Kidney Transplant

Towards A New Beginning

What is kidney (renal) failure/injury?

Kidney Injury/Failure can be acute, which means that the kidneys have suddenly stopped working. Acute Kidney Failure is potentially reversible.

Chronic Kidney Failure is a slow progressive and irreversible loss of kidney function.

What is chronic kidney disease (CKD) and what are the common causes of CKD?

Chronic kidney disease is the presence of functional or structural abnormality in the kidney for three months or longer. eg. presence of screening “Maker” such as protein in urine or having a decreased kidney function for more than 3 months.

There are many causes of CKD. The kidneys are most commonly affected by diseases, such as diabetes and high blood pressure.

Some kidney conditions are inherited (run in families). Others are congenital, i.e., individuals may be born with an abnormality that can affect their kidneys.

What is end stage kidney disease (ESKD)?

ESKD is a stage at which practically the entire kidney function is lost. On ultrasound examination, the kidneys are usually small and shrunken. The kidneys can be considered to be dead for all practical purposes. Life long dialysis or transplantation becomes mandatory for survival. Each year approximately 350,000 – 400,000 people develop ESKD.

What are the signs and symptoms of kidney disease?

Kidney disease usually affects both kidneys. If the kidneys’ ability to filter the blood is seriously compromised by the disease, then wastes and excess fluid may build up in the body. Although many forms of kidney disease do not produce symptoms until late in the course of the disease, there are six warning signs of kidney disease:

• Puffiness around eyes, swelling of hands and feet
• More frequent urination, particularly at night. Difficult or painful urination.
• Blood and/or protein in the urine
• High blood pressure
• A Creatinine & Blood Urea Nitrogen (BUN) blood test, above the normal range (BUN & creatinine are waste products that build up in the blood when the kidney function is reduced.)

What are the treatment options for ESKD?

There are only two options for End Stage Kidney Disease:

• Life Long Dialysis
• Kidney Transplantation

What is dialysis?

It is a process that removes the waste products and helps maintain the volume and composition of body water – the most important and indispensable function of the kidneys It does not help in blood formation and activation of vitamin D as is the case with normal kidneys. Hence supplementary therapy is required It does not improve the function of diseased kidneys

What are the types of dialysis?

There are two types of dialysis:

Haemodialysis, where the blood is cleaned outside the body via a machine Peritoneal dialysis, where the cleaning is done inside the body by the peritoneal membrane Occasionally, there may be medical reasons to prefer one dialysis over the other.

What is the best option for the treatment of ESKD?

Kidney (Renal) Transplantation is the best available treatment for ESKD because of the following reasons:

• Improved survival
• Better quality life
• Improved cost effective

Who is eligible for transplantation?

• All patients with ESKD should be assessed for suitability of kidney transplantation
• Patients having cancer or other active infections cannot go for transplantation

Special assessment is required for the following groups of patients:

• Old age
• Severe heart disease, lung disease or liver disease
• HIV positive patients
• Psychiatric Illness

Who can donate/give kidneys?

Living Donors

Indian Law permits near and dear ones to donate organs (kidney, liver, bone marrow). Parents, siblings, son, daughter, grandparents and spouse are treated as ‘near relatives’.

If a family member cannot donate a kidney because of difference in blood group and if there is another pair with a similar problem, the donors can be exchanged for the purpose of kidney transplantation. This is called a Swap Transplant.

Living donors are thoroughly investigated by the physician. The donors should be in good overall physical and mental health and free from uncontrolled high blood pressure, diabetes, cancer, HIV, hepatitis, and organ diseases (such as those related to the kidney, heart, liver, lung, intestine and pancreas). Living donors should be older than 18 years of age and compatible with the intended transplant candidate. The donors are screened from medical and psychosocial aspects.

Deceased Donor (Cadaver Donor)

A deceased donor is a person who is brain dead.

A person is dead when his heart stops beating permanently.

A person is dead even when the brain is dead but the heart is functioning. At this stage the heart can function for hours or days. During this period, if the family consents, various organs and tissues can be used for transplantation.

One can register for a cadaver organ with the ZTCC – Zonal Transplant Coordination Committee (city waiting list) through the Transplant Coordinator & the Nephrologist at the hospital.

