Kidney Transplantation

(Kidney Transplant, Renal Transplant)

Procedure Overview

What is a kidney transplant?

A kidney transplant is a surgical procedure performed to replace a diseased kidney with a healthy kidney from another person. The kidney may come from a deceased organ donor or from a living donor. Family members or individuals who are unrelated but make a good match may be able to donate one of their kidneys. This type of transplant is called a living transplant. Individuals who donate a kidney can live healthy lives with the remaining kidney.

A person receiving a transplant usually receives only one kidney, but, in rare situations, he/she may receive two kidneys from a deceased donor. In most cases, the diseased kidneys are left in place during the transplant procedure. The transplanted kidney is implanted in the lower abdomen on the front side of the body.

How do the kidneys work?

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The body takes nutrients from food and converts them to energy. After the body has taken the food that it needs, waste products are left behind in the bowel and in the blood.

The kidneys and urinary system keep chemicals, such as potassium and sodium, and water in balance, and remove a type of waste, called urea, from the blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys.

Two kidneys, a pair of purplish-brown organs, are located below the ribs toward the middle of the back. Their function is to:

• remove liquid waste from the blood in the form of urine
• keep a stable balance of salts and other substances in the blood
• produce erythropoietin, a hormone that aids the formation of red blood cells
• regulate blood pressure

The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule.

Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney. 

Reasons for the Procedure

A kidney transplant may be recommended for persons with end stage renal disease (ESRD), a permanent condition of kidney failure that often requires dialysis (a process used to remove wastes and other substances from the blood). Some conditions of the kidneys that may result in ESRD include, but are not limited to, the following:

• kidney failure caused by diabetes or high blood pressure
• polycystic kidney disease or other inherited disorders
• glomerulonephritis - inflammation of the kidney’s filtering units
• hemolytic uremic syndrome - a rare disorder that causes kidney failure

Other conditions, such as congenital defects of the kidneys, may result in the need for a kidney transplant.

There may be other reasons for your physician to recommend a kidney transplant.

Risks of the Procedure

As with any surgical procedure, complications can occur. Some complications may include, but are not limited to, the following:

• bleeding
• infection
• blockage of the blood vessels to the new kidney
• leakage of urine or blockage of urine in the ureter
• initial lack of function of the new kidney

The new kidney may be rejected. Rejection is a normal reaction of the body to a foreign object or tissue. When a new kidney is transplanted into a recipient's body, the immune system reacts to what it perceives as a threat and attacks the new organ, not realizing that the transplanted kidney is beneficial. To allow the transplanted organ to survive in a new body, medications must be taken to trick the immune system into accepting the transplant and not attacking it as a foreign object.

The medications used to prevent or treat rejection have side effects. The exact side effects will depend on the specific medications that are taken.

Contraindications for kidney transplantation include, but are not limited to, the following:

• current or recurring infection that cannot be treated effectively
• metastatic cancer - cancer that has spread from its primary location to one or more additional locations in the body
• severe cardiac or other medical conditions preventing the ability to tolerate the surgical procedure
• serious conditions other than kidney disease that would not improve after transplantation
• noncompliance with treatment regimen

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Before the Procedure

In order to receive a kidney from an organ donor who has died (cadaver), a recipient must be placed on a waiting list of the United Network for Organ Sharing (UNOS). Extensive testing must be done before an individual can be placed on the transplant list.

Because of the wide range of information necessary to determine eligibility for transplant, the evaluation process is carried out by a transplant team. The team includes a transplant surgeon, a transplant nephrologist (physician specializing in the treatment of the kidneys), one or more transplant nurses, a social worker, and a psychiatrist or psychologist. Additional team members may include a dietician, a chaplain, and/or an anesthesiologist.

Components of the transplant evaluation process include, but are not limited to, the following:

• psychological and social evaluation: Psychological and social issues involved in organ transplantation, such as stress, financial issues, and support by family and/or significant others are assessed. These issues can significantly impact the outcome of a transplant.
• blood tests: Blood tests are performed to help determine a good donor match, to assess your priority on the donor list, and to help improve the chances that the donor organ will not be rejected.
• diagnostic tests: Diagnostic tests may be performed to assess your kidneys as well as your overall health status. These tests may include x-rays, ultrasound procedures, kidney biopsy, and dental examinations. Women may receive a Pap test, gynecology evaluation, and a mammogram.

The transplant team will consider all information from interviews, your medical history, physical examination, and diagnostic tests in determining your eligibility for kidney transplantation.

Once you have been accepted as a transplant candidate, you will be placed on the United Network for Organ Sharing (UNOS) list. When a donor organ becomes available, you will be notified and told to come to the hospital immediately.

If you are to receive a kidney from a living family member (living-related transplant), the transplant may be performed at a planned time. The potential donor must have a compatible blood type and be in good health. A psychological test will be conducted to ensure the donor is comfortable with the decision.

