relatives can donate an organ. First degree relatives mean patients Parents, Siblings, Offspring and Spouse. Recently the government has amended the law to allow extended family to donate with permission of local state authorization committee. Thus now grandparents and In laws can donate kidney.
Living Unrelated donors: Bylaws do not allow an unrelated person to donate an organ in India. In the past these form of transplants were carried out for commercial gain. At present it is illegal and punishable act. Only form of transplant that is unrelated but permitted is a Swap transplant.
What is Swap transplant?
Here there are two or more pairs of recipients and donors who are exchanging their donors to optimize success of transplant. For example recently KEM hospital did a swap between pair 1 with “ A “ blood group recipient and “B “ blood group donor, with Pair 2 which had “B” blood group recipient and “A” blood group donor. By swapping their donors both pairs ended up receiving compatible blood group kidneys. There is a Swap transplant registry being maintained in the city of Mumbai for this purpose. As a result multiple pairs had exchanged organ donation to achieve their blood group compatibility across multiple city hospitals.
What is ABO incompatible transplant?
When the blood group of potential donor is not compatible for organ donation e.g. “A” donor for “B” recipient, still it is possible to do the transplant. This is a highly skilled procedure where the antibody against the donors blood group (Anti A antibody in above example) is removed from recipient body by doing plasmapheresis. Once we have assured very low levels of Antibody titers by removing it from blood by Plasmapheresis, next step is to Block production of new antibodies with Anti Lymphocyte drug Rituximab. With this we have overcome an otherwise major contraindication for transplant due to blood group incompability.
Who can donate the kidney?
Age between 18 to 65, not suffering from Diabetes or Hypertension, viral disease like HIV,HBsAg, Hepatitis C virus, malignancy, mental disorders incapacitating to make rational decision to consent for organ donation, can all donate their kidneys. Marginal donors are accepted in select situation when the risk of accepting little inferior quality kidney out weighs the chances of survival.
Study of ventilated brain dead, dying patients revealed that there is long phase of several hours after the Brain death before the cardiac arrest. This is the time phase where the organs other than brain are functional till the time there is a circulatory arrest. Brain death is confirmed by a qualified personal by carrying out “Apnoea test” on two occasions at least six hours apart. This individual is now called as cadaver who can legally be called dead despite of intact circulation of blood. With the consent of the relatives one can now retrieve usable organs for the purpose of transplantation. Cadaver is carried to the OT, organ perfusion is carried out externally by inserting a perfusion catheter in the Aorta using cold perfusion fluid. The patients Aorta is then clamped and disconnected from the heart. Commonly used organs are cornea, Kidneys, Liver,Lungs, Heart, Pancreas and small intestine. Skin and tendons can also be used. The dead body is then respectfully handed over to the relatives for last rites.Organs are distributed to the retrieving hospital and outside institute as per city waiting list. ZTCC- Zonal Transplant Coordination Committee is the authority which carries out the organ distribution in a fair manner.
Post transplant Care:
Nephrologists try to strike a balance of immune suppressive medicines. Rejection should be prevented by giving adequate dose but at the same time avoid overdosing to make them vulnerable to get infection. Post transplant new onset diabetes is a common problem that affects about 30% of patients. It is caused by drugs like Steroids and Tacrolimus. First three months are crucial as the level of immunosuppression is high making the patient more prone for infection.
Steroid free transplants
Steroids are traditionally the most important drugs for prevention of rejection post transplant. However they have serious side effects in the long term. Osteoporosis, New onset Diabetes, worsening of pre existing diabetes and Hypertension, Cataract, Cushing’s syndrome and infection proneness are a few of them. These side effects profile lead to the development of steroid free protocols. It became possible mainly because of availability of newer potent but highly selective immune suppressive drugs namely the Monoclonal antibodies. Here the steroids are withdrawn from immunosuppressive regimen within first week post transplant. Obese and Diabetic patients are most suitable for steroid free transplant.
Outcome of Transplant:
Meticulous preoperative screening of recipients and expertise in maneuvering the dosages of immune suppressive has improved the survival of kidney transplant patients remarkably.One year survival is 95%,Five year survival about 80% and 10 year survival around 60 %. These figures are far superior compared to those who have continued on dialysis.
The author is one of the few in the country to do ABO incompatible and steroid free transplants.
MD, DNB Nephrology
Consultant Nephrologist at Asian Heart Institute, Breach Candy Hospital and Shushrusha Hospital.