Kidney transplantation is one option for patients with kidney failure or end-stage CKD (chronic kidney disease). Chronic renal failure is characterized by a progressive loss of kidney function.  

Categories of kidney failure: 

Kidney failure can be broadly categorised into two types.  Acute and Chronic.

Acute renal failure is defined by the emergence of decreased kidney function in a short period.

Chronic kidney on the other hand, develops gradually and results in decreased functioning of the kidney and is the more severe form. 

Underlying causes and indications of kidney failure: 

• Kidney failure can be attributed to a shortage of fluid in the circulation As a result, intravenous fluid administration is advised. It could also be due to an increase in the fluid build-up. This in turn causes leg swelling and cramps as a result of the poisonous accumulation of waste products. For the outflow of excess fluid, diuretics are indicated.
• High potassium levels in the blood is a warning sign of kidney disease. To combat the harmful accumulation of potassium, nephrologists recommend and deliver medicines such as glucose or sodium polystyrene sulfonate.
• High blood creatinine levels can indicate kidney disease, kidney stones, or glomerulonephritis. Creatinine levels should be between 0.7 and 2.0 mg/dL. The normal range of creatinine is between 0.7 to 1.2 mg/dl in males and 0.5 to 1.0 mg/dl in females. Anything outside that range is considered a red flag.
• GFR (Glomerular filtration rate) level lower than 15mL/min is considered to be serious. This is commonly seen in end-stage CKD. Dialysis or renal transplantation is recommended at this stage.

Key points to consider prior to Renal transplantation: 

• The decision to undergo transplantation lies on the patient, their family, and the physician in charge after careful consideration and patient evaluation. It is a surgical intervention that necessitates the placing of a healthy kidney in the body of the patient where it can perform all functions that a failing kidney cannot. 
• In most cases the diseased kidney located in the abdomen near the lower back is not removed, the new kidney is placed in the pelvic area where it is connected to the blood vessels and urinary bladder. The donated kidney can come from a living or a deceased donor. A living donor does not have to be a blood relative and can be spouses, co-workers, or friends. The potential donors undergo a series of tests to make sure that they donate a healthy kidney and donating a healthy kidney does not lead to any undue health issues on the donor. The deceased donor kidney is obtained from people who have expressed their desire to donate kidneys long with familial consent. 
• All donors are screened very carefully to prevent any transmission of disease. Certified nephrologists trained in dealing with renal transplants and associated procedures monitor patients both before and after transplant surgery. Transplant coordinators, urologic surgeons, living kidney donor advocate social workers, financial coordinators are other transplant team members that are all involved in providing holistic patient care. 

Benefits of renal transplantation: 

• Typically gives one more strength, stamina, and energy compared to dialysis.
• Return to a normal lifestyle.
• Associated with longer lifespan and life expectancy.

Risks: 

• Bleeding or haemorrhage at the site of incision or adjoining areas. 
• Chances of contracting infections.
• Wound associated complications.
• Side effects of medications.
• Weakened immunity.
• Rejection of graft. 

If a kidney transplant fails, the recipient can revert to a dialysis schedule or look for another potential transplant. But owing to intensive research and improved medicine the success rate of kidney transplants is comparatively higher. 

Immunological basis of renal transplantation:

The Immune System remains the most formidable barrier to transplantation as routine medical treatment.

Transplant or graft: Transplant also called a graft is a section of tissue removed from its original site and transferred to a new position in the same person or a separate individual. 

Concept of autograft: Organ tissues that are transplanted within the same person’s body are called autografts.

Concept of allograft: Transplants that are recently performed between two subjects of the same species are termed allografts. 

Concept of isograft: A subset of allograft in which organs /tissue is transplanted from a donor to a genetically identical recipient is termed isograft. They differ from other types of transplants because they do not trigger an immune response.

To understand the very basis of transplantation immunology one needs to understand the concept of human leukocyte antigen (HLA).

HLA: It is a locus of genes that encode for proteins on the surface of all nucleated cells, that are responsible for the regulation of immune response. They are of much importance as they exhibit a high degree of “polymorphism”. They reside on chromosome 6. HLA genes are nothing but the human version of MHC (major histocompatibility complex) present in other vertebrates.

HUMAN CHROMOSOME NO 6:

HLA –A

HLA-B

HLA-C

These are HLA TYPE 1 located on the P arm of the chromosome.

HLA-DQ

HLA-DP

HLA-DR

These are HLA types 2 located on the Q arm of the chromosome.

Major functions associated with HLA:

• HLA Type 2 encodes for the complement system.
• HLA is important in disease defence.
• HLA is the major cause of organ/tissue transplantation.

Types of Kidney transplant surgeries: 

There are two types of kidney transplant surgeries: open nephrectomy and laparoscopic nephrectomy. The cost of a kidney transplant in India is near about 7-8 lacs INR.

• Open nephrectomy: An open nephrectomy includes removing the damaged kidney and replacing it with a healthy kidney through a wide abdominal incision. It necessitates a lengthy recuperation period of one to two months.
• Laparoscopic nephrectomy is a type of micro surgery that is performed through small incisions in the abdomen. The laparoscope is also inserted into the keyhole incisions to locate and dissect the kidney. The kidney is then removed through an incision that already exists. In comparison, it is a more expensive operation since it incorporates cutting-edge technology that necessitates greater precision. 

