Renal - Kidney Transplant

This is an information leaflet for patients who have chronic kidney disease and are considering the possibility of kidney transplantation. This leaflet will provide some basic information on assessment for kidney transplant, the waiting list, the transplant operation and some of the benefits and risks of transplantation.

You do not need to wait until you are on dialysis to go on the waiting list for a transplant.

A transplant before dialysis is called pre-emptive transplant.

Types of kidney transplant

There are 2 ways in which you can receive a transplant:

1.    Living donor - just under half of all kidney transplants happen because a living person donates a kidney. This is usually the best way for you to have a transplant as it can be planned in advance and the kidney transplant often lasts for longer.

Salford Care Organisation have a live donor team which can be contacted on 0161 206 0531/07793 189544.
Email: livedonorteam@NCA.nhs.uk
Web: Becoming a living kidney donor | Kidney Care UK
www.kidneycare.org/about-kidney-health/treatments/becoming-living-kidney-donor/
 
There are several different ways in which a living donor transplant can occur:

• Living-related donor - this is when the donor is related to you by blood
• Living-unrelated donor - this is when the donor of the kidney is known to you but not related by blood to you, such as a spouse or friend.
• Altruistic donation - this is when you do not know the donor but they have donated one of their kidneys

2.    Deceased donor - this is when a kidney is taken from a person who has died. There are two types:

• DBD Donor – (Donation after Brainstem Death) this is the most common type. The kidney is taken from someone who has died but being kept artificially alive on a breathing machine (ventilator)
• DCD Donor – (Donation after Circulatory Death) this is when the person’s heart has stopped and cannot be restarted. With the family’s permission, kidneys are removed very soon after the person has died

What are the benefits of having a kidney transplant?

• A successful kidney transplant can give you the chance to lead a normal life without the need for dialysis
• Most people have a better quality of life and report having more energy following a kidney transplant
• Most people who receive a kidney transplant do not need any fluid or dietary restrictions that are necessary when on dialysis
• A healthy transplant has been shown to help people live longer when compared to those who remain on dialysis. The best situation would be for you to have a transplant before you need dialysis. This is called a pre-emptive transplant

Will I be able to have a kidney transplant?

About half of people with chronic kidney disease are fit enough to have a kidney transplant. These are some of the reasons why you may not be able to have a transplant:

• If you have had cancer in the last 2-5 years (this does not include some skin cancers)
• If you have had heart, liver or lung disease that would make it not safe for you to have a general anaesthetic
• If you suffer from frequent, severe infections
• If you have a type of kidney disease which can return very quickly in the new kidney – this will be discussed in your kidney clinic
• If you are overweight (Your BMI estimates the ideal weight of a person based on your height and weight. This will be explained and assessed in the clinic and support will be given to help you to lose weight. We need to make an assessment so we can decide whether you are able to receive a kidney transplant

The aim of this assessment is:

• To establish whether you wish to be considered for a kidney transplant
• To find out if you are well enough for transplant
• To see if there is anything else we can do to make you fitter to receive a transplant
• To find out if there are any reasons why a transplant cannot be carried out
• To provide you and your family with all the information that you need
• To discuss whether you have any potential living donors

The Kidney Transplant Assessment

The transplant assessment will start with discussions regarding the issues detailed in this leaflet, then with your agreement you will be required to have various outpatient investigations. Where possible we will try and get all of these tests done on the same day, but sometimes there are extra tests which the transplant surgeons want to be performed before having a kidney transplant.

If any extra tests are required, the reason for these will be discussed with you during your assessment. Most of these tests will be performed at Salford Royal Hospital, however sometimes further tests need to be performed at Manchester Royal Infimary.

Blood tests

• Blood Group – for compatibility with the donated kidney
• Tissue Typing (a blood test, tissue not taken) - for compatibility with the donated organ
• Virus tests – we test for viruses in the blood which may need treatment before or after transplant, for example HIV and the hepatitis viruses. We also test to see if you are immune to chicken pox. If you are not then we will recommend that you have the chicken pox vaccine at your GP surgery

X-rays and scans

• Chest X-ray – this is always done to check that the lungs are healthy and the size of the heart is normal

You may need other scans or x-rays depending on other health problems you have.

