Information on transplants

Who can have a transplant?

Although renal transplantation is the preferred method of treatment for many patients with end stage renal failure, only 20-30% are suitable.

There are several reasons why an individual may fit into this category. If you do the renal transplant surgeon will refer you back to your consultant nephrologists to discuss with you further.

Where do kidneys come from?

Living donor kidneys

• Live - this is a direct donation generally from a relative, friend, spouse, sibling or altruistic donor, who donates one of their healthy kidneys to you
• Live unrelated - A live donated kidney does not have to be blood group compatible. Incompatible live donors can be used if a willing compatible donor cannot be found. This can occur if the donor/recipient is blood-group incompatible (ABOI). 95% that are straight forward living donor kidneys, will be working after one year
• Deceased (cadaveric kidney) - This is from someone who has died and during their life expressed a wish to become an organ donor at the time of their death. Ideally with consent from their next of kin

Marginal kidneys

Some donor card kidneys will come from an individual who has suffered with health problems that may have affected their kidneys. If it is felt that a donor kidney is available for you and would have a decreased chance of working, this is something that will be discussed with you prior to the operation.

How do I get a kidney?

There is no age restriction to receive a kidney transplant as each person is assessed individually. However in order to receive a transplant kidney, we need to ensure you are fit enough for the operation.

You will need various cardiac (heart) investigations to be carried out to assess your suitability. You should ideally have a body mass index (BMI) of less than 35 and you will be advised to stop smoking as this can damage your blood vessels, making the operation more risky.

Once the surgeon has agreed your suitability for receiving a transplant you will have some bloods taken for testing.

To receive a deceased donor kidney you are registered with ODT on the transplant waiting list. Kidney donation is based on a best match with your blood group, tissue type, age and duration. Therefore the time on the waiting list is like a lottery ticket, with the average waiting time for a transplant being three to four years. As tissue matching is more difficult for people of non-white ethnicity, patients from these groups may need to wait longer for a kidney. It is important that during your wait for a kidney, you remain as healthy as possible.

To receive a live donor transplant, we need to assess those individuals willing to donate a kidney to you. This will be discussed with you when being assessed. The live donor team at QEHB or your local hospital will arrange some tests on any potential live donors. The donor will be given a health questionnaire to complete and contacted at a later stage with further information.

What happens when a suitable kidney has been found?

A transplant coordinator will call you as soon as a suitable kidney has been found for you. If you are hard of hearing or profoundly deaf, please discuss your options with the transplant coordinator.

You may be asked the following:

• What form of dialysis are you on (if any)?
• When did you last have dialysis?
• How am I going to get to the hospital?
• How long will it take you to travel to the hospital
• What will I need whilst in hospital?
• To bring a list of medications to the ward
• To have nothing to eat or drink (nil by mouth)
• Have you had any blood transfusions in the last year?
• Are you on Warfarin or Clopidogrel?

When you receive the phone call the transplant coordinator will ask you to come into hospital straight away and will advise you not to eat or drink at this stage. Please tell the transplant coordinator if you are currently unwell, have had any recent hospital admissions or if you suffer from any allergies.

Occasionally you can be called into hospital and the transplant may not go ahead. This may be due to several reasons and will be discussed with you further by the renal transplant surgeon.

What happens when I get to the hospital?

You will need to make your way to the transplant ward 305. A nurse will meet you there and you will need to have several tests carried out, such as an ECG, chest X-ray, and blood tests. You will then be examined by a doctor to check you are well enough for the transplant.

You may need to be dialysed, or if you are on CAPD (Continuous Ambulatory Peritoneal Dialysis), carry out some quick bag exchanges. You will need to drain out before the operation.

You may be asked to participate in a clinical drug trial. This is usually to trial new medication for transplant patients or may involve new ways of taking existing medicines. Your doctor will explain these trials to you. You do not need to take part in these trials if you feel unhappy to do so.

Sometimes it is necessary to call you into hospital before a final blood test, called a cross match, is carried out. This may be because your antibody test is out of date. It is important whilst you are on the waiting list an antibody test is taken every three months. Please ask your dialysis nurses about this blood test when you are in clinic. If this test is positive you may be sent home.

The operation

The operation takes about two to three hours. The transplanted kidney is put into your right or left groin. It is placed here as it is close to your bladder, the surgeon will join up your blood vessels, to the new kidney, and the tube from the kidney (ureter) to your bladder. Your own kidneys will not be removed.

Whilst you are anaesthetised you will have several tubes placed in your body. You will have a tube placed into your bladder called a urinary catheter. This will drain out all the urine your new kidney will produce into a bag so it can be measured. This will be in place for three to five days.

You will have a tube from the operation site, called a redivac drain. This will remove blood or fluid after the operation and will be in for approximately three days.

You will have a central line put into one of the blood vessels in your neck. This is so the nursing staff can measure your fluid balance very accurately after the operation. It can also be used to attach pain killing drugs and a fluid drip.

