Evaluation and preparation of Renal Transplant
What will happen before the transplant?
Recipient will be assessed to know:
- If he/ she is fit to undergo transplant and tolerate lifelong medications
- If he/she has any medical condition that would decrease the success rate of the transplant
- Are willing and able to take medications and make lifestyle changes after the transplant
While waiting for a transplant the recipient should follow the advice below:
- Diet prescribed
- No alcohol
- No smoking
- Keep weight in the range recommended
- Follow the exercise regimen prescribed
- Take all medication prescribed regularly
- Ensure all appointments are kept
Various blood tests, urine, stool examinations, x-rays, ultrasound tests and any other tests that may be deemed necessary by the treating doctor will be carried out on both the recipient and donor to ensure compatibility and fitness.
First a blood group compatibility is checked. Thereafter the tissue compatibility is done.
Sometimes, one may require examination by various specialists, like psychiatrist, cardiologist, endocrinologist, etc.
It is only after all these tests are done, will a decision be taken on the suitability of the donor and fitness for a transplant in the recipient.
What is the preparation required for transplant?
It is important to accept transplantation with a positive attitude because it is a big step and although its preparation is cumbersome, waiting period unpredictable (for a cadaveric kidney), operation complex and recovery prolonged, most patients do well after transplant and lead an excellent quality of life.
The preparation starts with recipient’s evaluation. A thorough medical, surgical and psychological history, including blood products or platelets transfusion in the past, previous pregnancies or transplants will be taken. The purpose is to anticipate problems in the transplant and outcomes. Co-morbidities that can make a candidate ineligible for transplant are identified.
- Blood tests to check for suitability for any surgery and to ensure there are no infections. ECG, ECHO or cardiac catheterisation (in case needed) are done. X-ray chest and abdomen and ultrasound KUB region are also done.
- Blood tests include: Blood type, blood count, blood urea, serum creatinine, serum electrolytes, calcium, phosphorus, albumin levels, liver function tests, coagulation profile, parathyroid hormone levels, HbA1c
- Serology tests for HIV, Hepatitis B and C
- Pregnancy test for potentially fertile women
- Urine analysis for proteinuria and bacteruria
- Chest x-ray
- ECG and ECHO
- Additional tests for those with known heart disease, infections, malignancies, pulmonary disease and liver disease
Once the patient is found suitable for transplantation, any potential donors in the family should have their blood group checked and one who is compatible should undergo donor evaluation. If the donor is suitable, authorization committee clearance is obtained and transplant scheduled.
If a suitable family donor is not available, after the recipient evaluation is found satisfactory, the patient is registered on the waiting list for a deceased donor kidney transplant.
The Act and Rules permit transplantation between unrelated Donor and Recipient who do not fall under the category of near relative as defined under the Act.
Patients should make adequate arrangements for blood products well in advance before surgery as this will be kept on standby.
While preparing for a transplant, all doubts should be clarified and understood. Patients and the donors are encouraged to meet other patients and families who have undergone the operation and willing to share their experiences.
The evaluation period may be very hectic and stressful. Patients are advised to relax between tests and follow the instructions for each test carefully for accurate results. The transplant coordinator is the main contact person during evaluation and will fix appointments for any tests or procedures. At every stage of evaluation, the plan for further tests may change depending on the reports; therefore it is important to visit the transplant clinic routinely for review by the transplant team. Patients who are sick may be advised to undergo evaluation in the hospital. If unexpected/ incidental problems are discovered on evaluation such as cardiac disease, thyroid disease, infection, etc. these might have to be treated before transplant.
Patients with other co-existing diseases such as uncontrolled blood pressure, diabetes or untreated cardiac problems, might have to wait until they are corrected. Renal transplant can even be performed after successful cardiac angioplasty or with heart bypass surgery.
Who can be a living kidney donor?
A living donor should meet the following criteria:
- Compatible blood group with the recipient
- A family member (wife, husband, mother, father, brother, sister, son, daughter, grandfather, grandmother, grandson, granddaughter) or close relative of the patient as defined by the Act.
- Age group 18-55 years
- Not overweight, because people who are overweight may associated co-morbidities themselves
- The donor should have both actively functioning kidneys
- Donor should be in good overall physical and mental health and undergo a thorough medical and psychological evaluation and volunteer for donation after fully understanding the risks of surgery.
- The decision to donate can be changed at any stage of the evaluation, before or after the tests are done or any time before the surgery.