Heart tests

• Echocardiogram (Echo) – this is an ultrasound scan to look at the structure and pumping function of your heart
• ECG – this test looks at the electrical activity of your heart and can give us information about any previous damage to your heart

Further heart tests which you may need

If you are over the age of 60 or have diabetes, you will need an additional heart test, called a Dobutamine Stress Echo Test (DSE).

On the day of your appointment if you require a DSE this will be arranged for you and performed on the same day. This test is similar to an echocardiogram scan, but also assesses how well your heart managers when it has to work a little harder, as if you were exercising. It involves the injection of a medication called dobutamine and you will be monitored closely. If you require this additional test, you will be sent an information leaflet in the post regrading this test prior to your appointment.

For the test to work correctly the following medications must be stopped 48 hours prior to your test, this will be highlighted in the leaflet and a member of the chronic kidney disease team will ring you a week before your test to remind you.

Beta blockers
Atenolol
Bisoprolol
Carvedilol
Acebutelol
Nebivolol
Metoprolol
Propranolol
Nadalol
Oxprenolol
Sotalol
 
Calcium channel blockers
Verapamil
Diltiazem

Sinus node inhibitor
Ivabradine

If you have any concerns, please contact the chronic kidney disease team.

Coronary Angiogram

This is a test to look at the coronary arteries (the blood vessels supplying your heart muscle) in detail. A flexible tube is inserted into one of the large arteries (usually in the leg) and a special dye is put into the coronary arteries, so that x-ray pictures can be taken. This is always done following assessment by a cardiology doctor and will be discussed in detail with you if you need it.

You may need other tests because of other health problems and these will be discussed with you on an individual basis.

Pre-transplant psychology review

As part of the transplant work-up you may receive an appointment with one of our renal psychologists. This is because both kidney disease and transplants can be stressful experiences and we want to make sure that people have all the support they need if they were to find things difficult.

Some people experience low mood, panic attacks or other emotional issues during the work-up or after transplant. Due to this, the psychologist will discuss with you how your mood is, if you have ever had depression, anxiety, needle phobia or other emotional problems in the past, as well as how you are coping with your medication. If someone is donating a kidney to you, we will talk about your relationship with the donor and how you feel about the donation.

Summary – you may find it helpful to fill this in for your records

Once your assessment is complete and all results are satisfactory, your kidney doctor will refer you to one of the consultant transplant surgeons at Manchester Foundation Trust. You will receive an appointment to attend their assessment clinic. The surgeons from Manchester Foundation Trust will see you either at Manchester or Salford Care Organisation. They may arrange to see you using video or telephone consultation as well.

If a patient has a potential live donor, the donor is encouraged to contact the live donor team as early as possible for initial testing to be performed. Your donor does not need to wait until you have been seen in AKC or attended one stop work up clinic.

My appointment date with the transplant surgeon is on:  .………………………………………………………………………………

The Transplant Unit - Manchester Foundation Trust (MFT)

You may be at this appointment for several hours as it involves a detailed explanation and assessment. The transplant surgeon will explain all the risks and benefits of having a kidney transplant with you and your family. He/she will examine you and look at the results of all the tests that you have had. The surgeon will inform you if he/she feels it is safe for you to go on the transplant waiting list.

If the surgeon feels that it would be higher risk than usual for you to have a transplant, you will be discussed with other surgeons at their multidisciplinary team meeting so that a decision can be made. They will then write to your kidney doctor at Salford with their decision. If the surgeon feels it would be higher risk than usual for you to have a kidney transplant he may advise you against it.

Within 3 weeks of seeing the transplant surgeon you should receive a letter from the transplant laboratory that informs you that you are now active on the kidney transplant list.

