Kidney Transplant: Before the surgery – I


Kidney transplant 

Every patient with End Stage Renal Disease (ESRD) or in other words, Kidney failure needs to go on treatments that would “fill the gaps” in the errant functioning of the unwell kidney or completely replace it with healthy functioning. Dialysis is a way to fill the gaps while a Kidney Transplant is a complete replacement.

In our previous article, we explained the bare basics of a Kidney Transplant.

This article covers an outline of what an average pre-transplant preparation for the patient and the kidney donor may entail.


Contents

1. Finding a matched kidney donor

2. What-why-how of cross matching & tissue typing

3. Pre-transplant testing to assess donor fitness

4. Pre-transplant testing of patient & assessment of general fitness for surgery

5. In-camera donor consent (in select nations only)



 

I. FINDING A MATCHED KIDNEY DONOR

The one thing that is the pivot of the entire transplant procedure is finding a matched & willing kidney donor. No amount of medical care, clinical infrastructure, social support or legal assistance can help you get a life-saving transplant surgery unless a medically fit kidney donor is available.

However, with organ donor shortage a grim reality, finding a matched & willing Kidney donor (Live/Deceased) takes both time & effort.

But understanding the procedure & knowing your options can make your search for a donor, a lot less stressful than otherwise.

Here’s a brief rundown on how to approach the situation:

1. FAMILY FIRST

Talk to family members, friends & acquaintances about your need for a healthy kidney to survive and how a kidney donation from a willing, matched relative could be their ultimate gift of life to you.

2. GO CREATIVE!

If you reside in a country where altruistic living donation from non-relatives is legally permitted, get creative with your outreach for a healthy, willing donor! Consider reaching out on social media/public platforms to maximize your search for a blood group matched kidney donor from your country.

3. REGISTER FOR PAIRED DONATION / CHAIN DONATION PROGRAMMES

If you are on the deceased donor transplant list, your transplant centre may carry out an “antigen sensitivity test” to determine how easily you may find a matched kidney from a deceased donor as and when available.

This is called a “Panel Reactive Antibodies” or PRA test:

🟠 Here, your blood sample is made to interact with a “panel” of blood samples from potential kidney donors registered with the transplant centre. This is to look for any unfavourable “immunological” reactions between your blood sample and the randomly selected donor samples in the panel.

🟠 The “percentage” of samples that give an unfavourable reaction is your PRA value.

🟠 If your PRA value comes out above 80%, it means immune cells in your blood sample reacted unfavourably with over 80% of donor samples in the panel.

In other words, you are highly sensitive to kidneys that may come to you from the local registered donor pool. So, finding a properly matched donor in the registered local donor pool may be difficult for you.

🟠 In such a situation, ask your transplant co-ordinator to register you for a Paired organ transplant/Chain donation initiative.

 

Paired Donation

Here, if the available registered local donor pool is found to have a match with a kidney patient in another jurisdiction where, in turn, a matched donor is available for you, donors in both these places can go for a “swap arrangement” or let’s say, a “give and take arrangement”.

Kidney transplant paired donation

 

Chain Donation

Sometimes, the entry of an independent kidney donor can initiate a cascade of 3 or more “out-of-centre” matched kidney donations simultaneously. This is such that donors from each place have a corresponding transplant patient match in another place. Then, the system works as a “Chain donation” as illustrated below:

Kidney transplant chain donation



 

II. WHAT-WHY-HOW OF “CROSS MATCHING & TISSUE TYPING”

Amid all the talk of finding a “matched donor” for a kidney transplant, many of you must be wondering as to what is it that you need to match?

Let’s give you a brief context here.

If you consider the human body as a country, it is strictly guarded by the military and immigration officials of your Immune System. NOTHING that does not naturally belong within the body can make its way in without “proper checks” by our immune system.

So, how does your immune system recognize what’s “self” and what’s “non-self”?

This becomes possible with the help of unique, tiny chemical patterns and surface proteins present on each cell which differ in part from person to person.

Your immune system is kind towards patterns that most closely resemble “self” while it diligently mounts an immune “attack” to effectively reject and eliminate any pattern or protein arrangement that appears “non-self”.

By this very logic, organ transplantation requires donors whose organs have “favourable chemical and protein signatures” that closely match that of the patient. Else, the patient’s body will reject the organ and the transplant surgery will go in vain. A simple blood test can help your medical team assess if a potential organ donor is a good match.

 

Generally, the following factors would chiefly determine the suitability of an organ for transplant:-

1. BLOOD GROUP (ABO compatibility)

There are 4 major blood group types in humans, namely A, B, AB & O. Based on whether blood cells with these blood groups contain a special protein called “Rh factor” on their surface or not, a ‘+’ (positive) or ‘-‘ (negative) sign is added with these groups.

