Maine Transplant Program FAQ
Kidney transplantation is the treatment of choice for selected patients with end-stage renal disease. Freedom from dialysis and greatly improved life expectancy are the major benefits of transplantation compared with other renal failure treatment options. Unfortunately, many patients with kidney failure are not healthy enough to receive a transplant. What follows are some frequently asked questions about kidney transplantation.
Why Have a Kidney Transplant?
A successful kidney transplant is about five times more effective than dialysis in replacing kidney function. A transplanted kidney removes wastes from the body and is better at maintaining the correct salt and water balance. Having a properly functioning kidney means freedom from the time and travel restraints of dialysis. You will no longer spend several hours a day, three days a week at dialysis. Most people that have had a transplant say they feel better and have more energy and stamina than they did on dialysis. They are able to return to a more normal and active lifestyle and most are able to return to school or work full time. Most importantly, patients with successful kidney transplants live longer.
Kidney transplantation offers many benefits, but it does have some limitations and risks. It is not always the right treatment option for everyone. These limitations include:
- The uncertainty of success (the transplanted kidney may fail)
- The risk of the surgery itself
- The need for close follow-up appointments at the doctor's office
- Possible hospitalizations
In addition, there are also risks associated with the drugs necessary to prevent the body from rejecting the transplanted kidney. These drugs that suppress your overall immune system are called immunosuppressants. They must be taken for the rest of your life or for as long as the kidney functions. Immunosuppressants are powerful drugs that can produce a number of side effects, including cancer, infection, and cardiovascular disease.
The decision to have a kidney transplant is an important one. A kidney transplant is not a cure for kidney disease. The decision to have a kidney transplant will mean that you are willing to make a life-long commitment to take care of yourself and your new kidney.
Is a Kidney Transplant Right for Me?
The transplant team will take a number of factors into account to determine if kidney transplantation is right for you. These factors are listed in detail in our Guidelines for Kidney Transplant. Some things you can do something about, like obesity, smoking, or compliance with your dialysis treatments and medical regimen. Other things, like having cancer or heart disease, may mean that you will not be able to receive a transplant at all. If you want to be considered for a kidney transplant, we will weigh the benefits you might receive with the risks you would face to determine if kidney transplant is right for you.
Where Does the Kidney Come From?
Donor kidneys come from two sources: living people or from someone that has died and whose family has consented that their organs be used for transplantation (also called a deceased organ donor).
In a living donor transplant, a family member, spouse or a friend donates a kidney to the recipient. (Remember only one healthy kidney is needed to live a normal life and once recovered from surgery, the donor can resume a totally normal lifestyle.) Any potential living kidney donor is thoroughly evaluated to make sure that he or she is healthy enough to donate. The steps to living kidney donation can be found here.
If a patient has a family member or friend who would like to donate but they are not the same blood type, it is possible to arrange a swap through the Kidney Paired Donation Program.
If a deceased donor kidney is used, the kidney comes from a person has died. Their family is informed, and given the opportunity to donate their loved one's organs.
Where do I Start?
The process begins when your local nephrologist refers you to the Maine Transplant Program for evaluation as a potential transplant candidate. The transplant team consists of all the people that work together to make your transplant a success. The members include your local physician, a transplant nephrologist, a transplant surgeon, a transplant coordinator, nurse practitioner, social worker, clinic/dialysis nurse, immunologist, dietician, financial coordinator, and pharmacist. Each has his or her role in determining if you are a suitable candidate for renal transplantation. The steps to receiving a kidney transplant can be found here.
What Happens During the Transplant Evaluation?
The transplant evaluation consists of a review of your medical records and a complete physical by the transplant nephrologist. You will have a chest X-ray and EKG if you have not had one in the past year. Blood work will be drawn for routine studies and infectious disease testing. You will also meet with a transplant surgeon. Further testing is performed as necessary depending on underlying medical conditions.