Once you are on the Kidney Transplant the list:

• Regular tissue typing blood samples are required every three months for MFT. This is usually taken when you attend your Advanced Kidney Care clinic appointment. When you attend your Advanced Kidney Care clinic appointment, please remind the member of staff you are seeing that your transplant bloods are required. The sample will also need to be updated if you have a blood transfusion. However you should wait for 2 weeks after your blood transfusion before arranging the sample
• You will need to inform the CKD team if you are going on holiday so that we can temporarily suspend you from the transplant list for the time that you are away
• If you are staying in the UK on holiday you need to make sure that you can get to Manchester Foundation Trust within 2-3 hours. If you are further away than this you will need to be suspended from the waiting list
• You need to inform the CKD team of any changes in your contact numbers so that if a kidney becomes available you can be contacted without delay. If you cannot be contacted, the offer of the kidney could go to someone else
• If anything changes in your health or you are admitted to hospital you need to contact the CKD team for advice
• It is recommended if you have a smart phone, you download the Transplant Alert App. Manchester Foundation Trust (MFT) have a Transplant Alert App (TAA) This was created by MFT and is aimed at patients or their nominated representatives on the organ transplant waiting list, to notify the patient when a kidney becomes available

Transplant listing annual review clinic

Once you are on the transplant waiting list in either the active or the suspend category, every year you must attend Salford Royal Hospital for an annual review.

The annual review is required to ensure:

• There have been no changes to your health
• Your contact numbers are up to date
• You have no new concerns about receiving a transplant
• To carry on discussions if you have any live donors

Every two years the investigations that were required to get onto the transplant list will also need repeating. This is yearly for kidney pancreas patients.

If due, the following tests can be completed on the day:

• Chest x-ray
• ECG

If you are due an Echocardiogram or a Dobutamine Stress Echocardiogram, then these tests will be discussed with yourself and you will need to re attend Salford at a later date for these investigations to be planned.

How long will I wait for a kidney transplant?

The UK kidney transplant waiting list is growing and the average waiting time for a kidney transplant is 3-4 years. The number of kidneys required greatly exceeds the number available, and you may have to wait a long time (sometimes years) before a kidney suited to your blood group and tissue type is found. Some patients, however, are lucky and get a kidney transplant within a few months.

How is the recipient chosen?

There is a nationally agreed formula that determines who gets the kidney, all kidney transplants in the UK adhere to this formula. Almost all kidneys retrieved from deceased donors in the UK are offered to the National Pool of Kidneys. All of the donor details are entered into a national computer in Bristol. The donors details are matched against the recipients who are in the active category. The computer will then generate a list of potential recipients for the kidney.

Receiving a Transplant

The offer of a kidney transplant can come at any time, day or night. Once you have been contacted, have nothing else to eat and drink or else you may not be able to have the transplant.

You will be asked to go to the Manchester Transplant Unit as soon as possible. Remember to take with you the medicines that you currently take and a copy of your last clinic letter. It may be helpful to have a bag packed in advance with some essentials to stay a few nights in hospital. It may be helpful to plan how you will attend for your transplant, you will not be able to drive yourself. If you think you may have problems attending MFT, then please inform them when they ring you and advise you to attend.

If you have any children or pets it may be worth having a plan of care in place of who will look after them whilst you are in hospital.

When you are on the transplant ward, you will be assessed by the doctor to ensure you are well enough to have the kidney transplant. Final checks will be carried out including blood tests, a chest x-ray and ECG. A special blood test called a cross match test will be performed before the transplant can go ahead. This is a special test which is done in the transplantation laboratory. It involves mixing some of your blood with white blood cells from the donor, and waiting for a few hours to see if your serum has killed any of the donor cells. This test is mainly done virtually, as long as MFT have an up to date sample of your tissue tying sample. The benefits of doing the test virtually is it avoids delays in the operation being performed.

Sometimes the Kidney Transplant Unit will call two people when there is only one kidney available. This is done in case the first person is not able to receive the kidney, so that precious kidneys are not wasted whilst finding a suitable person to receive them.
 
