KIDNEY TRANSPLANTATION – PRESENT SCENARIO


Dr. Georgy K. Nainan D. M. , F.I.S.N.
Sr. Consultant Nephrologist PVSM &
Lakeshore Hospitals, Cochin.

 

Chronic Kidney Disease (CKD) necessitates Renal Replacement Therapy (RRT). The main causes in our state are unresolved / undiagonised childhood nephritis especially IgA Nephropathy, (30 %), Diabetic Kidney disease (40%) and the rest is due to systemic diseases like hypertension, stones, urinary infection, ischemiato kidmey & long term use of drugs harmful to kidneys. The quality of life of a transplanted patient after successful transplantation is better than that of a chronic
renal failure patient on haemodialysis or of an CAPD (Continuous Ambulatory Peritoneal Dialysis) patient. In busy units, patients receiving multiple blood transfusions and on prolonged dialysis, the incidence of hepatitis B and C is high. This increases the waiting period for transplantation, post operative morbidity and mortality. Incidence of hepatitis B in India is @ 10% and hepatitis C is 8-15% in dialysis units. Hepatitis B is a preventable disease with adequate vaccination, where as there is no vaccination for hepatitis C. Successful kidney transplantation is the only permanent cure for advanced renal failure and is very appropriate for a developing country. We have three types of kidney donors: 1) Live related (1st degree relatives): Between parents and Children, siblings and spouse. 2) Live unrelated donor:- An altruistic donor, for whom permission has to be obtained from the authorisation committee, Govt of Kerala 3) Kidney from the brain dead patients (Cadaver Kidney transplantation). The donor is evaluated for physical and mental fitness and made sure that he doesn’t have Hepatitis B, Hepatitis C, AIDS and other transmittable diseases. Simultaneously recipient is also made fit for surgery by correcting the anaemia with I / V Iron Sucrose & Erythropoetin, controlling uraemia with regular adequate dialysis and controlling blood pressure with fluid removal. If there is good Tissue matching, transplantation is performed. Usually the left kidney of the donor is transplanted to the right iliac fossa just above the urinary bladder. Renal artery is anastamosed to the iliac artery and renal vein anastamosed to the iliac vein. Ureter is implanted in the urinary bladder. Immuno suppressive medicines are used to prevent the rejection of the transplanted kidney and they are continued indefinitely. The dose of immunosupressive medicines, to a great extent is decided by the matching, basic disease of the recipient, co- morbid state & rejection tendency. The surgery takes five to six hours and patient needs post operative hospital stay of two weeks. The long term results of the transplantation will be decided by the matching of the kidney, rejection tendency by the recipient, dose and types of immunosuppressives used and the co-morbid conditions like diabetes, heart diseases etc. To regularize transplantation activities, Indian Organ Act 1994 was passed in the legislative assembly of each state. This act has defined organ transplantation criteria and registration is given only to hospitals having adequate facilities. “Brain Death’” is a stage where the brain does not function, there is no spontaneous breathing and the patient is on respiratory support. The heart is beating, blood pressure is maintained and kidneys are working producing more than 50 ml/hr urine. However, with disconnection of the respirator, life will stop and death will have to be declared. Anyone sustaining severe road accidents or intracerebral bleeding due to hypertension or other causes can go into this stage. Indian Organ Act, 1994 has defined brain death and hospital with adequate facilities are given registration to retrieve and transplant organs from brain dead patients to suitable recipients. A brain death committee at Cochin approved by the Government of Kerala, comprises of a panel of 8 doctors – 4 from specialists of neurosciences and 4 registered medical practitioners. Our aim should be to try and save any critically ill even if they come in severe coma state. They should be given adequate ventilatory support to prevent hypoxia and lifeline
support to sustain life. In case of brain death prompt declaration of brain death is needed. Once the family accepts brain death and decides to take the body after disconnecting the respirator (a point of no hope!), motivate them to donate organs. Since we have no National registry, regional societies with a “give and take” attitude should be necessary to encourage and motivate them to donate organs and increase the awareness. Society for Organ Retrieval and Transplantation (SORT – COCHIN) is a voluntary society in Cochin formed by people with social standing and doctors interested in the field of transplantation who would like to promote awareness about organ transplantation. In Kerala transplantation is mainly done in the private sector. Our team has done @ 750 transplantations at Cochin of which 7 are from brain dead (cadaver transplantation). The success rate of transplantation is around 90 - 95% in good centers. Laproscopic Donor Nephrectomy
(LDN) introduced in 1992 is gaining momentum. The advent and the widespread application of minimally invasive endoscopic techniques in the last decade is perhaps the most significant technological advancement in surgical technique in the 20th Century. The use of laproscopic techniques to remove the donor kidney for transplantation is an appealing cause in the donor who is an entirely healthy individual. The decreased postoperative discomfort and morbidity and the better cosmetic result that this procedures affords, are rewards for such an altruistic act, which he rightfully deserves. After all the wounds will heal but the scar remains. Laproscopic Donor Nephrectomy with a small scar has stimulated near relatives to donate a kidney to their next of kin. Newer Immunosupressives like Tacrolimus, Sirolimus Monoclonal antibodies to block the acute rejection have improved the results of transplanted kidney. Post transplant Diabetes continues to be a problem
along with the infections like Tuberculosis, cytomegalo virus, bacterial infections especially U T I and peripheral vascular disease in Diabetics. In this stage where information and technology are easily available, kidney transplantation especially Cadaver kidney transplantation is an area where we members of the medical fraternity have to put in more efforts and to cooperate closely. I am sure that in the coming years more successful renal and other organ transplantations from brain dead patients will take place.

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