Renal Transplantation
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BMJ 2011;343:d7300 doi: 10.1136/bmj.d7300 (Published 14 November 2011) Page 1 of 8 Clinical Review CLINICAL REVIEW Renal transplantation 1 Paul T R Thiruchelvam specialist registrar general surgery , Michelle Willicombe specialist registrar 2 2 nephrology , Nadey Hakim surgical director department of transplant surgery , David Taube professor 2 of transplant medicine , Vassilios Papalois consultant transplant and general surgeon, chief of service 2 1North West Thames, Department of Transplant Surgery, Imperial College Renal and Transplant Centre, Hammersmith Hospital, London W12 0NN, UK; 2Imperial College Renal and Transplant Centre, Hammersmith Hospital, London Epidemiological data from the past decade suggest that the Patients should have access to transplantation if they are global burden of patients with renal failure who receive renal medically fit for surgery. Ineligible patients will remain on long replacement therapy exceeds 1.4 million and that this figure is term dialysis. Patients who are awaiting a kidney transplant will growing by about 8% a year.1 2 The UK renal registry from 2009 be regularly reassessed. About 5% of patients are removed from estimated that over 47 000 people received renal replacement the transplant list each year, typically because they are deemed therapy in the UK.3 Renal transplantation increases survival and too unwell for transplant.7 improves the quality of life for patients with end stage renal 4 5 Pre-emptive kidney transplantation is transplantation before the failure. A recent UK estimate found that transplantation need for maintenance dialysis arises. It is the treatment of choice conferred a cost saving of £25 000 (€29 000; $40 000) a year 6 in patients nearing renal replacement therapy in both national per patient with end stage renal failure. In the UK rates of renal and international guidelines because pre-emptive kidney transplantation are increasing (fig 1⇓), and since 2006 the transplantation is associated with improved allograft and patient number of patients waiting more than five years for a transplant survival,9 12-16 reduced dialysis related cardiovascular morbidity has halved, but there are still a large number (about 7000) of 7 8 and sensitisation events, cost savings on dialysis, and better patients on the transplant waiting list (fig 1⇓). quality of life.17 In the UK in 2008 only 5.3% of the 6639 We review the process of selecting patients eligible for renal patients who met guideline criteria for kidney transplantation transplantation and the care of patients after renal transplantation received a pre-emptive transplant.3 Most pre-emptive transplants for the primary care physician. This article is based on evidence are living donations. If no suitable living donor can be found from large registries, case series, clinical trials where available, patients are placed on the deceased donor waiting list when their and national guidelines. glomerular filtration rate falls below the cut-off value. Patients Who is eligible for a kidney transplant? with type 1 diabetes should also be listed for a simultaneous kidney-pancreas transplant. Guidelines recommend that all patients with chronic kidney disease at stage 5 or stage 4 (glomerular filtration rates <15 How are donor kidneys sourced? mL/min and 15-30 mL/min respectively) with progressive disease likely to require renal replacement therapy within six Brain or cardiac death donors 9 10 months should be considered for transplantation. The mean Most transplanted kidneys in the past four decades have come estimated glomerular filtration rate of patients starting renal from “donation after brain death” donors. However the number 11 replacement therapy is 8.6 mL/min/1.73 m². A minority of of kidneys derived from “donation after cardiac death” donors patients with end stage renal failure are deemed unsuitable for has increased in recent years in the UK and comprised 34% transplantation. Absolute contraindications to transplantation (n=567) of all deceased donor kidney transplants in 2010-1 are few, but include untreated malignancy, active infection, compared with 66% (n=1100) from “donation after brain death” untreated HIV infection or AIDS, or any condition where life donors.7 Kidneys transplanted from “donation after cardiac 9 10 expectancy is under two years. Relative contraindications death” donors have a longer warm ischaemia time and higher and special considerations for transplantation are listed in box rates of both delayed graft function and primary non-function 1 and discussed in detail in the web extra appendix on bmj.com. but similar long term patient outcomes and graft survival.18 Correspondence to: P T R Thiruchelvam [email protected] Extra material supplied by the author: how kidneys are allocated for transplantation in the UK, special considerations for transplantation, and ethical issues in transplantation (see http://www.bmj.com/content/343/bmj.d7300/suppl/DC1) For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2011;343:d7300 doi: 10.1136/bmj.d7300 (Published 14 November 2011) Page 2 of 8 CLINICAL REVIEW Summary points The global burden of end stage renal disease is increasing Renal transplantation increases patient survival and quality of life and reduces costs of care for patients with end stage renal disease Most donor kidneys come from “brain death” or “cardiac death” donors, but donations from living donors are increasing Pre-emptive transplantation from a living donor is the best treatment choice for patients with end stage renal disease and has been associated with improved allograft and patient survival Long term outcomes in kidney transplantation are improving Sources and selection criteria We searched PubMed, the Cochrane Database, and ScienceDirect using the key words “kidney transplantation.” The search was limited to those journals published in the English language. The data were mainly derived from large registry descriptions, multiple case series, and clinical trials. We have combined our knowledge with that of recently published guidelines and reviews identified by the previously mentioned PubMed searches on kidney transplantation. Box 1: Relative contraindications to transplantation • Comorbid condition • Age >65 years • Untreated coronary artery disease • Obesity • HIV infection • Previous malignancy • Chronic hepatitis B or C Living donors described, but in the absence of a correlation between protein Living donor transplantation has also increased over the past excretion and blood pressure or renal function, the clinical importance of this finding is unclear.22 Long term outcomes of decade, with one in three transplants in the UK now from a 23 living donor.7 Living donor kidney transplantation has reduced uninephrectomy have found no major adverse consequences. the gap between demand and supply of kidneys. Donors include The lifespan of a kidney donor seems to be similar to that for the general population of similar age, and there is no increased those who are genetically related to the recipient or emotionally 24 25 related (such as spouse, partner, or close friend). A long term risk of developing end stage renal disease. series from the US found that living transplants are associated with reduced rates of delayed graft function and better allograft How is a patient with renal disease and patient survival.19 The United Network for Organ Sharing prepared for transplant surgery? (UNOS) reports five year allograft survival of 79.9% for living donor kidneys compared with 66.5% for deceased donor Patients are counselled about the risks of surgery and the risks, kidneys. With improvements in surgical nephrectomy techniques complications, and side effects of immunosuppressive therapy. (laparoscopic and mini-open donor), reduced postoperative pain, Patients must be clearly informed about their mortality risk, shorter hospital stay, and faster return to work, living donation rates of graft survival, and the potential impact of transplantation has become more acceptable.20 More complex procedures with on their employment activities. Explaining the potential risk of living donors are now being considered in certain centres, such recurrent kidney disease in an allograft is also important. as transplantation from obese donors with a body mass index Individual risks may change with the length of time that a person >35 and from older donors and transplants with multiple vessels. waits for a procedure, and patients may need repeated re-evaluation and counselling. A “matched pair donation” scheme exists whereby a relative, friend, or partner of a potential recipient can donate an It is important to remember that the mean age of patients starting incompatible organ by being matched with another incompatible renal replacement therapy is 64 years. Patients require a full donor-recipient pair, enabling both people in need of a transplant cardiac and respiratory assessment, including an assessment for to receive a compatible organ. Pooled donation is a form of the presence of peripheral vascular disease. A formal urological matched pair donation involving more than two living donor assessment is done (ultrasound, voiding cystourethrogram, pairs. Altruistic non-directed donation occurs when a kidney is cystoscopy) to exclude pre-existing disease that may donated by a healthy person who does not have a relationship compromise the function of the graft, such as bladder outflow with the recipient and is not informed who the recipient