You will be told if you are the second in line (“reserve”) patient. If the first patient is unable to receive the kidney, then hopefully you will be able to instead. If the first patient is able to have the transplant then unfortunately the “reserve” patient will go home again without receiving the kidney transplant. If this happens to you, please phone the CKD team afterwards so we can answer any questions you may have.

The Operation

The transplant kidney is placed in the right or left groin just under the skin at the front. It is placed here as it is close to the bladder and the main blood vessels of your leg. Your own kidneys are not removed, unless there is a reason to do so. This is usually decided at your initial assessment with the transplant surgeon. Usually the operation takes 2-3 hours, but you may be away from the transplant unit for up to 6 hours, as you will need to spend some time in the recovery department.

Whilst you’re in theatre the anaesthetist will insert a small plastic tube (central line) into one of the main veins in your neck (jugular vein) so that fluid and medication can be given. You could also have a smaller “cannula” in your arm. Usually these are removed 3-4 days after surgery.

You will have a urinary catheter inserted into the bladder while you are asleep so your urine output can be measured. This is usually removed a few days after your surgery.

You may have a wound drain inserted at the operation site for any excess fluid to drain out.

During the operation the transplant surgeon may insert a stent, which is a thin soft plastic tube inserted into the “ureter” (the tube which joins the kidney to the bladder). This is to protect the join between your new kidney and the bladder. The stent will be removed 4-6 weeks after transplant at MFT. This involves a small procedure and will be done as a day case.

After your kidney transplant operation

Kidney transplant is a complex operation and many things can go wrong. Fortunately, most patients do very well after a transplant. Some kidneys can work straight away but the length of time it takes for a kidney to start working can vary considerably. After surgery you will require regular blood tests and you will have scans to check how well the kidney is functioning. Some people may require dialysis after the transplant if the kidney is not working.

Antirejection (Immuno-suppression) Medication

On the day of the transplant, you will be started on anti-rejection medication and various combinations are used. Unfortunately, like all medication, there can be side effects but you are monitored closely. The following are important possible side- effects:

• Increased risk of cancer - there is a higher risk of developing some cancers, especially those involving the skin and lymph glands. Your transplant team will give you advice and support so you know what signs to look for and how to reduce the risk. Every year you will have a transplant anniversary check up with your transplant team
• Ladies have an increased risk of cancer of the womb. The condition is treatable if diagnosed at an early stage. Due to this ladies of all ages who have been transplanted are advised to have yearly smears
• Kidney damage – some of the medication can become toxic to the kidney if the levels run too high. You will have regular blood tests to check the levels of medication and allow adjustment of the dose
• Weight gain - this can happen because you feel better and your appetite increases, but may also be a side-effect of some types of antirejection medication. You will be advised to keep to a healthy weight and be offered help with this
• Increased risk of diabetes – this is sometimes because of weight gain but can be a side-effect of antirejection medication. Your blood and urine sugar levels will be monitored regularly to check for this
• Stomach upsets - nausea and diarrhoea may occur. If this happens, it can usually be resolved following alteration of your medication

Will the kidney transplant be successful?

About 93% of kidneys transplants are working after one year. For those who receive a kidney from a living donor, around 96% of kidney transplants are successful after one year.

Most kidney transplants are very successful but, just like all operations, problems may occur. Some kidney transplants take a while to start working and a very small number of transplants each year do not work at all. The following problems can occur in the first few days or weeks:

Bleeding – as with all surgery, there is a risk of internal bleeding which may require a further operation or procedure to stop the bleeding.

Kidney Clotting (Thrombosis) - this is rare complication where a blood clot blocks the blood supply to the kidney. Unfortunately, when this occurs the kidney has to be removed and will not work again. You will be able to go back on the transplant list after 2-3 months when fully recovered.

Sleepy Kidney (delayed graft function or acute tubular necrosis) – this can be the kidney’s response to being handled in surgery.
The blood supply to the kidney is fine but the kidney has sustained some temporary damage and is not yet functioning. The kidney will recover, it just takes time.
 
