Renal Transplants Essay Example
Renal Transplants Essay Example
During this time, approximately one third of potential living donors are unable to donate to their potential recipients due to ABO or antigen incompatibility. Kidney paired donation (KPD) and kidney list donation (KLD) were the alternative options for candidates with incompatible donor (McKay, 2010, 103). The first KPD transplant was performed on South Korea in 1991. The United States performed its first KPD transplant in 2000 in Rhode Island Hospital while the first KLD occurred in England in 2001 (McKay, 2010, 104). The kidney is the most commonly transplanted organ in the world with more than 160,000 persons in the United States living with a transplanted kidney by the end of 2008 (Shoskes, 2011, 154). But despite this number, persons needing kidney transplantation still increases and a relative scarcity in terms of resource arise. A complete array of information about kidney transplantation was included in the databases of U.S. Renal Database System (USRDS), Scientific Registry of Renal Transplants Recipients (SRTR), United Network for Organ Sharing (UNOS), and Collaborative Transplant Study (Shoskes, 2011, 154). Procedures Before a patient undergo kidney transplantation, a series of laboratory tests and procedures are needed to perform and complete. Matching is the key tool is successful transplantation. The donor’s organ should match the recipient’s body in terms of ABO and antigen incompatibility to avoid risks of rejection. The patient with end-stage renal disease may choose from treatments such as peritoneal dialysis, hemodialysis, or transplantation. Transplantation is done if the patient wants the treatment or if according to disease severity, requires the transplantation procedure. The surgical team involves the pre-emptive living donor (LD) transplantation to minimize pre-operation transplant list and maximize operative choices.Renal Transplants Essay Example. The LD transplantation decreases the risk of acute tubular necrosis due to ischemia, increases potential for matching, and offers opportunity to initiate and optimize immunosuppressive therapy, thereby reducing acute rejection episodes (McKay, 2010, 17). Background regarding the quality of the donor’s organ was predetermined and positive outcome was expected. Then, the transplant team prepares the patient for the procedure. However, if the patient has superior vena cava syndrome due to an AV graft in the previous hemodialysis, a different procedure is done by the nephrologists and cardiologists. The organ transplantation is divided into five separate procedures (McKay, 2010, 18) and discussed as follows: 1) Preparation – the surgeon discuss to the patient the surgical procedure. General anesthesia is introduced after and intraoperative measures are implemented. 2) Exposure – after prepping and draping, incision is made in the right or left lower quadrant. 3) Vascular Anastomoses – venous anastomoses first and arterial anastomoses must be last to avoid complications of bleeding and thrombosis. The kidney is chilled and topical iced is used liberally. Clamp is placed in the renal vein. 4) Ureteral anastomoses – is the preferred method to establish urologic continuity 5) Closing – wound/skin closure and measures to prevent complications. After completion of all the procedures in kidney transplantation, the patient is placed in the recovery area and post-operative interventions are applied. Renal Transplants Essay Example. Health providers monitor for rejection signs post-operative
The kidneys are twin organs about the…show more content…
Specific blood tests also can be an accurate diagnostic tool. A kidney biopsy can also provide accurate results. Chest x-ray, ultrasound, and electrocardiogram can be effectively used (Stevens, 2009).
According to National Kidney Foundation (2010), the majority of people with diabetes tend to develop kidney disease. This is probably the result of poor or improper dietary and life-style practices, although genetics seem to be a factor. This makes it the single leading cause of kidney failure. High blood pressure/Hypertension is another pre-disposing factor of kidney failure. This disease is also aggravated by improper dietary and life-style practices. High blood pressure/Hypertension speeds up the loss of kidney function and eventually leads to kidney failure. It also appears to have genetic and familial factors (National Kidney Foundation, 2010).
