Kidney transplant

Kidney failure can occur for several reasons including:

• Autoimmune kidney disorders
• Infection
• Diabetes
• Blood-clotting disorders
• Decreased blood flow caused by low blood pressure
• Urinary tract infections
• Complications from pregnancy
• Dehydration
• High Blood pressure

The treatment choices for kidney failure include:

• Dialysis
• Transplantation

Dialysis or transplantation is needed when there is less than 10% of kidney function left. These options are also known as kidney replacement therapy.

Dialysis

Dialysis artificially removes waste from your blood. There are two forms of dialysis:

• Haemodialysis
• Peritoneal dialysis

Haemodialysis filters wastes and removes extra fluid from the blood. Peritoneal dialysis uses the lining of the abdominal cavity (peritoneal membrane) and a solution (dialysate) to remove wastes and extra fluid from the body.

The choice of dialysis method depends on factors such as your age, health, and lifestyle. Over 2,000 Australian adults commence kidney replacement therapy each year. The cost of kidney dialysis to the Australian Government is significant, running into hundreds of thousands of dollars each year.

Transplant

A kidney transplant is a treatment for kidney failure, but not a cure. This is a surgical procedure that takes a kidney from the body of one person (called the Donor) and places it in the body of the person (Recipient) whose kidneys no longer function.

To receive an organ from a donor, you will need to be on the official hospital ‘waiting list’. You will be put on a transplant waiting list when you have end-stage organ failure, all other treatments have failed and your medical specialist believes you will benefit from a transplant. Additionally, you will have to commence dialysis to be placed on the waiting list. – To see more click here

A transplant offers a more active life as well as freedom from dialysis and food and fluid restrictions. It is important to remember that a new kidney requires a lifetime of management and care.

Kidney transplants are the most common transplants that take place in Australia. While most people are born with two kidneys, we can survive with one. The donation of the organ can be made either by:

• Deceased donors or
• Living donors

Deceased Donors

In Australia, many people sign up to donate their organs after their death. Deceased donor kidney transplants are from individuals that have died from brain death or a circulatory death and have consented through the Organ Donor Register or their next of kin have agreed to donate their loved one’s organ. Deceased donors cannot be directed to a specific recipient, and enter a rigorous and unbiased patient matching scheme. (Scroll down to the appendix to see more on the types of deceased donations).

The typical wait for a kidney transplant in Australia is 4 years.  However, waiting times can sometimes be shorter or longer depending on the blood and tissue types of the recipients and donors. The waiting times are also different in each state depending on the population of the state and the number of people that are on the waiting list. E.g. South Australia has the shortest waiting list.

Living donors

If you are waiting for a kidney, in some cases a person who is close to you may be willing to donate one of their kidneys. They are called living donors. Family members are more likely to match the recipient in terms of blood and tissue type, but not always.

Living donors can also be non-related individuals. In some cases, altruistic donors are willing to donate even if they do not know the recipient.  Altruistic donors are entered into the same patient matching scheme as for deceased donors.

There are many steps to becoming a living donor. If you wish to become a living kidney donor, you need to be healthy and over the age of 18. Each case is assessed individually. The living kidney donation process can take up to 3 – 6 months. Even elderly people and those with certain chronic health conditions can be donors. The few medical conditions that prevent organ donation include:

• Active malignancy
• Infectious disease
• Behavior that puts you at risk of infectious disease (e.g. intravenous drug users, sex workers etc.)
• Significant lung and heart disease
• Obesity
• Psychiatric disorder

Living donors are required to undergo certain tests to ensure they are suitable and healthy enough to donate to their own loved ones without putting their own health at risk. Additionally, the medical staff must be certain that the potential living donor is making the decision to donate of their own free will and is not pressured into being a donor through a sense of duty, or through financial incentives. If you’re thinking of becoming a live kidney donor, you may find these videos* and fact sheets helpful to make an informed decision. Find out more about preparing to be a living donor here:

VIDEO – Living Donation. What you need to know – part 1

VIDEO – Living Donation What you need to know – part 2

VIDEO – Jenny’s Story

*Permission to host these videos has been provided by Queensland Health.