Diagnostic tests conducted before transplant surgery: 

Several blood tests and scans are used to determine whether a donor is compatible and healthy enough to donate a kidney. The necessitated tests are enlisted below:

1. HLA typing and serological CDC crossmatch: 

The cost of the aforementioned molecular tests can range between 1,00,000 to 2,00,000 lakhs in 

1. Biochemical Kidney and Liver functioning Tests: Before a transplant, kidney, and liver tests are done to rule out infections and monitor enzyme levels in the blood.

The metabolic panel blood test assesses blood sugar, electrolytes, fluid balance, kidney, and liver function.

The Liver Function Test (LFT) is a blood test that examines protein, liver enzymes, and bilirubin levels. A lipid profile is a set of tests used to determine the levels of cholesterol and triglycerides in your blood.

1. Immunological Diagnostic Tests:

• A blood typing test determines the blood group and checks the compatibility of blood between recipient & donor.

• A CBC blood test evaluates overall health and detects blood disorders.

• A coagulation test detects blood’s ability to clot.

• The antigen-antibody test detects the presence of specific antibodies in the blood.

• HIV tests are designed to detect antibodies to HIV.

1. Lung functioning tests: A chest X-ray is used to identify a lung infection and to obtain images of the airways, heart, blood vessels, and bones of the chest and spine.
2. Heart functioning Tests: An electrocardiogram (ECG) is used to detect changes in heart rhythm and to calculate the electrical activity of the heartbeat.

While exercising on a bicycle or treadmill, a cardiac stress test examines the electrical activity of the heart.

1. Hematological blood flow Tests: Doppler Ultrasound is used to determine the amount of blood flowing through the arteries and veins.

Sources of donors in Renal transplantation: It refers to the process of transplantation of the kidney from a donor to the recipient (having an impaired kidney). The donor might be a deceased donor (cadaver) or a living donor. This process is recommended to patients only with end-stage CKD. But finding an ideal match for the recipient with kidney failure is often a cumbersome process. 

Several aspects of renal transplantation:

• ABO compatibility: O blood type people can donate a kidney to all groups but can only receive the graft from blood type O. AB blood type can receive a graft from all blood group types but donate graft only to AB blood groups.
• HLA matching or cross-matching– ABO compatibility is not the only criteria. HLA (human leukocyte antigen) matching needs to be performed. Cross-matching blood, in transfusion medicine, refers to another testing that is performed before a blood transfusion to determine if the donor’s blood is compatible with the blood’s intended recipient. Cross-matching is always performed by certified laboratory technologists in the laboratory. HLA are antigens expressed on cells that allow differentiation between self and on self. So, any incoming graft can be considered foreign and rejected. So, when the graft or kidney is introduced from donor to the recipient with no prior HLA matching, the recipient might develop antibodies against it and reject the graft. So, HLA matching needs to be done to prevent graft rejection. The detection of anti-HLA Abs in the recipient’s serum. A negative CDC crossmatch is desired. The underlying principle of CDC (Complement dependent cytotoxicity) crossmatch is to detect clinically relevant donor-specific anti-HLA antibodies that could result in hyperacute rejection following transplantation. In addition, immunosuppressants like cyclosporine are administered for preventing graft rejection.
• Luminex technology: This is another platform that uses the principle of flow cytometry for the determination of anti-HLA Antibody specificity. It’s a high-end technology with very high resolution and is a clear voice for histocompatibility and transplant immunology labs requiring a high degree of multiplexing and throughput reducing costs and boosting productivity.   
• Inclusion of a healthy donor: The donor should have two pairs of healthy kidneys, should not have any comorbidities such as diabetes, hypertension, or any other underlying diseases like HIV and cancer. 
• Participation of donors: In India usually, family members, relatives, spouses, and siblings are recommended to donate the kidney. After HLA matching the donated kidney is flushed with a physiological solution and then introduced to the recipient in a couple of hours.
• Marker for accessing successful engraftment: A serum creatinine level between 100-120 µM/L is indicative of successful renal transplantation and graft acceptance. However, a persistent increase in serum creatinine may be checked for acute graft rejection.

Post transplantation, patients should follow the following dietary recommendations:

• A high-protein diet (eggs and green vegetables) is required. Consumption of low-sodium, low-potassium diets is a must for keeping the kidneys in good shape. 
• It is suggested that fluids and beverages be consumed in a balanced manner. Dietary requirements include cauliflower, blueberries (antioxidants), eggs, garlic (alternative to salt), onions, and pineapples. Drinking plenty of water is highly recommended. 
• The levels of potassium, calcium, creatinine, and urea in the blood should be monitored regularly.
• Traveling is not advised because dialysis may be missed. Regular dialysis (3 times a week) at a reputable health center is a must for regaining renal function.
• Both health care providers and family members must provide support and care. Family members must receive additional training to operate and use the machine.

Common FAQs on Kidney transplantation:

• Effect on fertility? 

Fertility (the ability to conceive children) is also on the rise. Men who have undergone kidney transplants have fathered healthy offspring, and women who have had kidney transplants have given birth to healthy babies.

• Total fund and cost involving transplantation surgery?

Medicare or the recipient’s insurance will fund the operation and examination. The living donor will not be responsible for any costs associated with the surgery.

• Effect on work life?

Many people can return to work after their transplant in as little as eight weeks.

• Frequency of medical check-ups and follow ups?

Regular checks are required especially during the first year, to ensure that one’s transplant is effective. Blood tests may be required multiple times each week in the beginning. After that, one just needs a few more check-ups to ensure that your kidneys are operating well and that one is taking the right quantity of anti-rejection medication such as immunosuppressant drugs e.g., cyclosporine.