Kidney failure is the result of kidney disease that has either not been treated, or failed to respond to treatment. Some kidney diseases are: Acute kidney failure (potentially reversible), Acute nephritic syndrome, Goodpasture syndrome, Atheroembolic renal disease, Glomerulonephritis, Polycystic kidney disease, and chronic kidney failure (end stage) (United States National Library, 2010).Renal Transplants Essay Example. The usual treatment for kidney failure is medication and dialysis. Dialysis is used for end stage kidney failure, when the patient has lost
Since the first successful transplant of a kidney from one twin to another in 1954, renal transplantation has moved from being at the cutting edge to being a mature technology. Registry data show that the current survival rates for grafts from cadavers are around 88% and 60% at one and 10 years after transplantation, respectively, while comparable rates for grafts from living donors are in excess of 95% and 70% (fig (fig11).1,3 These rates have shown steady improvements over the past 10 years, with the one year survival rates for grafts from cadavers and living donors improving by around 5% in that time.1,3 One year patient survival after transplantation is steady at 95%, with 87% alive at five years. In the medium term (one to three years) after transplantation, clinical outcomes are now so good that it is difficult to improve the survival of the patients or the grafts. Rejection rates have fallen over the years, and rejection is now an uncommon cause of early loss of a graft. Renal Transplants Essay Example.
Kaplan-Meier analysis of survival of cadaveric and living donor grafts in renal transplants in the United Kingdom. Data reproduced by permission of UK Transplant1,2
Major issues that now need to be resolved include the inadequate supply of donor organs, the side effects of treatment, the epidemic of cardiovascular disease in patients who have received renal transplants, and equity of access to transplantation. This paper discusses the recent progress in the field of renal transplantation and considers what work is needed to tackle the current issues facing transplant specialists.
Methods
Topics to include in this article were chosen by searching Medline for articles published between 1999 to 2001 with the keywords “kidney” and “transplant”, by discussing renal transplantation with clinical colleagues, and by reviewing articles in specialist journals and abstracts from conferences.
New approaches to increasing organ donation
In December 2001, 6101 patients were waiting for a renal transplant in the United Kingdom.1 Waiting lists continue to grow by about 3% per year.1 The reasons for this increase in recent years have been well documented,4 but two are particularly important. Improved road safety and a lack of neurosurgical facilities have led to fewer organ donors becoming available in recent years. During the same period, the incidence of renal failure in our ageing, more ethnically diverse population has increased, resulting in more patients being considered for transplantation. Renal Transplants Essay Example.
Cadaver donation
Several steps have been taken to improve the rate of organ donation from cadavers. The first has been to improve the organisation of transplant coordinators. This step has drawn on a programme of changes made to the coordinator service in Spain, which involved heavy investment and gave outstanding results. The programme began in 1989 and included the appointment of a coordinator to every hospital; the result was an increase in the transplant rate to 33.6 per million population within 10 years. In contrast, the number of organ donors in the United Kingdom and Germany remained static, at 13 per million, over this period.5
A second initiative uses increasing amounts of investment in neurosurgical facilities. This might increase the numbers of potential organ donors to be admitted, and pilots will soon begin under the auspices of UK Transplant.
Launched in 1994, the NHS organ donor register is a third step that is intended to promote organ donation in the United Kingdom. This register allows individuals to register their willingness to be considered as an organ donor. To date, nine million people have registered, often when they renewed their passport or driving licence. However, the usefulness of the register has been questioned, and there is no evidence that shows that donation rates have improved since its launch.
Three systems of organ donation are used in current practice worldwide: “opting in,” “opting out,” and “required request” (box (boxB1).B1). In practice, in all three systems, the wishes of the potential donor’s next of kin remain paramount.
Current systems of organ donation
The adoption of an opting out system as a means of increasing organ donation remains controversial.Renal Transplants Essay Example. This option has little political support, despite being supported by the British Medical Association and by surveys that show that most people in the United Kingdom would favour a system of “presumed consent.” After Belgium introduced such a system in 1982, the numbers of organ donors increased considerably.6 Germany and Italy introduced similar legislation in 1997 and 2000, respectively. The opting out system will continue to be a subject for debate.
