Kidney Transplantation and Factors that Affecting The Process

A kidney transplant is the transfer of a kidney (healthy kidney) from a donors body into the body of a patient who has very little / no kidney function. There are two types of donations for kidney transplants, living donations, deceased donations. Although there are major differences between both of the donation types, they both need to meet certain conditions/ standards.

These conditions are the ability to meet the donor/ recipient compatibility e. g. if the donor and the recipient do not have the same blood types, then the compatibility will be affected and the transplant will not be a success as the recipient will reject the kidney. The ability to meet certain standards/ requirements of the donor condition such as if the donor does not meet the minimum age requirements (for a living donation) or does not meet the certain requirements in terms of physical well-being or if they have diseases such as diabetes or high blood pressure etc. The ability to meet certain requirements of the patient condition such as if the patient has any diseases such as HIV, hepatitis A or B, cancer or diabetes.

These requirements mostly apply to live donations but some also apply for deceased donations such as donor/ recipient compatibility. If these conditions are not met, there can be serious complications for the patient mostly but also the donor, these complications can affect the kidney survival times (how long the kidney lasts for in the patient) and can cause the patient to develop

Chronic rejection, acute rejection and/or cause the patient to develop diabetes, cancer (there is a higher chance of developing melanoma, Kaposi’s sarcoma or lymphoma) and so on.

However, ethical issues are present in living donations, there is a high risk-benefit ratio, there is a higher risk to the donor. Additionally, the process of giving a kidney can result in some negative psychosocial consequences and so on, this will be discussed in detail in the essay.

The patient/ recipient compatibility is crucial to consider when going through a kidney transplant. A number of issues/ problems can arise if the donor/ recipient compatibility does not meet the standards and requirements that healthcare professionals have ruled out. Firstly, the blood type needs to match the donor’s blood type so that it is compatible. This means that if the patient has type A, B, AB or O, the donor must also have the same blood type or have a blood type of O as blood type O is universal. If the patient’s blood type is not correctly matched to the right donor blood type, it will have serious implications, because a reaction occurs when the antigens on the red blood cells of the donor blood react with the antibodies in the recipient's plasma. For example, if a small amount of blood type A, possibly a unit of this type of blood which consists of A antigens is transfused into someone with type B who have anti-type A antibodies in their blood, a transfusion reaction will occur.

When a transfusion reaction does occur, an antibody attaches to antigens on several red blood cells. This, in turn, can cause the red blood cells to clump/ form together and block up blood vessels. Hemolysis then takes place where the cells are destroyed by the body causing the body to release hemoglobin from the red blood cells into the blood. Bilirubin is then produced from the breakdown of hemoglobin, which can cause the patient to develop jaundice. It can cause the patient to also develop acute hemolytic reaction where the patient can develop fevers, chills, chest or back pain, bleeding, increased heart rate, shortness of breath, a rapid drop in blood pressure, and/or kidney damage. A delayed hemolytic reaction can also occur, which is generally less severe or even asymptomatic, but there will still be the destruction of blood cells.

The patient will need an emergency blood transfusion, if however for some reason, the blood type of the patient is unknown it is safe for the patient to receive type O- blood. Type O- blood (which has no antigen on its surface) will not react with antibodies in the recipient's plasma (Blood type O- is universal and can be used for all blood types). Those with type AB blood (which has no antibodies) are universal recipients because their plasma will not react with donated blood. This can severely affect the process of a kidney transplant as it will slow down the process of the transplant surgery, so the determination of blood type of the patient and the donor is crucial. All of this, however, does not affect the donor. Secondly, HLA typing is carried out. HLA typing is also called “tissue typing”. HLA stands for human leukocyte antigen, antigens are proteins on the cells in the body and there are six that are proved/ shown to be the most important in organ transplantation. Each person's tissues (there is an exception for identical twins) are all different when compared with each other’s. The transplant will be much more successful and will last over a longer period of time if the HLA match is better between the donor and the recipient. This is due to the way chromosomes/DNA are inherited or passed down in a family, for example, a parent and their offspring have at least a 50 percent chance of matching, however, siblings have varied compatibility, it can range from 0 to 100 percent match rate. Unrelated donors (those who are not from the same family as the patient) The best match for the recipient is to have 12 out of the s12antigen match. (This is known as a zero mismatch.) are less likely to match at all. Although, if the patient has a very common HLA type it is possible and likely for all 12 markers to match, even if the deceased donor is unrelated, this may be a different case for live donations.

Furthermore, patients are required to go through a blood test where they measure antibodies to HLA; it is repeated monthly (sometimes) but less than that depending upon the transplant program policy. While waiting for a transplant, the level of HLA antibodies can increase or decrease over time, HLA antibodies can be harmful to the transplanted organ, so they must be measured while waiting for a transplant, this includes before the transplant surgery and after the transplantation. Patients are considered HLA “sensitized” if their blood contains HLA antibodies, this means that it is best to find a donor with HLA types that avoid the HLA antibodies that are present in the patient’s blood. If this is not met then there is a 13% higher risk of organ mismatch in the patient’s body [1]which can lead to side effects that can reduce the patient’s quality of life as well as reducing the kidney’s working ability throughout the years of transplant.

The crossmatch test is considered to be very important and is repeated before the kidney transplant. Blood is taken from the recipient and the donor and is mixed together, if the recipient's cells attack and kill the donor cells, the crossmatch will be positive meaning that the recipient has antibodies against the donor's cells meaning that It is not compatible and carrying out with the transplant will result in kidney rejection. It is considered compatible if the results are negative.