Rejection – you will be started on antirejection medication (immuno-suppression) to try to prevent this from happening. About one in 10 patients have an episode of “rejection” in the first few months, when your immune system tries to attack the new kidney. You will not usually feel any different but your blood tests may be worse. You will usually need to have a kidney biopsy under local anaesthetic to decide whether you have rejection. If you do, don’t worry – it is usually treatable by altering your antirejection medication. You can reduce the risk of rejection by making sure you don’t miss any doses of medication.

Urine leak – occasionally there can be a leak where the tube (ureter) from the transplanted kidney joins the bladder. This usually requires another operation to have the leak repaired.

Infection – you are more at risk of infection due to the antirejection medication, especially at the beginning when the doses of medication are much higher. Infections can vary from wound infections, urine infections, and chest infections to more serious or unusual ones. You will be monitored closely for signs of infection when you are in hospital.

How long will I be in hospital for?

The transplant team will monitor you closely for any signs or symptoms that you may need treatment for. When the transplant team feel your kidney function is stable and it is safe for you to go home you will be discharged from the unit. Most patients go home after 7-10 days. You will attend the transplant clinic at MFT regularly.

MFT have provided the following general guide for how often you will need to attend the transplant clinic. The frequency may change and if needed you will be soon more often.

The transplant surgeons will decide when you are ready to have your care transferred back to the transplant team at Salford Royal Hospital. This is usually around 3 months after transplant providing everything is stable. You will always need to come to a transplant clinic whilst you have a working kidney transplant.  The transplant team at Salford will monitor and provide advice and support in the same way as at Manchester Foundation Trust.

Emotional reactions after a transplant

Everyone reacts differently to their transplant, depending on their experiences in life and what kidney disease has been like for them. A transplant is a life changing event and may alter how you see yourself and your relationships with family and friends.  For most people, a transplant is a positive experience. However, some people find it brings about emotional challenges or difficulties. Even if health improves, it can be difficult to make the transition from a life with dialysis or severe symptoms of kidney disease, back to a life with reasonably good health.  Sometimes, people worry that the transplant will fail or feel more vulnerable than they did previously. It is therefore important to remember that after your transplant, if you do experience any difficulties, don’t suffer in silence. Tell any member of the renal team who, with your consent, can then refer you to a psychologist. These problems can often be successfully dealt with using psychological therapy.

Questions and Answers

The next section will focus on common questions regrading a kidney transplant. It is important to note that you may have questions that are not listed below. Please be aware that you can discuss any further questions with the CKD team and any point.

The questions below have also been produced in conjunction with Kidney Care UK (www.Kidneycareuk.org).

How do I ask my family and friends to donate a kidney?

If you need a kidney the thought of asking someone to consider donation can be scary. You may feel nervous about asking someone, which is a normal reaction. A lot will depend on your relationship with the person you are asking. Below are some suggestions to try and help make it easier to ask family and friends to consider donation.

Learn all you can

Learning as much as you can about kidney donation and live donor will help you to explain the process. Attending your transplant work up clinic and this leaflet will help you to be able to do this. However, if you feel you need further support please contact the CKD team on 0161 206 1882.

It may also be useful to look at the following web page:
https://www.organdonation.nhs.uk/become-a-living-donor/ donating-your-kidney

Starting the conversation:

This is a very individual choice but could be something along the lines of:

“You may not be aware but I am in kidney failure, and I am being worked up for a kidney transplant (or I am on the transplant list). One of the best treatments for this disease is a new kidney, it can take many years to get a kidney from a deceased donor. Another way to get a kidney is from a living person who wants to donate a kidney to me, this process happens much quicker and I don’t even have to go on dialysis before the transplant”.

Explain how your condition affects you

Explaining to your family and friends what dialysis will mean to you if you are pre-dialysis, how this potentially will affect your lifestyle. If you are on dialysis explain how this makes you feel. Being open an honest with your condition is one way to start the conversation.

Let your family and friends know that you understand that living donation is not for everyone and your relationship will not change it they choose not to donate.

You can also bring a family or friend to your transplant work up appointment where the CKD team will explain the process of transplantation and average waiting times on the cadaveric donor list.