Pre-transplant donor evaluation
Both the patients’ and donors’ emotional health and willingness for transplant is important for the operation and they would be counselled by a psychologist during evaluation.
HLA testing and matching is performed before the authorization committee meeting.
Regardless of the type of kidney transplant-living donor or deceased donor-special blood tests are needed to find out what type of blood and tissue is present. These test results help to match a donor kidney to the recipient.
Blood Type Testing
The first test establishes the blood type. There are four blood types: A, B, AB, and O. Everyone fits into one of these inherited groups. The recipient and donor should have either the same blood type or compatible ones, unless they are participating in a special program that allow donation across blood types. The list below shows compatible types:
- If the recipient blood type is A Donor blood type must be A or O
- If the recipient blood type is B Donor blood type must be B or O
- If the recipient blood type is O Donor blood type must be O
- If the recipient blood type is AB Donor blood type can be A, B, AB, or O
The AB blood type is the easiest to match because that individual accepts all other blood types.
Blood type O is the hardest to match. Although people with blood type O can donate to all types, they can only receive kidneys from blood type O donors. For example, if a patient with blood type O received a kidney from a donor with blood type A, the body would recognize the donor kidney as foreign and destroy it.
The second test, which is a blood test for human leukocyte antigens (HLA), is called tissue typing. Antigens are markers found on many cells of the body that distinguish each individual as unique. These markers are inherited from the parents. Both recipients and any potential donors have tissue typing performed during the evaluation process.
To receive a kidney where recipient's markers and the donor's markers all are the same is a "perfect match" kidney. Perfect match transplants have the best chance of working for many years. Most perfect match kidney transplants come from siblings.
Despite partial or absent HLA match, transplant can be done with some degree of "mismatch" between the recipient and donor.
Throughout life, the body makes substances called antibodies that act to destroy foreign materials. Individuals may make antibodies each time there is an infection, with pregnancy, have a blood transfusion, or undergo a kidney transplant. If there are antibodies to the donor kidney, the body may destroy the kidney. For this reason, when a donor kidney is available, a test called a crossmatch is done to ensure the recipient does not have pre-formed antibodies to the donor.
The crossmatch is done by mixing the recipient's blood with cells from the donor. If the crossmatch is positive, it means that there are antibodies against the donor. The recipient should not receive this particular kidney unless a special treatment is done before transplantation to reduce the antibody levels. If the crossmatch is negative, it means the recipient does not have antibodies to the donor and that they are eligible to receive this kidney.
Crossmatches are performed several times during preparation for a living donor transplant, and a final crossmatch is performed within 48 hours before this type of transplant.
Testing is also done for viruses, such as HIV (human immunodeficiency virus), hepatitis, and CMV (cytomegalovirus) to select the proper preventive medications after transplant. These viruses are checked in any potential donor to help prevent spreading disease to the recipient.
Phases of Transplant
This period refers to the time that a patient is on the deceased donor waiting list or prior to the completion of the evaluation of a potential living donor. The recipient undergoes testing to ensure the safety of the operation and the ability to tolerate the anti-rejection medication necessary after transplantation. The type of tests varies by age, gender, cause of renal disease, and other concomitant medical conditions. These may include, but are not limited to:
- General Health Maintenance: general metabolic laboratory tests, coagulation studies, complete blood count, colonoscopy, pap smear and mammogram (women) and prostate (men)
- Cardiovascular Evaluation: electrocardiogram, stress test, echocardiogram, cardiac catheterization
- Pulmonary Evaluation: chest x-ray, spirometry
Authorization committee clearance
All patients planned for living donor transplant need clearance by the government appointed authorization committee. Our administrative staff will help patients and their families understand and prepare various legal forms, affidavits (statements under oath) and supporting documents. Proof of identity, residence and donor-recipient relationship have to be submitted with the application to authorization committee. Donors who are not near relatives and foreign nationals have to obtain a no-objection certificate (NOC) from the state of domicile (residence) or embassy. The transplant team is independent of the authorization committee and cannot influence its decision. Falsification of documents or other efforts to provide false information / mislead the authorization committee constitutes violation of the law and carries heavy penalty.
All cases who have completed both patient and donor evaluations are reviewed by the multi-disciplinary transplant team, where their suitability for transplant is discussed and tentative date for transplant decided. The transplant is scheduled only after clearance by the authorization committee.
Arrangement of blood and blood products
Once the medical decision for transplant is made, patient’s family may be asked to donate blood in case it is needed
What if a patient does not have a suitable living donor?