You will be given information concerning the transplant process, and have an opportunity to ask questions. You are encouraged to learn as much as possible about transplantation before making a decision about having a kidney transplant. The members of the transplant team will explain the benefits and risks of transplantation.
The members of the transplant team will also discuss any special medical problems you have that may require additional evaluation. These conditions could include diabetes, heart disease, infections, bladder dysfunction, ulcer disease, gallstones, or a neurological problem such as a stroke. If you have any of the above, additional testing may be needed to determine that you are healthy enough to have the transplant surgery. Female candidates will need to have documentation of an annual Pap test and mammogram.
After your evaluation, members of the transplant team will meet to review your case at Transplant Candidate Review Meeting, which is held twice a month. They will decide as a group if further testing is necessary before any decision regarding transplantation can be reached.
What Does "Tissue Typing" Mean?
For your new kidney to work properly, you and the donor's kidney must be "compatible." To determine compatibility, three tests are done:
- ABO (blood type) Compatibility
- Crossmatch Compatibility
- Human Leukocyte Antigens (HLA) Tissue Typing
ABO (blood type) Compatibility
Initially, your blood is tested to be sure that you are the same or a compatible blood group with the donor. In the case of kidney transplants, matching is done for blood group (O, A, B, AB). An O donor can donate to an O, A, B, or AB patient, whereas an O patient can only receive an O kidney. The Rh factor (positive or negative) is not a consideration in transplantation.
Can Receive a Kidney From:
Can Donate to:
O, A, B, AB
AB, A, B, O
The second absolute immunological requirement for transplantation is a negative crossmatch test. This test detects antibodies directed against the donor cells. In the laboratory, a small amount of blood from the recipient is mixed with a small amount of blood from the donor. If the cells live, the crossmatch is negative. If the cells die, this is a positive crossmatch. If the crossmatch is positive, the transplant cannot occur. ABO compatibility and a negative crossmatch test are the minimum immunologic requirement for transplantation.
Human Leukocyte Antigens (HLA) Tissue Typing
This test identifies which genetic markers we inherit from our parents. A comparison is then made between the number of shared donor and recipient genetic markers called antigens. Recent improvements in the anti-rejection medications have made this number less important short term. Long term, HLA matching still has an important impact, with better-matched kidneys lasting longer. A kidney from a living donor may last twice as long as a deceased donor kidney, even if there are no common antigens.
What Happens after I'm Put on the List?
Once you have been accepted for transplantation, you will be placed on the deceased donor renal transplant list. The Maine Transplant Program is a member of the New England Organ Bank, a regional organ procurement organization and the United Network for Organ Sharing (UNOS). When a kidney becomes available, it is matched with a recipient according to a point system. The average waiting time for a kidney in Maine is between sixteen months and five years, depending on blood type. Some people have antibodies against potential donors, so it will take longer to find a kidney for them.
When you are on the kidney transplant waiting list, a sample of your blood must be sent monthly to the Maine Medical Center Immunogenetics Laboratory by your dialysis center (or you will be sent a request to have the blood drawn and sent to the Immunogenetics Laboratory). The purpose of this test is to monitor your antibody level and use the blood to perform a crossmatch should a donor kidney becomes available for you. Specimens will be collected on a regular schedule until after your transplant. It is absolutely essential to keep these samples up to date.
When a kidney becomes available for you, one of the transplant coordinators will call you to come to Maine Medical Center. You will first be called at home, then using alternate numbers and, finally, we will page you. Pagers are available free of charge for our patients on the transplant list. Therefore, it is critical that your contact information as well as your insurance information be accurate and up-to-date. Please call your transplant coordinator if:
- You change your name (marriage), address, or telephone number;
- Your insurance coverages changes;
- You receive a blood transfusion; or
- You are hospitalized for any reason.
Please do not assume that the dialysis unit or your local doctor will call the transplant program. The toll free number is 1-800-870-5230.