Do you have to be the same blood type to donate a kidney?

Kidney donors must have a compatible blood type with the recipient, and once your potential donor makes contact with the live donor team an initial blood test will be performed.

What this means

Donors with Blood type A can donate to recipients with blood types A and AB.

Donors with blood type B can donate to recipients with blood types B and AB.

Donors with blood type AB can donate to recipients with blood type AB only.
 
Donors with blood type O can donate to recipients with blood types A, B, AB and O.

What if my donor is not a match?

If blood types are not compatible, your potential donor cannot donate directly to you. However, the potential donor can still donate via a paired pool scheme. The CKD team and the living donor team can explain this process to you in more detail.

Is there an upper age limit for a potential donor?

There is no upper age limit for a potential donor. However, the potential donor will have to be medically fit to be able to donate.

Can my potential donor live a normal life with just one kidney?

Donors can live normal lives with just one kidney. During the live donor work up process the potential donor will undergo various investigations to ensure they are suitable for donation. If your potential donor has any concerns, these can discussed in confidence with the live donor team.

Will my potential donor be paid for donating a kidney?

Under the Human Tissue Act 2004. Payment for donating a human organ is illegal.

However, the Act supports the reimbursement of reasonable expenses for travel, loss of earnings and other expenses directly involved with the donor process. The live donor team will help and complete the reimbursement form and can help advise on any concerns regarding this.

Can my children donate?

Yes, but they will need to be over 21 years old.

Can I get pregnant after transplant?

Yes, but is recommended that you wait until you have had your transplant for at least 1 year. Please discuss this with your kidney team so that you can be assessed before you become pregnant.

Can I father children after my transplant?

Yes there is no evidence that anti-rejection drugs will adversely effect this. However there is a greater risk of erectile dysfunction in transplanted patients. If this affects you please talk to your transplant team for advice and to discuss potential treatment.

How long will the transplant last?

The average time a kidney lasts is 11-12 years, but there a high number of patients who still have a function kidney transplant 15-20 years.

Why do I need to send in a monthly blood test?

Antibodies are normally present in the blood. Some patients have antibodies which can be a problem if you have a kidney transplant. The transplant team will test your blood every month for these antibodies which can help them to make sure a kidney is suitable for you before they call you in to receive it. You can have this test at your kidney clinic appointments or at your local hospital.

I’ve had one transplant so I won’t get another?

Most people can have further transplants if a transplanted kidney fails. However, you may have to wait longer as it can be harder to get a match.

The success rate for second or third transplants is generally as good for the first.

You will need to go through the same tests again to make sure you are healthy enough to have another kidney.

Contact Numbers

CKD nursing team - 0161 206 1882 / 0161 206 7043

Live Donor co-ordinator -0161 206 0531 / 07793189544

Janet Cribbin (Patient knows best Contact) - 0161 206 5710

Useful web addresses

NHS

Kidney Research UK - https://www.kidneyresearchuk.org/ transplantation/

NHS Kidney Transplant - https://www.nhs.uk/conditions/kidney- transplant/

Blood and Transplant - https://www.nhsbt.nhs.uk/organ- transplantation/kidney/

Manchester Foundation Trust - https://mft.nhs.uk/mri/services/ transplants/

Edinburgh Renal Website - https://edren.org/ren/transplant-unit/ about-transplantation/

KidneycareUK - https://www.kidneycareuk.org/about-kidney- health/treatments/transplantation/

British Transplantation Society - https://www.bts.org.uk

National Kidney Federation - https://www.kidney.org.uk

Social Media

Salford Royal Renal Department Twitter - @salfordrenal

Salford Royal Renal Department Facebook - www.facebook.com/ SCOrenal

MFT renal transplant coordinators Twitter - @MRI_TxRecipient

MFT Transplant unit Twitter - @MRITransplant

Renal Patient Led Advisory Network Twitter - @RPLANNW

KidneyCareUK Twitter - @KidneyCareuk

NHS Blood and Transplant - @NHSBT