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Kidney Transplantation

by Martin Hertl, MD, PhD, Paul S. Russell, MD

For people of all ages who have irreversible kidney failure, kidney transplantation is a lifesaving alternative to dialysis. In the United States, more than 17,000 kidneys are transplanted each year. About 94% of kidneys from living donors are functioning 1 year after transplantation. Some (3 to 5%) of these kidneys stop functioning each year after the first. About 88% of kidneys from deceased donors are functioning 1 year after transplantation, and about 5 to 8% of these kidneys stop functioning each year after the first. Transplanted kidneys sometimes function for more than 30 years. About 94 to 98% of kidney recipients are alive 1 year after transplantation. People with successful kidney transplants can usually lead normal, active lives.

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.

The kidneys are removed from the donor, 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.

Complications

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

Acute rejection occurs within 3 to 4 months of transplantation.

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.

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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