The use of “marginal donors” is also a subject of debate (box (boxB2).B2). Grafts from very old donors are associated with reduced functioning of the nephron mass, increased susceptibility to cold ischaemic injury, and impaired survival of grafts in the long term.7Similarly, very young donors are associated with inadequate nephron mass and a higher incidence of technical failure compared with adults.8 Some doctors have advocated the use of dual organ transplantation from such donors, although such a policy would inevitably further reduce the total number of patients who could receive transplants.9,10In practice, most units continue to broaden their definition of acceptable donors, but they ensure that potential recipients are aware of and accept the possibility that they may receive suboptimal organs.
Marginal donors
Living donation
Enthusiasm for transplants with kidneys from living donors varies, but the shortage of kidneys and the excellent survival rates for such grafts has driven the development of such programmes. In Norway, for example, 38% of transplants use kidneys from biologically or emotionally related donors; as a result, Norway is almost alone in seeing a reduction in the numbers of patients on its waiting list for transplants.11 In the United Kingdom only 20% of transplants use kidneys from living donors.1 This low number, and the need to establish standards for organ donation, led a joint working party of the British Transplantation Society and the Renal Association to publish guidelines for transplanting kidneys from living donors in January 2000.12
The better survival of grafts from living donors than grafts from cadavers reflects the high quality of the donor organs and the optimal circumstances under which they are retrieved. A genetic relationship means that the tissue match between the graft from a living donor and the recipient is often good. Renal Transplants Essay Example. However, a good match is less important with a living donor, and many transplant units now promote transplants of kidneys between spouses and partners.1,3,12 Initiatives such as these mean that living donation is likely to be responsible for most of the increases in the numbers of available donor organs for the foreseeable future.
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For living donors, nephrectomy is a painful and unnecessary procedure. The technique of laparoscopic nephrectomy has received much attention, with excellent results reported from several centres in the United States.13,14 Postoperative pain and inpatient stay are shorter and wound size smaller with laparoscopic nephrectomy than open nephrectomy, the former producing only a small increase in warm ischaemic time and, to date, few complications. The surgery is technically demanding, however, and damage to the donor kidney may transfer morbidity from the donor to the recipient. A controlled trial comparing the open and laparoscopic techniques is needed before the use of laparoscopic nephrectomy can be promoted uncritically.14
Non-heart beating donation
Most kidneys are retrieved from patients who are brain stem dead, but whose circulation and ventilation are supported until the organ is removed. In contrast, a smaller number of organs are retrieved from donors without an active circulation—non-heart beating donors. In these cases rapid organ retrieval is needed to minimise damage secondary to warm ischaemia. Research in this area is bedevilled by differing case mixes, with not all centres agreeing on the definition of a non-heart beating donor. Renal Transplants Essay Example. However, data from the United States, the United Kingdom, Europe, and Japan indicate that carefully selected kidneys can give excellent graft function, approaching that of grafts from cadavers.15–17This technique needs staff to be immediately available to retrieve organs from non-heart beating donors; it is labour intensive and needs considerable commitment of resource. However, the transplant rate may be increased by 20%-40% if such donors are used.15,17For these reasons, central funding will soon be available to increase the use of this technique in the United Kingdom.
Advances in immunosuppression
Research into immunosuppression after transplantation has been relatively stagnant for many years. Recently, however, great progress has been made in the options available.
Tacrolimus and mycophenolate mofetil—Although most centres still use treatments based on steroids and ciclosporin, tacrolimus and mycophenolate mofetil have emerged as effective and well tolerated options for inducing and maintaining immunosuppression.18,19 Hypertension, hyperuricaemia, and cosmetic side effects all seem to be less severe with these newer agents, while rejection rates are equivalent and lipid profiles are significantly improved.18,19 Mycophenolate mofetil exerts effects on B cells and T cells, and recent data suggest that it may also reduce the incidence of chronic allograft nephropathy—a poorly understood condition that is a major contributor to graft loss (fig (fig22).20 If mycophenolate mofetil does reduce the incidence of chronic allograft nephropathy, it would be a major therapeutic advance. However, cost issues have restricted the use of mycophenolate mofetil in the United Kingdom, and long term follow up of patients is needed to determine whether the levels of immunosuppression produced by mycophenolate mofetil are associated with long term problems related to infection and malignancy. Renal Transplants Essay Example.