What is the success rate of kidney transplantation?

• Overall, transplant success rates are very good
• Transplants from deceased donors have an 85 to 90% success rate for the first year. That means that after one year, 85 to 90 out of 100 transplanted kidneys are still functioning
• Live donor transplants have a 90 to 95% success rate. Long term success is good for people of all ages

What if my donor’s blood group does not match mine?

There are three options available for such patients:

• Blood group Incompatible transplantation ( ABOi)
• Living Donor Paired kidney exchange ( LDPE)
• Deceased donor ( cadaver) donor listing

What can my kidney donor expect?

The procedure for the person who is donating a kidney to you is exactly the same as for blood group compatible
donors. The special treatments are only necessary for you.

Is it expensive?

The cost of the kidney transplant surgery remains the same except that the cost of plasma exchange procedure is additionally to be calculated based on the amount of antibodies in your body.

Why Kokilaben Hospital?

The Nephrology and Urology departments boast of one of the largest dialysis units in the city and a sizeable renal transplant program, having performed both living and cadaveric transplants.

The stringent infection control practices, immunosuppressive protocols and proactive vigil for complications and their prompt management make the service comparable to the best. The Transplant Unit also integrates, analyses and addresses the health needs of the transplant patient and his or her family.

State-of-the-art procedures for kidney transplantation include:

• Cadaver Donor Kidney Transplantation
• Living Donor Kidney Transplants
• Paired Kidney Exchanges
• ABO-Incompatible Transplantation
• Laparoscopic Donor Nephrectomy

The Kokilaben Hospital Kidney Transplantation Team comprises of specialists in transplantation medicine and surgery. The team comprises of 2 nephrologists, 2 transplant coordinator and 3 transplant surgeons.

Introduction

Liver transplantation is a surgery in which the diseased liver is removed and replaced with a healthy one. Cirrhosis of the liver is the commonest indication for a liver transplant. Other indications include liver cancer, acute liver failure of genetic diseases. Liver failure can be acute (one that can happen in a short period of time) or chronic (which can occur over a longer period of time). Across the world, there are thousands of patients who have had a liver transplant and are now leading normal lives.

What can damage the liver?

Liver damage can occur suddenly or it can happen over a prolonged period due to various causes:

Sudden or Acute Liver Failure

• Severe Infection
• Some drugs such as herbal treatments, some Ayurvedic medicines or Chinese medications

Chronic (Long term) Liver Failure

• Excessive intake of alcohol,
• Infective Viruses like Hepatitis B and Hepatitis C,
• Fatty Liver (due to excessive weight gain, diabetes, high cholesterol and high blood pressure)
• Autoimmune Diseases

In children, the liver can be damaged due to a condition called ‘Biliary Atresia’ and some other metabolic disorders and liver tumours.

How do I know if my liver is damaged?

Some of the important signs of liver failure are as follows:

• Yellowish discolouration of the eyes (Jaundice)
• Swelling of the feet
• Blood in the vomit or stools
• Swelling of the abdomen due to water collection
• Feeling weak with loss of appetite
• Confusion or disorientation
• Muscle wasting
• Bruising and bleeding easily from gums

How do I know if I need a liver transplant?

The team at our hospital will examine you and evaluate all your blood and radiological results. Based on their assessment, they will recommend a liver transplant if it is required.

If a transplant is not deemed suitable or not required, they will treat you with the necessary medications.

If you do need a liver transplant, other aspects of your health including the condition of your heart, lungs and kidneys will be assessed.

What are the types of liver transplant?

There are two types of transplant

a) Cadaveric liver transplant

In these cases, the liver is harvested from a brain dead person whose heart is still working. Such a person is legally considered dead, but as long as the rest of his organs are well, they can be transplanted to the patient.

b) Living donor liver transplant (LDLT)

A healthy person from the patient’s family donates a part of his/her liver. This donor is called a ‘living donor’. The donors undergo a thorough and detailed evaluation of their health. Liver is the only solid organ that has a capacity to regrow and regenerate when it is cut, thus, making LDLT a realistic option.

In Asian countries including India, 90% of liver transplant are of the Living Donor Type. Safety and advances in liver surgery has enabled successful implementation of LDLT.

Is it a must for the blood groups to match for liver transplant?