Overall, the donor/ recipient compatibility is crucial for the process of kidney donation and transplantation as if the tissue typing, blood types or the crossmatch does not match with both the patient and the donor, it can cause complications for the patient, they can develop a number of diseases such as CKD or can reject the kidney which can cause the whole donation process and the transplant surgery to be unsuccessful and a waste of time, it can also cause lower survival rates in worst case scenarios. It can also affect the donor as it can cause them to also lose a kidney due to the unsuccessful operation, this can affect their quality of life and can cause emotional distress as well as physical complications such as high blood pressure, trauma, and diabetes etc.

Secondly, the donor condition can affect the process of the kidney donation/ transplant. Factors such as age, diseases/illnesses, whether the person consumes drugs or smokes can all affect the kidney transplant and donation. To start with, the age of the kidney donor and its recipient has to be taken into consideration in the matching process due to donated kidneys being a scarce, life-saving resource, this is because it would help extend lives and reduce the number of patients on the transplant waiting list. This means that optimal young healthy kidneys are given to recipients who die long before the kidney would stop functioning. If young patients were to obtain kidneys from an old donor it can deteriorate long before the patient dies, this, in turn, means that it would require them to return to dialysis or be re-transplanted, making the procedure much more time-consuming as well as further increasing the number of patients on the waiting list. Donor age is proved to be a powerful factor in terms of predicting the long-term renal allograft function as “Histopathological studies reveal a 20–25% loss of volume particularly in the cortex, fibrous intimal thickening of arteries as well as the loss of glomeruli because of global sclerosis with enlargement of the remaining glomeruli and lastly patchy tubular atrophy and interstitial fibrosis [4] in particularly aged kidneys.”

A research conducted by a medical professional in the American Society of Nephrology's 37th Annual Meeting and Scientific Exposition in St. Louis, Missouri. They examined over 74,000 deceased donor kidney transplants between 1990-2002, the age of the donors and their recipients were compared. The ages were compared because doctors were trying to determine how to maximize the use of the donated kidney and how to maximize it’s lifespan when it is transplanted into the patient. The findings showed that 6,850 graft years could have been saved over this twelve year period if young donor kidneys (ages 15-50) were matched with young recipients under the age of 60 and older kidneys (age 50+) were given to older patients over the age of 60. The kidneys could have increased the life of each transplant patient by an average of nine months. because of the 9,250 transplants that would have been affected by this reallocation, this would have saved 6,850 graft years over a twelve-year period. A total of to 27,750 more graft years could’ve been saved as well as the kidney surviving for 3 more years over the time of the transplanted kidney.[3] Additionally, In 1991, Donnelly et al. [5] published the results of 141 consecutive first cadaveric transplants and noted that graft failure at 2 years was significantly greater when the donor was more than 5 years older than the recipient suggesting that age is a factor that should be taken into consideration when carrying out with a kidney transplant and can affect the lifespan of a kidney.

Another factor that should be taken into consideration is whether the donor has 20% more protein in their urine. This is because it can be a sign of the donor having kidney disease, diabetes or high blood pressure (hypertension). This can affect the process of the kidney transplant as it can mean that the kidney will not function properly and the kidney life-time will be reduced as well as the donor developing even higher hypertension or worsening of kidney disease which means that the donor will also need dialysis and in worst cases a kidney transplant, this will slow down the process of a kidney donation and transplant due to the complications that the donor faces as well as the patient as it means that the kidney does not function well and so the patient will require further dialysis or another kidney transplant.

The last factor that should be taken into consideration is whether the donor smokes or consumes alcohol Firstly, smoking can affect the process of a kidney transplant as smoking slows the blood flow to important organs like the kidneys and can make kidney disease worse, it can increase hypertension as well as reducing the ability of kidneys. This is detrimental to the health of the patient as it can mean that the kidney will not function to the best of its abilities and can mean that the patient will have to receive further dialysis to increase the function of the kidney. It will not be long-lasting and the patient will be required to have another kidney transplant.

Alcohol consumption can affect the kidney as it has been proved that there is an “increase in kidney swelling, impaired renal functioning, and enlarged kidney cells containing a considerable increase in water, fat, and protein”. [8] The increased amount of fat and other components can mean that the kidney will be unhealthy and it will be harder to find correct arteries due to the increased fat and so the kidney transplant process will be slowed down as well as the patient receiving a kidney that is unhealthy and unable to function properly, the whole process of the kidney donation and the kidney transplant will be seen as a waste of time as the kidney transplant will have a reduced chance of being successful.

In conclusion, if one condition is not met properly, it can mean that the kidney transplant and donation process will become a “waste of time” due to the unsuccessful outcome (the patient needing another possible kidney transplant and more kidney dialysis, if this is not met then the survival rate of the patient is quite low). Factors such as alcohol consumption and the age can make a subtle difference between life or death of the patient as well as determining the lifespan of the kidney which can affect the quality of life of the patient. This determines that the donor condition can majorly affect the process of kidney transplantation and donation but significantly less than the donor and recipient compatibility as only age is a major concern, other factors can be fixed to make sure that the lifespan of the kidney is longer such as quitting smoking or reducing alcohol consumption.

The third factor that can affect the process of a transplant and donation is the patient condition. Cancer is one of the main factors that can ultimately decide if a recipient is eligible for receiving a kidney transplant. This is because “transplantation does not improve and may reduce the patients’ prognosis, and to avoid placing scarce donated organs into recipients with a limited prognosis.”[9].. Additionally, it has been proven that patient lifespan is decreased to the median patient survival after the diagnoses of cancer were only 2.7 years, compared with an average survival of recipients without cancer of 8.3 years.[10] The patient’s risk of developing cancer will also be increased after the transplant.[11] All of these factors will affect the process of a donation and transplant as it would not take place due to the survival outcome of the patient, kidneys may be saved for other people on the ongoing transplant waiting list.