For instance, if someone says their blood group is A+, their blood type is ‘A’ and they contain Rh factor on their surface. Similarly, a blood group of B- represents a blood type ‘B’ without any Rh factor on their surface.

Please understand that preferably, a kidney donor and a kidney patient should have the same blood group. This is to increase the chances of a successful transplant outcome.

An organ from a donor with the same blood group (known as ABO compatible transplants) settles in more easily within the patient’s body over donors with other blood groups (called ABO incompatible transplants).

To understand why, go through the next point.

 

2. A FAVOURABLE TISSUE TYPING / HLA TYPING

How well a donor organ matches with the patient’s body is determined by doing what is called a “HLA typing”.

Kidney transplant HLA typing

HLA stands for Human Leukocyte Antigen. It is a group of proteins present on most cells of the body that are unique to one person.

HLA typing compares specific genes (coded by number combinations for easy reference) from the respective HLAs between the donor and recipient.

There are six sets of such numbers that are studied from the blood samples of both the prospective donor and the patient.

 

🟠 For Live-related donor (blood relation i.e. parents, siblings, children):

Here, if at least 3 sets of gene numbers match, and the prospective donor meets all health criteria for the surgery, the transplant team will agree to go ahead.

🟠 In unrelated donors (live or unrelated deceased donor)

The transplant team prefers a match between at least 4 or 5 sets of gene numbers along with absence of any systemic disorder such as hypertension or Diabetes mellitus in the donor.

The more closely the HLA matches, better would be the transplant outcome. A donor with the same blood group would lead you one step closer to a favourable HLA typing.

 

However that does not mean ABO incompatible (unmatched blood group) transplants do not succeed.

The table below shows all patient blood groups (both matched & unmatched), a kidney donor with one of the major blood groups can possibly donate to:

 

Donor blood groupPatient blood groups that can be donated to
AA, AB
BB, AB
ABAB
OA, B, AB, O

 

It’s all about matching the gene numbers, getting a healthy organ, good post-transplant care by your doctor & responsible self-care.



 

III. PRE-TRANSPLANT SCREENING TO ASSESS DONOR FITNESS

Irrespective of whether it has affected the donor’s kidney or not, it is preferable that the donor be free from conditions like Hypertension (High BP), Diabetes mellitus, any immune system disorder or active infections. This is crucial to ensure a better transplant outcome for the recipient.

This is precisely where living donation scores better than deceased (after death) donations. That is because in deceased donations:

❗ There is less control over who the donor is or deciding by their past disease/infection history.

❗ Less time to screen the donor kidney properly because there is a window of a few hours after brain-death of the donor, within which the transplant needs to be carried out.

If the surgery is not carried out within that time-frame, the cadaver kidney will start losing its ability to function well after transplant.

 

So, once an HLA-matched donor is found & confirmed on the patient’s end, he/she needs to undergo intensive medical testing to:

✅ Check their general health status to rule out any concerning systemic illness

✅ Assess how fit they are to endure major surgery under general anaesthesia

 

The list below mentions the tests that every kidney donor needs to undergo as part of pre-transplant checks.

NOTE: There may be minor variations based on in-centre protocols in different countries, but the basic outline remains the same.

 

🔴 BLOOD

1. ABO grouping-Rh typing (Blood grouping is the first step to assign the donor for matching with a suitable recipient)

2. Complete Blood Count (Haematological system)

3. Electrolytes (to check for mineral imbalances)

4. Renal Function Test (baseline kidney function)

5. Liver Function Test (liver abnormalities adversely impact the ability to process anaesthesia or post-transplant meds, so assessing the liver is necessary)

6. Coagulation profile (A blood clotting mechanism is necessary before any major surgery)

7. Lipid profile (Cholesterol levels and heart health)

8. Blood glucose profile – FBS-PPBS-HbA1c (To assess if the donor is Diabetic or not)

9. Exocrine pancreas for pancreatitis

10. HTLV-1, HTLV-2 (to rule out HIV infection)

11. HBsAg (Hepatitis B viral traces)

12. CMV titre (Cytomegalovirus viral activity)

13. VDRL (to check for Syphilis – a venereal disease)

 

🔴 URINE

1. Urine Routine Examination

2. Urine Albumin-Creatinine Ratio (ACR)

3. 24-hr Urine Protein

4. Urine for Culture & Sensitivity (to check for urinary tract infection)

 

🔴 IMAGING SCANS

NON-INVASIVE

1. Chest X-Ray (Lungs & Heart health)

2. Echocardiography (Heart pumping status)

3. Ultrasound Scan Whole Abdomen & Kidney-Ureter-Bladder (KUB) region

4. Plain Helical CT scan (to look for abnormalities in the kidney tissue mass, like cysts, tumours etc.)

 