Blood group should be identical or compatible to the patient’s blood group. Positive or negative does not matter. Also, ‘O’ blood group people are universal donors and people with ‘AB’ blood group are universal recipients.

For eg: A patient of ‘A’ blood group (positive or negative) can receive a liver from either ‘O’ or ‘A’ group (positive or negative). A patient whose blood group is ‘AB’ can receive a liver from anybody.

Who needs a liver transplant?

It has been estimated that about 2, 00,000 deaths occur due to liver failure in India every year, of which many would be candidates for a life-saving liver transplant. The actual number of liver transplants performed in India is about 1200 a year- a minute fraction of the real requirement.

In this group of patients, timely referral is crucial. A delay in referral results in a sick patient, whose capacity to survive a major operation has been seriously compromised because, besides liver, even other organs have been severely damaged. The indications for liver transplantation may be divided into the following categories:

1. Chronic liver disease (cirrhosis)

This is the most common indication for liver transplantation. Cirrhosis, by itself, is not an indication for liver transplant but decompensated cirrhosis is. Complications of cirrhosis include ascites, encephalopathy, gastrointestinal bleeding (typically from gastro-esophageal varices), renal dysfunction (hepatorenal syndrome) and pulmonary problems (hepatic hydrothorax and hepatopulmonary syndrome).

The risk of mortality within one year in a patient with ascites and varices is about 20% and in a patient with ascites, who has had a variceal bleed is nearly 60%. A patient with even a single episode of spontaneous bacterial peritonitis has a one year mortality risk of 50%. There are scores to calculate the risk of mortality in patients with cirrhosis.

The Childs-Turcotte-Pugh (CTP) score would be familiar to everyone. It is based on five parameters: serum bilirubin, serum albumin, INR (International Normalized Ratio of Prothrombin Time), severity of ascites and severity of encephalopathy. Each of these parameters is given a score of 1-3. The normal CTP score is 5 and the highest possible is 15. Anyone with a CTP score of 10 or more should be referred for a transplant. The three-month mortality risk for a patient with this CTP score is over 50%. Another score used to assess risk of mortality is the Model for End Stage Liver Disease (MELD). This requires only the bilirubin, creatinine and INR. Patients with a MELD score of 15 or more need a liver transplant.

2. Acute liver failure (Fulminant Hepatic Failure)

This occurs when a toxic attack on the liver causes death of most of the liver cells. In the West, the commonest cause of FHF is paracetamol overdose. In India, the common causes are hepatitis B, hepatitis A, hepatitis E and some drugs, such as those used to treat tuberculosis. Jaundice, encephalopathy and coagulopathy are the indicators of a failing liver and a patient with hepatitis who becomes drowsy or confused or who has coagulopathy (an INR of more than 2), should be referred for an emergency liver transplant. These patients can deteriorate very rapidly (within a matter or hours) due to cerebral edema. If transplanted on time they do very well because they are usually otherwise healthy and often young and have not been debilitated by long standing chronic liver disease.

3. Liver cancer

Primary liver cancer often occurs in a liver which is already cirrhotic and this limits the treatment options. In a normal liver, a large part of the liver can be resected in order to remove tumor (up to 75%) with the knowledge that the liver has enough reserve, not only to continue functioning but also to regenerate and rapidly grow back to its full size. In a cirrhotic liver, however, this reserve as well as capacity to regenerate is lost and a safe liver resection is not possible. In this situation a liver transplant is life-saving provided there is no spread outside the liver or invasion of the major blood vessels of the liver.

4. Rarer causes

There are many rarer diseases which require a liver transplant such as hepatic venous obstruction which progresses to cirrhosis, biliary atresia in babies (treated unsuccessfully or too late) or genetic disorders (Wilson’s disease, Crigler Najjar Syndrome, etc.).

The liver transplant operation

While planning a Living Donor Liver Transplant (LDLT), it is vital of explain to the family who can donate. Every living donor liver transplant has to be authorized by a committee. It is the committee’s responsibility, as well as the treating physicians, to ensure that no one is paid or coerced to donate. For practical purposes, this is impossible to establish unless the donor is a relative of the patient. The blood group of the donor must be compatible with that of the patient.

