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Life After Kidney Transplant
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The Technological advances in transplantation have enabled thousands of procedures that benefit organ and tissue recipients worldwide. Transplantation benefits patients who need solid organs, tissues and cells by means of the development and improvement of surgical techniques, inputs, equipment and immunosuppressive drugs needed to this therapy. The number of kidney transplant performed has increased significantly.

In most situations these procedures are presumed as the only resource for sustaining life. However, this treatment option is not always available for those who are waiting for organ transplantation because it requires a donation.

Kidney transplantation requires compatibility between tissues obtained for the Human Leukocytes Antigen typing (HLA).While waiting for a donor, the chronic renal disease patients have other forms of Renal Replacement Therapy (RRT) which allow the maintenance of their life and also justify the increasing number of patients registered on the waiting list for kidney transplantation.

Renal Insufficiency and the complications associated with its treatment constitute a serious public health problem worldwide, with social and financial burden resulting from increasing rates of young patients with renal function failure.

A number of diseases are capable of destroying renal function in all age groups. The most common causes for renal disease leading to kidney transplantation are the following:

Diabetes -31%

Chronic glomerulo nephritis -28%

Polycystic kidney disease -12%

Nephrosclerosis ( Hypertensive)-9%

Systemic lupus Erythematosus (SLE)-3%

Interstitial nephritis -3%

Thus, measurement of the patient’s quality of life after kidney transplantation is a relevant topic for many individuals who are on dialysis and receive care in a dialysis center.

Renal transplantation is the best therapeutic option for patients with chronic kidney disease. The surgical procedure is relatively simple, and post transplantation certain actions are necessary such as the use of immunosuppressive drugs and the outpatient follow-up. Therefore for these patients, the clinical management, the evaluation of treatment results and impacts on quality of life are important issues.

Health –related quality of life contains multiple aspects of health related issues from the patient’s perspective including physical, psychological and social functioning and overall well being. Numerous clinical trials have established the importance of health related quality of life in various diseases and it is increasingly popular to evaluate disease specific health related quality of life as a measure of patient’s subjective state of health.

Kidney transplantation is the treatment of choice for end stage renal disease (ESRD). Advances in renal transplant procedures and immunosuppressive therapies have increased dramatically the survival over the last decades, one year allograft survival rates are currently over 90%.

The major goal of transplantation is the achievement of maximal quality and quantity of life while minimizing the effects of disease.

In renal transplantation the costs are not only limited to the transplant procedure but also to the evolving costs to treat adverse events, some of them caused by the immunosuppressive therapy.

Since the first successful kidney transplantation as early as the early 1950s, immunosuppressive therapies improved considerably, the most revolutionary development being the introduction of cyclosporine in the early 1980s. The introduction of new immunosuppressive agents has further increased the therapeutic options for immunosuppressive combination therapies in transplanted patients.

In parallel to better patient care and new immunosuppressive regimens the median survival of renal allograft improved continuously. Hand in hand with these achievements, greater attention has been given to long term quality of life. It is generally accepted however, that patients with a functioning renal allograft have a improved health-related quality of life as compared to patients on dialysis.

Summary Points:

·         The global burden of End Stage Renal Disease is increasing.

·         Renal transplantation increases patient survival and quality of life and reduces the cost of care for patients with End stage renal disease.

Longer life with a transplant

On the other hand, patients who receive a kidney transplant typically live longer than those who stay on dialysis. A living donor kidney functions, on average, 12 to 20 years and a deceased donor kidney from 8 to 12 years.

·         Most donor kidneys come from ‘brain death’ or ‘cardiac death’ donors, but donations from living donors are increasing.

·         Pre-emptive transplantation from a living donor is the best treatment choice for patients with end stage renal diseases and has been associated with improved allograft and patient survival. ***

·         Long term outcomes in kidney transplantation are improving

·         Better Quality of life

 

Even though kidney transplant is major surgery with a phased recovery period, it can, in comparison to dialysis, offer you the opportunity for a longer, more satisfying life. Most patients who have been on dialysis and then had a transplant report having more energy, a less restricted diet and fewer complications with a transplant than if they had stayed on dialysis. Transplant patients are also more likely to return to work after their transplant than dialysis patients.

 

*** Data from the Organ Procurement and Transplantation Network for transplants performed in 2002-2004 show that the 1-year survival rate for grafts from living donors is approximately 95% and the rate for deceased donor grafts is approximately 89%. The half life for grafts from living donors increased steadily from 12.7 to 21.6 years.

Preemptive transplantation refers to kidney transplantation before a patient needs to start dialysis therapy. Patients who get a preemptive transplant receive their kidney when their health is generally good, which can improve new kidney function and enhance overall health and life expectancy.