MINIMALLY INVASIVE

1. Renal Angiogram (This is like an X-ray where a dye is injected to look for health of blood vessels going to, coming out of & those within the kidneys)

2. IVP (In this test, a dye is injected to look for any abnormalities in the structure of your urine forming tubes within kidneys)

 

🔴 OTHERS

1. ECG (Heart function)

2. Gynaecological evaluation (Vaginal fluid Cytology/histopathology) (For female donors)

3. Psychological Evaluation: In most settings, donors will undergo psychological evaluation. The purpose is to:

◾Provide information & emotional support to the donor

◾Assess how motivated the donor is

◾Evaluate if the kidney donation is altruistic or driven by family pressure or financial incentives. ◾Facilitate the donor to express himself / herself more fully than she may be able to, before the physician, or with the recipient or family present

◾Help the transplant coordinator & support staff work with the donor and family before and after surgery.

◾If, at any point in the process, the potential donor does not want to donate, the transplant team can help the donor decline in a sensitive manner such that family relationships stay preserved.



 

IV. PRE-TRANSPLANT SCREENING OF PATIENT AND ASSESSMENT OF GENERAL FITNESS FOR SURGERY

Just like the donor, it is of paramount importance that patients with kidney failure are thoroughly assessed for their fitness to endure a long, major surgery & anaesthesia. If found unfit for surgery, kidney patients will be advised to stay on Dialysis for life.

The list below mentions the tests that every kidney patient needs to undergo as part of pre-transplant checks.

NOTE: There may be minor variations based on in-centre protocols in different countries, but the basic outline remains the same.

 

🔴 BLOOD

1. ABO grouping-Rh typing (Blood grouping is the first step to match with a suitable kidney donor)

2. Complete Blood Count (Haematological system)

3. Electrolytes (to check for mineral imbalances)

4. Renal Function Test (baseline kidney function) 

5. Liver Function Test (liver abnormalities adversely impact the ability to process anaesthesia or post-transplant meds, so assessing the liver is necessary)

6. Coagulation profile (A blood clotting mechanism is necessary before any major surgery)

7. Lipid profile (Cholesterol levels and heart health)

8. Blood glucose profile – FBS-PPBS-HbA1c (To assess if the donor is Diabetic or not)

9. Exocrine pancreas for pancreatitis

10. HTLV-1, HTLV-2 (to rule out HIV infection)

11. HBsAg (Hepatitis B viral traces)

12. CMV titre (Cytomegalovirus viral activity)

13. VDRL (to check for Syphilis – a venereal disease)

 

🔴 URINE

1. Urine Routine Examination (URE)

2. Urine Albumin-Creatinine Ratio (ACR)

3. 24-hr Urine Protein Estimation

4. Urine for Culture & Sensitivity (to check for urinary tract infection)

 

🔴 IMAGING SCANS

NON-INVASIVE

1. Chest X-Ray (Lungs & Heart health)

2. Echocardiography (Heart pumping status)

3. Ultrasound Scan Whole Abdomen & Kidney-Ureter-Bladder (KUB) region (to estimate the size of diseased kidneys and assess the health of abdominal organs around diseased kidneys)

4. Renal Doppler Scan (to look for the health of larger blood vessels in your lower abdomen. Necessary for transplant surgeons to find the best location to surgically attach the donor kidney to)

 

🔴 OTHERS

1. ECG (Heart function)

2. Gynaecological evaluation (Vaginal fluid Cytology/histopathology) (For adult female patients)

 

🔴 PRE-TRANSPLANT VACCINE COVER FOR RECIPIENT

1. It is essential for your medical team to record all your past and present viral infections, ask your prior vaccination history & assess viral titres (HbsAg, CMV, BK virus etc.)

2. Infections, especially those from viruses can grossly interfere with the success of the transplant procedure.



 


 

V. IN-CAMERA DONOR CONSENT (IN SELECT NATIONS)

🟠 This step may or may not be applicable to you based on your transplant centre protocol.

🟠 It is to ensure that the donor has consented for transplant after fully understanding the possible short-term & long-term complications that may potentially arise after kidney donation.

🟠Also serves as a solid evidence in case bogus litigation is pursued on behalf of the willing donor against the transplant centre at a later date.

 

 

So, this was a comprehensive insight of all the steps that every kidney patient waiting for a transplant and their prospective donor need to undergo, before getting “under the knife”.

In some countries like India, there are additional legal approvals necessary for getting clearance for the transplant surgery. We will write about it in detail separately.

Keep a tab of this space for our next guide in the series on “what to expect after hospital admission up until actually getting the transplant.”

Till then, stay vigilant & informed.

 


 

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