The following steps will precede the transplant:

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if something is not clear.
• If you have been on routine dialysis before the procedure, you will receive dialysis prior to the procedure.
• For a planned living transplant, you should fast for eight hours before the operation, generally after midnight. In the case of a cadaver organ transplant, you should begin to fast once you are notified that a kidney has become available.
• You may receive a sedative prior to the procedure to help you relax.
• The area around the surgical site may be shaved.
• Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

Kidney transplantation requires a stay in a hospital. Procedures may vary depending on your condition and your physician’s practices.

Generally, a kidney transplant follows this process:

1. You will be asked to remove clothing and given a gown to wear.
2. An intravenous (IV) line will be started in your arm or hand. Additional catheters may be inserted in your neck and wrist to monitor the status of your heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.
3. A catheter will be inserted into your bladder.
4. You will be positioned on the operating table, lying on your back.
5. Kidney transplant surgery will be performed while you are asleep under general anesthesia. A tube will be inserted through your mouth into your lungs. The tube will be attached to a ventilator that will breathe for you during the procedure. 
6. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
7. The skin over the surgical site will be cleansed with an antiseptic solution.
8. The physician will make a long incision into the lower abdomen on one side.
9. The physician will visually inspect the donor kidney prior to implanting it.
10. The donor kidney will be placed into the abdomen. A left donor kidney will be implanted on your right side; a right donor kidney will be implanted on your left side. This allows the ureter to be accessed easily for connection to your bladder.
11. The renal artery and vein of the donor kidney will be sutured (sewn) to the external iliac artery and vein.
12. After the artery and vein are attached, the blood flow through these vessels will be checked for bleeding at the suture lines.
13. The donor ureter (the tube that drains urine from the kidney) will be connected to your bladder.
14. The incision will be closed with stitches or surgical staples.
15. A drain may be placed in the incision site to reduce swelling.
16. A sterile bandage/dressing will be applied.

After the Procedure

In the hospital:

After the surgery you will be taken to the recovery room for observation. Once your blood pressure, pulse, and breathing are stable and you are alert, you may be taken to the intensive care unit (ICU) or your hospital room. Kidney transplantation usually requires an in-hospital stay of several days.

A kidney from a living donor may begin to make urine immediately, but urine production in a cadaver kidney may take longer. Until urine output is sufficient, dialysis may be required.

You will have a catheter in your bladder to drain your urine. The amount of urine will be carefully measured to evaluate the new kidney’s function.

You will receive IV fluids until you are able to take in adequate food and fluids.

Your immunosuppression (anti-rejection) medications will be closely monitored to make sure you are receiving the optimum dose and the best combination of medications.

Blood samples will be taken frequently to monitor the status of the new kidney, as well as other body functions, such as the liver, lungs, and blood system.

Your diet will be gradually advanced from liquids to more solid foods as tolerated. Your liquid intake may be restricted until the new kidney is fully functional.

You may begin physical activity by the day after the procedure. You should get out of bed and move around several times a day.

Take a pain reliever for soreness as recommended by your physician. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.

Nurses, pharmacists, dietitians, physical therapists, and other members of the transplant team will teach you how to take care of yourself once you are discharged from the hospital.

At home:

Once you are home, it is important to keep the surgical area clean and dry. Your physician will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up office visit.

You should not drive until your physician tells you to. You should avoid any activity or position that causes pressure to be placed on the new kidney. Other activity restrictions may apply.

Notify your physician to report any of the following:

• fever - may be a sign of rejection or infection
• redness, swelling, or bleeding or other drainage from the incision site
• increase in pain around the incision site - may be a sign of rejection or infection

Fever and tenderness over the kidney are some of the most common symptoms of rejection. An elevation of your blood creatinine level (blood test to measure kidney function) and/or blood pressure (monitored by your physician) may also indicate rejection. The symptoms of rejection may resemble other medical conditions or problems. Consult your transplant team with any concerns you have. Frequent visits to and contact with the transplant team are essential.

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.

What is done to prevent rejection?

To allow the transplanted kidney to survive in a new body, you will be given medications for the rest of your life to fight rejection. Each person may react differently to medications, and each transplant team has preferences for different medications. The anti-rejection medications most commonly used include:

• cyclosporine
• tacrolimus
• azathioprine
• mycophenolate mofetil
• prednisone
• OKT3
• antithymocyte Ig (ATGAM)
• sirolimus

New anti-rejection medications are continually being developed and approved. Physicians tailor medication regimes to meet the needs of each individual patient.

Usually several anti-rejection medications are given initially. The doses of these medications may change frequently, depending on your response. Because anti-rejection medications affect the immune system, persons who receive a transplant will be at higher risk for infections. A balance must be maintained between preventing rejection and making you very susceptible to infection.

Some of the infections you will be especially susceptible to include oral yeast infection (thrush), herpes, and respiratory viruses. You should avoid contact with crowds and anyone who has an infection for the first few months after your surgery.