                                Epidemiological data from the past decade suggest that the global burden of the patients with renal failure who receive renal replacement therapy exceeds 1.4 million and that this figure is growing by 8% a year.

Transplantation is the renal replacement modality of choice for patients with diabetic nephropathy and pediatric patients.

PRETRANSPLANT EVALUATION:

Candidates for renal transplantation undergo and extensive evaluation to identify factors that may have an adverse effect on outcome.

Mostly, all transplant centers have a committee that meets regularly to discuss the results of evaluation in a patient and select medically suitable candidates only to place on the waiting list.

In addition to a thorough medical evaluation the committee also evaluates the social background of the patient to determine conditions that may interfere with the outcome of transplantation, such as financial and travel restraints or a pattern of noncompliance.

Laboratory Studies in transplant candidates

Infectious profile in transplant candidates

Blood Chemistries

Hepatitis B And C serology’s

Liver function tests

Epstein –Barr Virus, serology (IgM and IgG)

Complete Blood Count (CBC)

Cytomegalovirus (CMV) serology’s (IgM and IgG)

Coagulation  Profile

Varicella –zoster virus, serology’s (IgM and IgG)

 

Rapid plasma reagin (RPR) test for syphilis

 

HIV

 

Purified protein derivative (PPD)- tuberculosis skin test

 

Urine analysis, Urine culture and cytospin should be ordered when indicated.

A complete cardiac workup and immunologic evaluation (ABO blood group determination, Human Leukocyte Antigen (HLA) typing, serum screening for antibody to HLA phenotypes, cross matching) are also done.

Management

In addition to the surgical transplantation procedure itself, management includes the following:

·         Organ procurement

·         Provision of immunosuppressive therapy to the recipient

·         Short and long term follow-up to look for indications of renal allograft dysfunction and other complications

Organ Procurement

·         Identification of potential donors

·         Assessment of donor suitability

·         Determination of donor brain death

Immunosuppressive therapy after transplant

All kidney transplant recipients require life-long immuno suppression to prevent a T-cell alloimmune rejection response. The goals are as follows:

·         Prevent acute to chronic rejection

·         Minimize drug toxicity and rates of infection and malignancy

·         Achieve the highest possible rates of patient and graft survival

The critical considerations in medical follow up are as follows:

·         Rejection

·         Nephrotoxicity of calcineurin inhibitors (i.e. cyclosporine, tacrolimus)

·         Recurrence of native kidney disease

Transplant recipients tend to be highly experienced patients. Many dealt with their chronic illness for years have been treated and examined by innumerable doctors, have undergone dialysis and its attendant intrusions on their lifestyle, have managed a complicated regimen of medications and have (in many cases) developed a certain expertise related to their own care.

Such patients are invariably grateful for any recognition or acknowledgment of their ordeal. Thus, it is advisable that they are educated about and encouraged to participate actively in their disease management to the fullest possible extent. That said, these patients problems are often complex and decisions regarding their care should be made after consulting the appropriate transplant team.

It is worthwhile to mention-

·         Till date, more than 250,000 kidney transplants have been performed in United States alone.

·         In 2007,6037 kidney transplants were performed from living donors and 10,082 from deceased donors.

·         Currently more than 100,000 people in the United States are living with the functioning kidney transplant.

This number represents 27% of the nearly 350,000 persons enrolled in the US ESRD program.

In1973, congress enacted Medical entitlement for ESRD treatment to provide equal access to dialysis and transplantation for all patients with ESRD in the Social security system by removing the financial barrier to care.

Currently, the main obstacle is donor organ shortage. An increasing rise in ESRD coupled with a lack of donor organs has resulted in an average waiting time of more than 4 years for a deceased donor renal transplant.

The social factors and the perception of the complications of donation by the donor, family members or even the recipient can affect the act of voluntary donation. In India, the Human Organ Transplantation Act of 1994 and its amendments discourages unrelated transplant due to ethical reasons and to avoid exploitation of the financially disadvantaged people.

The latest statistics says that the donors volunteer themselves for transplant evaluation in 28% of the cases and in the rest, it is either requested by the recipient or suggested by the recipient’s physician.

Of all the donors who come for evaluation, 46 (22%) report at least one instance of an attempt to discourage donation and donor’s spouse is the commonest (47.8%) identified cause. Similarly the commonest cause for some of the possible donors declining to even come forward for donor evaluation is again the spouse refusing to give consent.

This emphasizes the fact that the donor’s spouse is always a part of decision making along with the donor to alley some of the fears associated with donation.

It takes courage to ask others for help- and there’s no bigger ask than asking for a kidney and it is always good to help others and there is no greater help than donating an organ and giving a new lease of life to someone.

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