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Kidney Transplantation

By Martin Hertl, MD, PhD, Jack Fraser Smith Professor of Surgery, Director of Solid Organ Transplantation, and Chief Surgical Officer, Rush University Medical Center

For people of all ages who have irreversible kidney failure, kidney transplantation is a lifesaving alternative to dialysis. In the United States, about 17,000 kidneys are transplanted each year. It is the most common type of organ transplantation procedure.

Kidney transplantation is indicated when people have

  • Advanced, irreversible kidney failure

People in their 70s and sometimes 80s may qualify for transplants if the following apply:

  • They are healthy in other respects, can function independently, and have good social support.

  • They are expected to live a reasonably long time.

  • Transplantation is likely to substantially improve their ability to function and their quality of life beyond simply freeing them from dialysis.

People who also have type 1 diabetes may be candidates for simultaneous pancreas-kidney or pancreas-after-kidney transplantation.

Kidney transplantation is not done (is contraindicated) if people have certain disorders, such as a severe heart disorder or cancer. Special precautions are required when people have poorly controlled diabetes (which can result in kidney failure) or viral infections (such as advanced hepatitis C) that may be made worse by taking the drugs required after transplantation. These drugs inhibit the immune system and thus make it less able to defend the body against infection.

One year after transplantation, about 94 to 98% of kidney recipients are alive. The percentage of transplanted kidneys still functioning is

  • For kidneys from living donors: About 95%

  • For kidneys from deceased donors: About 88%

Each year thereafter, about 3 to 5% of kidneys from living donors and about 5 to 8% of those from deceased donors stop functioning. Transplanted kidneys sometimes function for more than 30 years.

People with successful kidney transplants can usually lead normal, active lives.

Donors

More than one half of transplanted kidneys come from previously healthy, deceased donors. About one third of these kidneys are damaged but are used because the demand is so great. The rest of transplanted kidneys come from living donors.

Procedure

The kidneys are removed from the donor, usually using thin instruments and a small video camera inserted through several tiny incisions (laparoscopic surgery). Occasionally, a larger incision (open surgery) is required. After removal, the kidney is cooled and transported quickly to a medical center for transplantation to a person who has a compatible blood and tissue type and who does not make antibodies to the tissues of the donor.

Kidney transplantation is a major operation. Dialysis may be required before the operation if the person has electrolyte abnormalities or if waste products have accumulated in the blood (because the kidneys are too damaged to remove them). The donated kidney is placed in the pelvis through an incision and is attached to the recipient’s blood vessels and bladder. Usually, the nonfunctioning kidneys are left in place. Occasionally, they are removed because they are infected.

Drugs to inhibit the immune system (immunosuppressants), including corticosteroids, are started the day of transplantation. These drugs can help reduce the risk that the recipient will reject the transplanted kidney.

Complications

Transplantation can cause various complications.

Rejection

Despite the use of immunosuppressants, one or more episodes of rejection may occur after kidney transplantation.

Acute rejection occurs within 3 to 4 months of kidney transplantation. It can be accompanied by fever, decreased urine production with weight gain, pain and swelling of the kidney, and elevated blood pressure. Blood tests show deteriorating kidney function. Because these symptoms can also result from infections or use of a drug, the diagnosis of rejection sometimes needs to be confirmed with a needle biopsy of the kidney.

Chronic rejection that develops over many months to years is relatively common and causes kidney function to gradually deteriorate.

Rejection can usually be effectively treated with high doses of corticosteroids or antilymphocyte globulin. If these drugs are ineffective, they are gradually stopped, and dialysis must be started again. Dialysis is continued until another kidney transplant is available.

The rejected kidney may be left in place unless fever, tenderness, or blood in the urine persists. The chance of success with second transplants is almost as good as that with first transplants.

Cancer

Compared with the general population, kidney transplant recipients are about 10 to 15 times more likely to develop cancer, probably because the immune system helps defend the body against cancer as well as infections. Cancer of the lymphatic system (lymphoma) is 30 times more common among kidney transplant recipients than the general population, but lymphoma is still uncommon. Skin cancer is common.

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