For many people transplantation is the best treatment option and will improve overall health. It does have risks however so it is important that everyone with kidney failure is carefully assessed to ensure transplantation is the right option for them.
Having a transplant involves an operation with general anaesthetic, and then requires the immune system to be suppressed by taking tablets in the long-term (to prevent rejection). For some people, with additional health problems, the risks of serious harm are too great to proceed with a transplant operation. Everyone with kidney failure is carefully assessed in the following three areas:
Suitability for general anaesthetic & surgery
People with kidney failure, particularly if they have spent time on dialysis, can also have heart disease and may require investigation to ensure the heart will be strong enough to withstand the operation. The risks associated with surgery are much greater in those who are very overweight, who smoker, and in people who are unfit. Others may have specific health problems such as those with have had a stroke, blood clots, or poorly controlled diabetes that makes complications more likely.
Some people will require only an X-ray of their chest and a heart tracing (ECG) while others will require several other tests and an assessment with a consultant anaesthetist before deciding if they are suitable for transplantation. Obviously it is possible that someone initially deemed unsuitable for surgery can be reconsidered e.g. with losing weight, stopping smoking, having consistently good dialysis and blood pressure control etc.
Suitability for transplant surgery
A kidney transplant is almost always placed in the pelvis near the bladder. From a technical perspective there are three main issues to consider:
- Space – people with cysts on their kidneys (polycystic kidney disease) can have very large kidneys and in some there is no physical space to place a new kidney. This is usually assessed by a CT scan and then a review by a transplant surgeon. If necessary they will be offered surgery to remove their own kidneys first, so that after a period of recuperation they can then have a transplant. Space can also be an issue for someone who has had more than one kidney transplant already (a previous transplant may need to come out), and sometimes tiny children have to grow before they are suitable to receive a transplant kidney.
- Bladder – it is essential that there is an adequate way to drain urine from the new kidney. Some people have kidney failure because of problems with their bladder and they need further assessment to ensure that the same issue will not happen again with a transplant kidney. In some cases this will involve surgery before transplantation.
- Blood vessels – ‘hardening of the arteries’ is common in people with long-term kidney failure, especially those who have been on dialysis for some time. This can be so severe that it is not possible to be able to attach and stitch in the blood vessels of a new kidney. Some individuals will require additional scans to assess this.
Suitability for immunosuppression
There are two main possible problems with suppressing the immune system by anti-rejection drugs.
- Infection – everyone on anti-rejection medication is more prone to getting infections and getting sicker than normal when this does occur. However, if someone is already more prone to infection, for example from a leg ulcer or urinary catheter, it may be that giving anti-rejection drugs would result in potentially life-threatening infection and therefore to proceed with a transplant would be too great a risk for them.
- Cancer – the immune system is involved in dealing with abnormal cells from the person themselves as well as ‘foreign’ material that comes with bacteria or viruses. While being on anti-rejection drugs for many years increases the chance of developing cancer, if someone with kidney failure has already had any type of cancer then giving anti-rejection drugs may make it more likely that the cancer will come back. This varies depending on the type of cancer and treatment that was required. However, the risks of the cancer recurring have to be balanced against the risks of deteriorating health and death on dialysis. Usually even those with cancer can proceed to having a transplant if the cancer hasn’t come back after a period of time. Depending on the type of cancer and treatment this typically varies between 2 and 5 years.
It is obvious that the person who needs, or who will require a transplant in the future, can really ‘help themselves’ in terms of being suitable or not. Keeping fit (regular walking and climbing stairs counts!), losing weight or avoiding becoming too heavy, stopping smoking, keeping blood sugars under good control etc. will all make a difference in terms of readiness for transplantation. Those who are fitter coming into the operation will also recover more quickly afterwards.