TRANSPLANT OPERATION

On schedule date both patients (Donor & Recipient) are simultaneously taken to the adjoining operation theaters.

The donor's kidney is placed on the right or left side of the abdomen below the navel. The new kidney's artery and vein are joined to an artery and vein of the recipient in the pelvic area of the recipient. The ureter (urine tube) of the donor's kidney is attached to the bladder of the recipient.

Donor surgery lasts for two to three hours while recipient surgery lasts for four to five hours. Donor is taken to the regular room after the surgery while recipient is taken up in isolation room for five to seven days. He/she is observed very closely for Pulse, Blood Pressure, Urine output and Fluid intake is closely monitored. In majority of cases patient starts passing urine on operation table only and good output is maintained with adequate fluid intake. High dose Immunosuppressive therapy is started on the patient two days prior to operation.

Transplanted Kidney

Recipient care

After the surgery, patient has to stay in the hospital for two to three weeks. After this he/she is discharged from the hospital and is advised close medical follow up at three days interval for first four weeks and later on at weekly interval for four weeks and subsequently at two weekly interval for another two to three months. During this time his/her immunosuppressive therapy is gradually decreased till maintenance dose is reached within four months time.

The problems of transplantation

The problems of transplantation are not usually from the operation itself. The difficulty arises from the fact that the body can recognize what is a part of itself and what is not, and its defence mechanism go into action to destroy what is other's, this process is called rejection. Rejection is mediated by white blood corpuscles which are the guardians of the body.

Rejection

There are four types of rejections:

1. Hyperacute rejection can occur minutes or hours after transplant. This type of rejection is very rare. It is untreatable and the kidney is removed immediately.

2. Acute Rejection can occur anytime from a week to a year after transplant. Occasionally it can occur some years after transplant. This form of rejection is experienced by most transplant patients and is usually treatable. It is certainly likely to occur if the drug treatments prescribed are not taken regularly. This rejection can be reversed with high dose of Immunosuppreissive drugs.

3. Chronic Rejection occurs slowly over a long period of time and there may be no obvious symptoms. Chronic rejection is also difficult to treat if the kidney stops working the patient can return to dialysis and await another transplant.

4. Infection because the drugs used to prevent and control rejection weaken the body's defenses. Patients after transplant are more prone to infection. Risk of infection commonly in the wound site, mouth, urinary tract and lungs is highest in the first few months after transplant because drug dosage is highest. Most of the infections are controlled by antibiotics and/or reducing doses of anti rejection drugs.

HOW TO OVER COME REJECTION

To over come the rejection after initial period is over the patient is given three drugs - Cyclosporine (Sandimmun), Prednisolone (Deltacortil or Wysolone) and Azoran (Imuran). Initially high dose is given and gradually dose is decreased to maintenance dose within three to four months time. Generally patients are instructed to come for a regular follow up and also to report to concerned doctors about any unusual symptoms like decrease in urine output, fever, cough or cold, breathlessness etc. These symptoms need full evaluation and prompt treatment in patient with Immunosuppressive therapy.

Only word of caution is that many times patient manipulates drug dosages by themselves or even stops that. This is the most important cause of rejection. At times with rejection doctor is forced to give very high dosages of prednisolone (Intravenously) and this can lead to life threatening complications too.

Generally patient is told to take rest and avoid coming in contact with people for three months. After this time he/she can start his/her work gradually and return to normal activity within two to three months time.

Renal transplant surgery is no doubt expensive - May cost patient around Rs. 50,000/- to Rs. 150,000/- depending on hospital and class patient gets admitted to the hospital. Even after discharge patient has to take immunosuppressive therapy and this too is costly. Sandimmun itself may cost patient around Rs. 40,000/- or so in first year or so. But inspite of all these renal transplantation is less expensive than life long dialysis and quality of life is better with transplantation.

In case patient develops rejection and loose transplanted kidney, he/she can go again for dialysis and later on may consider second transplant too. With newer drug result or live related donor transplant is very good and approximate survival is around 80% or more at the end of five years.

Immunosuppressive Drugs

PREDNISOLONE

Prednisolone (Deltacortil or Wysolone) is very important and life saving drug. It has many side effects like moon face, diabetes, high blood pressure, swelling and even acidity or peptic ulcer disease or bleeding in stomach. With long term therapy it even causes bone damage and may require surgical intervention in some cases. It should not be taken on an empty stomach and not be stopped suddenly.