The following combinations are feasible:

From the above table, it is clear that ‘O’ blood group people are universal donors & ‘AB’ blood group people are universal recipients.

After establishing that the blood groups are compatible, a detailed history and physical examination is performed to establish that the donor does not have a medical condition that would increase the risk of surgery. For example, mild hypertension controlled with a single antihypertensive or with a low salt diet would not be a contraindication but sustained hypertension with a hypertrophied left ventricle and peripheral vascular disease would be. Similarly early diabetes controlled with diet, exercise and perhaps an oral hypoglycemic drug would not be a problem but long standing diabetes with retinopathy and nephropathy would be.

Next some basic blood tests are done. These include confirmation of the blood group, blood counts, liver and kidney function tests and tests for hepatitis B and C and HIV. A CT scan of the abdomen without contrast is done next. The LAI (Liver Attenuation Index) is used to estimate the extent of steatosis in the liver. If the CT shows a normal liver, we proceed to perform a contrast enhanced triphasic CT of the liver. This allows us to measure the liver (CT volumetry is done using specialized software). This allows us to decide which part of the liver to remove for transplant. As a general rule, the portion of the liver transplanted should be at least 0.8% of the body weight of the patient and the portion left behind should be at least 30% of the original liver volume. It is normally safe to remove up to 75% of the liver but we keep a margin of safety for the donor. The triphasic CT also demonstrates the vascular anatomy of the liver nicely and allows us to assess that the operation can be safely done leaving both the graft and the remnant with an arterial and portal venous supply, good venous drainage and bile duct suitable for reconstruction.

Subsequent tests are performed to assess the fitness of the donor to undergo surgery safely. This includes assessment by a Cardiologist, Pulmonologist, Psychiatrist, Gynecologist (for female donors), Hepatologist and Anesthetist. A multidisciplinary meeting is held and once there is unanimity regarding the need for transplant and the safety of the operation for patient and donor, the request for permission to perform the transplant is submitted to the authorization committee.

The operation

The patient is admitted 2 days before the transplant (if not already admitted) and the donor, the day before the transplant.

The donor surgery takes about 4-6 hours and involves resecting the right lobe with its vital structures (the right hepatic artery, right portal vein, right hepatic duct , right hepatic vein and in majority of the cases the middle hepatic vein). All the structures are looped and kept ready to cut in order to proceed with right lobe donation.

At the same time, the recipient team will remove the entire diseased liver and preserve the vital structures. (The right and left hepatic artery, main portal vein, the openings of the right, middle and left hepatic veins and the common hepatic duct). Once both the teams are ready, the donor liver (right lobe) is removed. It is then flushed with cold preservative solution and the structures are re-constructed on the ‘backbench”. It is packed in ice. This is the beginning of the cold ischaemia time.

Once the recipient liver (diseased) liver is out, the rejoining process of the donor right lobe structure to the recipient structures is commenced. It takes about 30- 60 mins for this procedure .The donor liver is removed from the ice bag. (end of cold ischaemia and beginning of warm ischaemia phase) The donor RHV and MHV is connected to patient inferior vena cava; the donor right portal vein to patients main portal vein. At this stage blood circulation is re-commenced via the portal vein (end of warm ischaemia phase). The artery and bile duct is then re-constructed.

Post-operative recovery

Both the recipient and the donor are shifted to the Intensive care unit (ICU). The donor is admitted to ICU for 1 day and then shifted to the wards for 4-5 days. (average stay for donor is 5-7 days)

The recipient stays in the ICU for 4-5 days and then shifted to the wards for 5-13 days. (average stay for recipient is 10-21 days)

As the end of the summer approaches, back-to-school time is top of mind for many parents. One of the most important ways to ensure a successful school year is to make your child’s sight a priority. To help raise awareness, Prevent Blindness has declared August as Children’s Eye Health and Safety Awareness month.

Lazy Eye (Amblyopia):

Lazy eye, also called Amblyopia, is decreased vision that results from abnormal visual development in infancy and early childhood and is the leading cause of decreased vision among children. This condition develops when nerve pathways between the brain and the eye aren’t properly stimulated. As a result, the brain favors one eye, usually due to poor vision in the other eye causing the brain to ignore signals from the other eye. Treatment includes eye patches, eyedrops, and glasses or contacts, or sometimes surgical treatment.