The Australian Paired Kidney Exchange (AKX) Program

This is a program that has been initiated by the Organ and Tissue Authority (OTA) to increase the options for kidney donation. Sometimes even if a person is ready and willing to donate, they may not be a suitable match for the recipient. The blood group or the tissue type may not be the right match. The Paired Kidney program helps people match up suitable living donors to recipients via a computer based program.

The AKX program uses a computer program to search the database of registered recipient/donor pairs where the donor is not a match for the recipient and identifies another similar pair to match them up so that two simultaneous transplants can occur by exchanging donors.

To find out more information about paired kidney programs, visit the Paired Kidney Program.

See Kidney Health Australia fact sheets for more details on donations.

And watch the video from National Kidney Foundation.

Inclusion criteria for kidney transplantation are:

• End-stage kidney failure requiring dialysis
• Anticipated low perioperative mortality
• A reasonable postoperative life expectancy, defined as an 80% likelihood of surviving for at least 5 years after transplantation

Exclusion criteria for kidney transplantation are:

• Diseases that might have a significant impact on the life expectancy of a kidney transplant recipient including cardiac disease, vascular disease, diabetes mellitus and malignancies
• Presence of certain infections that are uncontrolled and can prevent you from being active on the waiting list.
• Inability to comply with complex medical therapy. (The ability to correctly follow a treatment plan, particularly with respect to anti-rejection medications is an important predictor of a successful outcome after renal transplantation)

Assessment and acceptance principles

Referrals for renal transplantation (from renal/dialysis units) are assessed initially at the level of the transplanting hospital and involves a transplant physician and surgeon. Reassessment of patients on the waiting list occurs at least annually by the transplant unit. Transplant units have a process to formally ensure ongoing suitability. Only the Director of a transplant unit (or their delegate) has the authority to have patients added to the active renal transplant waiting list.

The allocation of a new kidney for you is determined by the National Organ Matching Service⁷ administered by the Australian Red Cross Service. A computer matching of your data against the data of a potential donor is carried out to determine the best possible match for you.

In preparation for your transplant, your doctor may require you to undertake certain changes to your lifestyle.  You may be required to stop smoking, lose weight, or take medications to manage your blood pressure or hypertension.

While you are waiting for your transplant, you need to think about a few things that will make it easier to manage your life after your transplant. You will need to attend the transplant clinic daily at least for 1 month after your surgery and progressively less frequently for at least a period of 3 months. Depending on your progress, you may be required to stay longer. Think about:

• How you will travel to and from the clinic during this time
• Accommodation during this period if you are a rural patient
• Accessing IPTAAS (Isolated Patients Transport and Accommodation Assistance Scheme) or equivalent schemes offered by each state
• Taking time off work, if you are in the workforce
• What you will need to carry with you if you are going to stay away from home during this period
• Care for your dependents (children or pets) while you are away

Your new kidney may be placed either on the left or right side of your abdomen, usually lower down. In most cases, your own kidneys are not removed and will remain with you.  You will have drips and monitors to give you the medications, manage your pain and monitor your heart rate and oxygen levels

Medications

After your transplant, you will immediately start taking a host of medications to keep your new organ healthy. These medicines will keep your immunity low so that your body does not reject the new kidney. Over time, the doses of the medicines will drop but you must take them throughout the life of your transplant.

Ensure you always have a ready supply of medications especially when you are traveling because these medications are not available easily. Ensure you carry a doctor’s letter if traveling overseas.  In many instances, you will need to keep track of all your medication spending through the Pharmaceutical Benefits Scheme.  Once you reach a certain limit each year, the price of the medicines will be significantly reduced or free (e.g. for those with a Health Benefits card or a Pensioner Concession Card).