AZATHIORPRINE

Trade names are Imuran (Burroughs-Welcome) or Azoran (Searle). It prevents rejection by reducing white cell count in blood. White cells are defense force of human body. When white cell count go below 4000, person becomes more susceptible to infection. In few cases it can give rise to Jaundice too.

CYCLOSPORINE

It is manufactured by Sandoz Limited only and is very expensive medicine. 50 ML bottle costs patient around Rs. 4,500/- at present. It is very good medicine and has improved kidney transplant result by greater than 15% above Steroid and Azathioprine therapy. It's main side effects are kidney damage and liver damage. It even causes excess hair growth, gum problems and fine tremors of hands. These all side effects are related to dose of drugs and with decrease in dosages (with time), side effects become lesser and lesser. Recently some of the centers in India have started combining Cyclosporine with some other drug (Ketoconazole) and this combination can allow doctors to decrease the Cyclosporine dose by 70% to 80%. This will be very cost effective in poor patient.

FK 508

Still experimental drug but seems to be promising in liver and kidney transplant patients.

This is the latest drug developed in Japan by Fusisawa Pharmaceutical of Osaka. This medicine is proving to be more powerful and less toxic than cyclosporine. However it is very expensive drug.

GOING HOME WITH A SUCCESSFUL TRANSPLANT

Leaving hospital with new kidney is an exciting time, but is not the end of contact with nephrologist and his team. In the first few months it is necessary to make frequent visit's to the nephrologist. Visits to Nephrologist become less frequent once kidney function stabilizes and general health improves.

Following precautions are necessary for first 2 to 3 months;

1. Keep a daily record of Blood Pressure/temperature/ fluid intake/urine output/weight initially for eight weeks (2 months).

2. Take your drugs regularly as prescribed by the Nephrologist.

3. Do not allow any sick person to visit you.

4. Allow only 2 to 3 visitors at a time with the mask without flowers and shoes.

5. No outside food, only home made hot food, salt intake to be restricted.

6. Take bath with hot water (put few drops of dettol in bucket). Wear only pressed clothes.

7. Everyday the room, furniture and other articles should be cleaned with dettol. Bed sheet/pillow cover should be changed every day.

8. Clothes to be washed in hot water with a few drops of dettol, do not mix up the patients clothes/bed sheets etc. with other family members clothes.

9. All dishes/thalis/watis/glasses/spoons to be cleaned with hot water before use.

10. Change mask every day.

11. Use only boiled & filtered water for drinking. Fruits and vegetables should be cleaned with hot water before use.

12. Keep the toilet clean as much as possible.

13. Salt and sugar intake as per instruction of your doctor.

14. Female patient should not try for children till two years are completed after the successful transplant surgery and only if reports are within normal limits and has no Hypertension.

Precautions as Transplant patient (after 2 to 3 months)

1. Try to mix up slowly with the crowd.

2. Do not forget daily medications as per the prescription of Nephrologist

3. Record your weight/B.P. and show it to your Nephrologist.

4. If any episode/rejection is there which can be found out by sudden fall in urine output, excess swelling, Blood reports, very high B.P. contact your Nephrologist immediately.

5. Your blood/urine tests should be done at a reliable pathological laboratory.

6. If there are any side effects (such as sugar in blood, calcium deficiency etc.) contact your Nephrologist and start treatment as per his advise.

7. Always inform any new doctor of your transplant and medications.

LIFE WITH A NEW KIDNEY

A kidney transplant can offer a 'New lease of Life' but patients and their families have to make many adjustments in the first year after transplant, particularly in learning to live with disruption to one's life and the 'uncertainty' about how long the kidney will function.

Most persons are able to get back to normal activities and work 3 to 6 months after transplant. For many people sexual function improves after transplant. Sexual activity will not harm the transplanted kidney nor increase the risk of infection. However as is the case for any major surgery it is advisable to consult your doctor. Having a child after a transplant is possible but it is advisable to wait 1 - 2 years of good kidney function. For woman transplant patients risks of complications during pregnancy are more such as premature baby and hypertension so careful monitoring of the pregnancy is needed.