Patients who do not have a suitable living donor or are unlikely to get a deceased donor transplant in the immediate future, might benefit from one of the following innovative procedures.
- Swap transplant: When one of patient’s family members is suitable and willing for donation, but is not a good match for the patient, a paired donation or swap transplant may be considered. In this type of transplant, two families with suitable living donors exchange their donors because they are not a good match for their own patient, but are appropriate for each other’s patients.Swap transplant is commonly done for blood group mismatch, e.g. if donors and patients of one family have blood groups A and B and that of the second family B and A, respectively, these donors are not suitable for their own recipient. However, if donors are exchanged, both patients can undergo transplantation. Both transplants are performed simultaneously and therefore can only be done by a large experienced transplant team with adequate infrastructure and after careful planning.
- ABO incompatible transplant: Even though the donor and recipient may have different blood groups and are not compatible, newer techniques enable transplant to go on between such incompatible individuals. Patients are encouraged to contact the transplant team for more details.
Deceased donor transplant
Once recipient evaluation is completed and patient is found medically fit for transplant, the prescribed forms have to be completed and submitted through the hospital to the state-wide appropriate authority for registering their names on the waiting list for a deceased donor transplant. Patients may register at more than one hospital, even in different states (Maharashtra, Gujarat and Karnataka). After listing, patients should undergo periodic testing and review with the transplant team and also inform them of any significant changes in patient’s medical condition.
When a potential deceased donor kidney is available, patients are alerted immediately and called to the hospital. The contact information of the patient should be updated with the co-ordinators so that the transplant team can contact the patient and the family when a kidney is available any time of day or night. The coordinators should be informed if the patient is going out of country.
Patients not living in the same city should pre-plan for the emergency trip well in advance. They should also have flight options to our centre and important phone numbers handy and plan on getting to the hospital quickly. They should alert their employer about sudden leave in advance. They should designate someone who will take care of their family and home in their absence and maybe make a power of attorney for their business. The waiting period is highly variable, ranging from weeks to months.
Precautions to be taken while waiting for the transplant
While waiting for the transplant, it is important that patients undergo regular tests, adhere to all appointments and medical advice, and comply with treatment and dietary restrictions. In order to remain healthy, prevent any infections, prevent any complications, enable early identification of any problems or significant change in condition and allow prompt treatment before transplant, some simple precautions can be taken.
- Hand washing and scrubbing for at least one-minute using soap and water including between fingers, under the fingernail and around the nail beds before eating after using the bathroom or when they are dirty.
- Using anti-septic hand-rubs frequently
- Malnourished patients may be advised few weeks of medical nutrition therapy.
- Perform light exercises, walk and remain active (as much as possible).
- Get enough rest
- Taking only the prescribed medicines. Do not take any new medicines, including vitamins, herbs or supplements without discussion with the transplant team.
- Children are advised to undergo all vaccinations appropriate for age, because they cannot receive live vaccines after transplant
- Eating low salt diet, as prescribed and adhering to liquid intake restriction.
- Eating smaller meals, low-fat, high protein adequate calorie diet, keep the muscles strong
- Patients can consider taking nutritional supplements if they are unable to get enough calories or proteins in your diet, as advised by the dietician
- The transplant team should be informed about any significant change in the health or any hospitalizations
- No alcohol intake, if the transplant team has any doubt about lifetime commitment to sobriety or abstinence from alcohol or illicit drugs, they can perform random screening blood or urine tests for the same and if found positive, make the patient inactive on the waiting list
- Patients should quit smoking before transplant, because it can cause lung infections after surgery and prolong recovery from ventilator after surgery.
- The transplant team should be notified any the unexpected change in health such as blood vomiting or black stools, changes in mental condition, excessive sleepiness (drowsiness), confusion, nose bleeding, weight gain, swelling in abdomen or arms and feet, severe or sudden abdominal pain, fever, fainting spell, severe vomiting or loose motions.
- Patients may be able to continue to work and even travel while on the waiting list after discussing the same with the transplant team. It may not be safe for patients with very low platelet counts, high INR, history of GI bleed or encephalopathy to travel. While travelling, the coordinators should be updated with the contact numbers. Patients should also identify a doctor locally who can take care of any urgent problems while travelling.
- Patients should keep the phone numbers of their family members and the transplant team handy to deal with any urgent situations.
ALL PROSPECTIVE RECIPIENTS ARE ENCOURAGED TO TALK TO THE TRANSPLANT TEAM ABOUT VACCINATIONS PRIOR TO TRANSPLANTATION.