Crossed Eyes (Strabismus)

Crossed eyes, also called strabismus, is a condition in which your eyes do not line up properly. If your child has this disorder, his or her eyes would look in different directions, with each eye focusing on a different object. It is very common, affecting four percent of children age 6 and younger. Nobody knows why some children are born with this condition, but it does tend to run in families. Crossed eyes can usually be corrected with eyeglasses and/or surgery.

Sports Safety

Eye injuries are the leading cause of blindness in children in India and most of those injuries are sports-related. Protective eyewear is the key to sports eye safety as ninety percent of sports-related eye injuries can be avoided with the use of protective eyewear. Even if your child’s sports league does not require eyewear, you as a parent have a right to insist on protecting your child’s eyesight.

Good vision is key to a child’s physical development, school success and well-being. By setting up a comprehensive eye exam for your child this month, you can get them on the right track for a happy and healthy school year.

13th August is observed every year as World Organ Donation Day. NGOs, hospitals, health professionals globally spread the message of the importance of organ donation.

What is an Organ Donation?

This is the process of surgically removing an organ or tissue from one person (the organ donor) and placing it into another person (the recipient). Transplantation is necessary because the recipient’s organ has failed or has been damaged by disease or injury.

Types of Organ Donation:

This is divided into two categories:

Living Donation: A living donation takes place when a living person donates an organ (or part of an organ) for transplant to another person. The living donor can be a family member, such as a parent, child, grandparent  or grandchild, brother or sister, (living related donation). It can also come from someone who is emotionally related to the recipient, such as a good friend, a relative, a neighbour or an in-law (living unrelated donation).

Deceased Cadaver Donation: In this the patient has to register in a hospital that does transplants. The patient will be put on a wait list and as and when the organ is available from an appropriate deceased donor (brain dead) the patient will be informed.

What Can be Donated:

• Deceased organ donors can donate kidneys, liver, lungs, heart, pancreas, intestines can be donated.
• Tissue donation refers to a process by which a deceased person donates parts of his/her body (e.g., skin, heart valves, ligaments, bones, veins, corneas, etc.) for use in transplant procedures in order to repair various defects, injuries, and so forth.
• Blood Stem cells, cord blood, and Bone Marrow is also donated. In order for this to be successful the patient and the blood stem cell donor must have a closely matched tissue type  or human leukocyte antigen (HLA).

Organ Donation and India:

The organ donation numbers of India are extremely poor as with over 5 lakh people die every year in India awaiting an organ transplant. This is especially unfortunate given the fact that an organ donor can help save up to 8 lives.

Sadly the lack of awareness, incorrect information and various myths leads to very few signing up for Organ Donation. Despite India being the world’s second most populous country, it has a deceased organ donation rate of just 0.26 per million population.

Organ Donation, Some Facts:

• In India, organ donations are legal under the Transplantation of Human Organs Act (THOA), 1994, that also legalises the concept of ‘brain death’, a permanent cessation of all brain functions.
• In brain death, a person cannot sustain life, but vital body functions can be maintained in an ICU. Such patients are kept on artificial life support so that the organs are in a healthy condition.
• Brain death is not the same as coma, which is a state of deep unconsciousness where the brain continues to function without external help. 
• In India, a panel of doctors examines the and conducts a series of tests before declaring the patient as brain dead.

Who Can Donate an Organ?

• Organ donation can be done irrespective of age.
• For organ donation after death, a medical assessment will be done to determine what organs can be donated. 
• Most medical conditions allow an organ donation, however the doctor takes the final call.
• Certain conditions, such as having HIV, actively spreading cancer, or severe infection would exclude organ donation.

Inform Your Family

As per law, organ and tissue donation cannot take place in India without the written consent of the donor’s family. Therefore, donors should help their families understand the reason behind their decision to be an organ donor. Timely intimation is required for your family to take the right decision in your absence. Even if you have pledges your organs, the hospital cannot take any action unless your family gives their consent. Hence it is important to discuss your wish to donate with your family. This is to enable your family to carry out your wishes in case the need arises.

Take a step further towards organ donation, pledge to donate your organs today. This is the noblest decision which helps humanity. Please visit the below website for more details on Organ Donation:  www.organdonationday.in