You will be given a pain control device (PCA or Patient Controlled Analgesia). This is a hand held device with which you can deliver a dose of painkillers yourself as required.

Sometimes a small tube (stent) will be inserted into the ureter of the new kidney. This is to help the kidney drain and prevent kinking of the ureter. This stent is removed approximately six weeks after your transplant.

Complications

Rejection

Rejection can occur at any time even though you are taking your anti-rejection medication to stop your body fighting your new transplant kidney. Most often rejection occurs in the first few weeks after the transplant but can also occur months or years later. 15% of all patients experience some form of rejection which is treated with extra anti-rejection medication.

Delayed graft function

This is when the transplanted kidney does not work straight away despite having a good blood flow. This is common in four out of ten donor card kidneys but uncommon in live donor kidneys. If a kidney does not work straight away, it usually recovers after a few weeks from the transplant date and the individual may require additional dialysis support during this time.

Hypertension (high blood pressure)

This is common post-transplant and medication will be prescribed to control this.

Infections

All anti-rejection medicines will reduce your body’s natural defence mechanism to fight infection. There is a virus called CMV (Cytomegalovirus) which displays its symptoms as flu-like. So if you have been in contact with anyone with flu or displaying flu-like symptoms, it is important you contact the transplant team to do a blood test to check. You also need to be particularly careful to avoid contact with anyone with chickenpox especially if you have not had it yourself. Contact us straight away if this happens so that you can be assessed in the transplant follow-up clinic promptly.

After the operation

When you return to the ward your doctors and nurses will monitor you closely. You may experience some pain, so it is important that you tell your nurse if your pain is not controlled.

You will be encouraged to get out of bed the day after your transplant. This is to help prevent blood clots. It is advisable to bring in some loose clothing so that you can get dressed during your stay in hospital. You will usually be in hospital for about 7–10 days.

Whilst you are in hospital you will have blood taken every day to check your kidney function, full blood count and also to check that you are taking the right amount of anti-rejection medication. You will be given lots of new tablets and your nurse will explain what they are for and how and when to take them.

If your new kidney does not work straight away you may need an ultrasound scan or a biopsy. This will allow the doctors to be able to find out what is happening to it. A biopsy will show if there is any rejection in your transplanted kidney

Follow-up care

You will need to come back to the Queen Elizabeth Hospital Birmingham (QEHB) frequently in the early stages. This will be two to three times per week when you first go home. If you do not usually attend the Queen Elizabeth Hospital Birmingham you will be able to return to your regular hospital for further appointments about three to four months following your transplant.

Hospital transport is not provided after your transplant unless you have a medical problem that prevents you from using private or public transport. If you think you meet the eligibility criteria you will need to fill in a Transport Booking Form. You can obtain a form by contacting the Hospital Transport Department and asking the staff to post you a booking form or downloading a form from:

• Patient transport

The first few months following a transplant can be very difficult. This can be due to the frequency of clinic visits, new medicines, side effects of the medicines and changes to your lifestyle. Please discuss any problems you have when you come to clinic so that the team can provide any available help.

You will be given further information following your transplant. If you would like to see a copy of this before your transplant please call the department.

Pregnancy

Although women with advanced kidney disease or those on dialysis have reduced fertility, it is still possible to become pregnant. The success of pregnancy in women on dialysis is relatively poor and is generally felt to be not advised. Some of the drugs used to prevent rejection can cause developmental problems and birth defects with a growing baby.

As you are waiting for a transplant you should be using contraception.

This can be discussed with your nephrologists or family planning clinic or dialysis nurse.

The following contraceptive methods are recommended:

• condoms
• the mini pill
• the mirena coil (intra uterine contraceptive device)

We would generally advice against the combined (oestrogen containing) pill as it can increase your blood pressure and may cause an increase risks of clots in some dialysis patients.

If you are planning a family please discuss this with your nephrologists. You can then be referred to the combined kidney/Obstetric clinic for advice with your partner.

Menstrual bleeding

Menstrual problems is common amongst women with end stage renal failure (ERSF) who usually suffer from absence of their menstrual cycle (Amenorrhea) and experience irregular periods with scanty flow by the time they start dialysis.

Although a kidney transplant can restore and greatly improve the menstrual pattern in 49% of women, however irregular bleeding is still a major concern amongst those with a transplanted kidney.

Contacts

The transplant team

Renal transplant coordinators

• 0121 371 4433

Renal transplant ward 305

• 0121 371 3050

Renal transplant clinic

• 0121 371 4428
• 0121 371 4427

The renal transplant surgeons, Mr Steve Mellor, Mr Ahmed Hamsho, Mr Nicholas Inston, Mr Thomas Nieto, Mr Jonathan Ellis, Miss Clare Pattenden, Miss Melanie Field, Mr James Barnes, and Mr Dilan Dabare can be contacted via their secretaries through main hospital switchboard:

• 0121 371 2000