Organ functioning after transplant

Your new kidney may start functioning immediately by producing urine. This is most likely if you have a living donor. In some cases, it may take a few weeks for the new organ to function.

Discharge from hospital

Your hospital stay can last from 10 – 14 days depending on the post-operative complications that can extend your stay. Your transplant nurses will encourage you to participate in your health care and help you mobilise to get you ready for discharge.

Discharge from hospital is often an exciting and significant step in your road to recovery.  A lot has gone on behind the scenes to ensure you have been able to receive this transplant, enabling you to regain your health or improve your quality of life.

Be sure to thank all the staff at the hospital, who were involved in your care, as they would really appreciate it

Blood tests and monitoring

You will be required to visit your doctor on a regular basis.  Initially, you will need to visit the hospital for tests every day for up to a month and then less frequently over time. If seeing multiple doctors for different things, please ensure that all doctors know what medications you are taking.  Some medicines do interact with other medications and must be taken with care.

For at least a few weeks afterward, do not over-do things.  But also do not lounge around all day.  You should be able to return to a normal lifestyle within a couple of months. Spend the time appreciating those around you and what this generous donation has done to improve your quality and quantity of life.

Healthy lifestyle 

Let good nutrition and exercise be part of your healthy lifestyle. Everything and anything in moderation until you are completely stable and maintain good food hygiene while preparing your meals.

• Avoid foods that may interact adversely with your medication.
• Maintain good food hygiene while preparing your meals.
• Maintain personal hygiene, including dental hygiene
• Clean open wounds and cuts with antiseptic. Consult your GP if your wound becomes red and painful.
• Always check with your transplant doctor if another doctor suggests you should receive any immunisations. The Mantoux test for tuberculosis and immunisations for yellow fever and polio, for example, are not recommended as are any other immunisations using live or weakened bacteria or viruses.  However, influenza vaccinations or immunoglobulins are okay.
• Reduce the risk of infection by maintaining your hygiene and reporting symptoms early. If possible, avoid coming into contact with people who have a cold or the flu.
• Avoid coming into close contact with children or people with chicken pox or measles and other viral and bacterial infections.

For more on caring for your new heart after discharge and the precautions to take, please refer to the section on “After your Transplant”.

Stages of returning to normal activity, including work 

Resuming normal activities gradually, only if you feel up to it.  Engage in normal activities like catching the bus and going to the movies, and attending parties.

It is recommended you start slowly in the first instance.  This also includes sexual activity. If in doubt, ask your doctor.  Don’t be shy – they have heard it all before.  It is also important that female recipients discuss contraception methods to prevent pregnancy in the early months following a heart transplant.

Returning to work is a big step and you should carefully consider and plan your return well in advance. Consult with your transplant team before you resume work. There may aspects of your job that you may not be able to resume immediately or even in the near future. Please refer to the section on “life Skills” (Place link here) for more information.

Smoking increases the risk of chronic rejection, cancer and heart disease. Do not smoke!

Alcohol in moderation (one standard drink per day) is usually acceptable, but you need to discuss this with your renal dietitian and nurse.

Driving after Transplant Surgery  

You may wish to resume driving as soon as possible after your surgery. You must check with your doctor to clarify when it is safe to drive. You can resume driving after three to six weeks’ post-transplant depending on the type of surgery you have had and the size of the wound. Before driving, ensure that your wound is healing well, that you are alert and not fatigued, no longer experiencing significant pain, or taking medications that can cause drowsiness.

For information on assessing fitness to drive, please visit the website www.austroads.com.au . The guidelines on this website outline the responsibility drivers, health professionals and the licensing authorities. The rules for driving are very clear and are set out to protect you, the transplant doctors, and the general public.

This information is intended for educational purposes only. Transplant Australia acknowledges that each patient experience is different and does not provide this information as a substitute for medical advice. Please contact your transplant unit or doctor if you need medical advice.

Transplant Australia thanks A/Prof Germaine Wong (Senior transplant specialist at Westmead Hospital) for reviewing this article.