What are the Hospitalization and Surgery Like?
Those who are receiving a transplant from a live donor will be able to schedule their transplant at a time convenient for the donor, the recipient, and the Maine Transplant Program. For someone on the deceased donor transplant list, the call to go to the hospital for a transplant may come at any time.
Before you have your transplant you will have blood tests, a chest x-ray, and an EKG. If you have an active infection or any other significant health problem, the transplant may have to be postponed or cancelled.
You will have an IV started to give you fluids since you are not allowed to eat or drink anything.
After you arrive in the operating room, you will have a blood pressure cuff applied and you will be placed on a heart monitor. Recipients will have a large central vein IV placed and a foley catheter inserted once they are asleep. This IV will be used for several days to administer anti-rejection medication.
An incision is made in the lower abdomen. The surgical team will then attach the artery and vein of your new kidney to one of your arteries and veins, and they will attach the new kidney's ureter (the tube that carries urine to the bladder) to your bladder. If you still have one or both of your own kidneys, they will not be removed. The procedure should take about 4 hours to complete.
The surgery for living donor nephrectomy and kidney transplantation occurs at the same time. The kidney donor and recipient are in adjoining operating rooms. As the transplant surgeon is removing the kidney from the donor; a surgeon is preparing the recipient for transplantation of that kidney. For additional information about living kidney donors, see A Handbook for Living Kidney Donors, included in this book.
You will wake up in a recovery room, called the post anesthesia care unit (PACU). Nurses will monitor your temperature, heart rate, blood pressure and urine output. They will encourage you to take deep breaths every hour so you do not develop pneumonia.
You will have an IV line and the nurses will be able to give you medicine for pain or nausea. You will have a catheter in your bladder to help you pass urine. It may feel uncomfortable, and you may feel that you have to urinate constantly. The catheter will only be in for a few days.
You will remain in PACU for several hours until you are fully awake and your blood pressure is stable. While you are in PACU, your family will not be able to visit you.
After recovery, you will be transferred to a private room on the 5th Floor, Richards Wing of Maine Medical Center. The nurses are specially trained to care for renal patients and are part of the healthcare team that will work collaboratively with you to provide the care and education necessary for you to recover from the surgery and return home in a timely fashion. Assuming there are no complications, you will be discharged from the hospital five to seven days after transplant surgery.
What are Some Possible Post-transplant Complications?
A number of complications are possible after surgery. There is no way to predict for sure which patients will have which problems. Your transplant team will do their best to reduce your chance of having complications and to treat them right away if you have any. Following instructions carefully and keeping your transplant team informed of any problems will help you return quickly to a normal, active life. Some possible complications are:
- Delayed graft function, which may briefly lead to the need for dialysis after transplant
- Anxiety and depression
- High blood pressure
- Weight gain
What is Rejection?
Rejection is one of the most important concerns for renal transplant recipients. Acute rejection most commonly occurs within the first twelve months after transplantation, but it can also occur many months or years after transplantation.
You must understand that despite efforts to prevent rejection, it may still occur. Generally, rejection is treatable with medication and usually does not lead to immediate loss of the kidney. However, for some patients, one or more rejection episodes or complete failure of a transplanted kidney can occur. It helps to understand just why your body might want to reject a transplanted kidney.
Your body's immune system protects you from infection by recognizing certain foreign bodies, like bacteria and viruses, and destroying them. Unfortunately, the immune system sees your new kidney as a foreign substance also. To prevent rejection, you must take anti-rejection medications, as prescribed, for the rest of your kidney's life.
What are Immunosuppressive Medications?
After your transplant, you will be required to take a combination of drugs designed to suppress your immune system and prevent rejection of your new kidney. Some of the most frequently prescribed are:
The transplant nephrologist will determine the particular combination of drugs you will take after your transplant and discuss the side effects of each. In general, immunosuppressive therapy carries an increased risk of infection and cancer.