Kidney transplantation

Dialysis restricts life of patients with kidney disease. Generally, after a transplantation, the quality of life as well as the life expectancy increases. Many dialysis patients hope for a better life and wait for a suitable, donated organ. Kidney transplantation is superior to dialysis.

People are free to decide if they what to donate one or multiple organs after their death to help foreign ill people and give them the chance of a new healthy/healthier life. Only if donors are brain dead („The complete and irreversible loss of all brain function[s.]“) – that means that their heart is still beating and supplies the body with blood with oxygen and nutrients –, their organs can be used for organ donation. 

After the diagnosed brain death of an organ donor, his or her death is reported to foundations like EUROTRANSPLANT (Regional differences: some countries have a different system!). Based on the compatibility, waiting time of patients and the locations of donor and recipient, the organs then are distributed.

Today, there are far more patients on the waitlist for a kidney or any other donated organ then there are deceased people who die by brain death and are organ donors. Currently, the wait time for a donated kidney is about six to eight years. Thus, some patients on the waitlist die before they even have the chance of receiving a “new” kidney.

Please, look up the transplantation laws in your own country! Laws differ.

DECIDE!: It is important to decide whether YOU personally want to donate organs OR not and if so, which organs and tissues you want to donate after your death.
The decision counts because after your death, you can be treated and buried as YOU like. Please, inform your closest relatives about your decision and please, record your decision in written form and in a legally secure manner!

Brain death is defined as „the complete and irreversible loss of all brain function[s]“. ‘Loss of all brain function’ means all brain functions in the cerebrum, the cerebellum and the brain stem are irretrievable destroyed. This can happen e. g. due to a hemorrhage or blood clot (both are forms of stroke), a brain tumor or a traumatic injury leading to insufficient blood supply with oxygen and nutrients and, thus, to the cell death of numerous neurons. Consequently, the brain can no longer function properly – the brain as the superordinate control organ of body functions failed. Shortly after the brain death, the heart stops beating and all other organs arrest too.

In the era of modern medicine, it is possible to artificially maintain circulation with ventilation machines and special pharmaceuticals. For a short period of time, the body and its organs are supplied with oxygen and nutrients so that the other organs do not undergo cell death. However, after brain death, enzymes start to digest the brain tissue. This process is irreversible. Now, the patient can receive the brain death diagnosis and might be prepared for organ donation if the organ donation was expressly desired before death. 

The decision for or against (!) organ donation can be made by the patient himself with e. g. an organ donor card or a living will. If no legal documents exist, it is possible that the closest relatives decide whether the organ donation is carried out. However, in some countries, every person who has not explicitly objected to organ donation is automatically a donor.

Please, inform yourself about the legal situation in your own country! Laws differ.

The diagnosis of brain death is very strict and must be carried out according to a clearly defined procedure with constant and strict recording. The brain function of each part of the brain (cerebrum, cerebellum, brain stem) is examined and evaluated in its entirety. Always, the irreversible brain damage and its reason have to be clearly proved. Furthermore, to ensure the irreversibility, the examinations are repeated at certain intervals and additional examinations take place. 

The diagnosis ‘brain death’ can only be made by two different specialist doctors. At least one of them has to be a medical specialist in either neurology or neurosurgery with long experience in treating patients with severe brain damage on the intensive care unit (ICU). In cases of children, the diagnostic is even more strict because the brain is not fully developed up to the age of two. Thus, the procedure must be adapted. For children up to the age of 14, one of the diagnosing specialists has to be a pediatrician. Moreover, these specialists are not allowed to participate in the transplantation process (neither removal nor transplantation) and must not derive any personal or professional benefit from the diagnosis, the transplantation itself and anything that follows.

The diagnostic process can take hours up to days. Every step and each test result has to be strictly protocoled and then archived for a long time (In cases of organ or tissue donation at least 30 years.).

Today, is not enough to diagnose cardiac and respiratory arrest for the pronouncement of legal death as they are no longer seen as unmistakable death signs. Only the certain diagnosis of brain death by two independent and neutral specialist doctors counts as an unmistakable death. If there is even the slightest uncertainty, further examinations have to take place. Only if there are no concerns about the certainty of the irreversible brain death, a person is approved for organ removal. Moreover, medical therapy will not be discontinued before brain death has been determined.

Nowadays, almost every third transplanted kidney was donated by a living donor.

Generally, the prognosis and outcome are better after receiving an organ of a living donor. Reasons for that is that the transplanted organ is often in better condition since it is from a healthy and living person and not from a deceased donor. Moreover, the cold ischemia time (see below) is significantly lower because the transport time is little to nothing since the surgeries for removal and transplantation are usually performed in the same hospital at the same time. Also, it is assumed that it the organ recipients of a living donation are more careful and compliant considering general health and the regular drug intake since they do not want to endanger the selfless gift of a relative.

A study demonstrated that kidneys, which were donated by a living donor, have a better prognosis considering the function of the transplanted organ: After five years 86 percent of the kidneys of living donors still functioned properly compared to 75 percent by postmortal donated organs.

Generally, kidneys and parts of the liver of a living donor are transplanted. It is medically and legally possible to transplant parts of the lungs, of the intestine and of the pancreas too. However, those surgeries are quite rare.

Basically, everybody who has reached the legal age of majority and has the capacity to consent can become a living donor. The donor has to be in good physical condition and both kidneys must be healthy and function normally. People who are pregnant, have a mental illness or any disease which is harmful for the kidneys like proteinuria (protein in the urine), hypertonia (high blood pressure) or diabetes are not allowed to donate they kidneys. 

Furthermore, it is only legally possible to donate organs to the closest relatives (first and second-degree relatives, spouses, registered or engaged partners or other persons with an extraordinary relationship). It is only allowed if there is no suitable organ of an deceased donor available and if the donor is not endangered by the surgery and its consequences of continuing life with only one kidney. Moreover, there must be no suspicion of a relationship of dependency, organ trafficking or forced donation. The living donation must be the free and own will of the donor and is not compensated with money or any other good.

After the determination of the patient's brain death, he or she is reported to an organization like Eurotransplant which then distributes the organs based on different criteria. They are among others: compatibility (e. g. blood type, tissue characteristics like HLA-antigenes as well as height, sex, age and weight), previous waiting time and transport time / low cold ischemia time. In cases of living kidney donation, if compatibility is determined and everything legal has been clarified, both donor and recipient are prepared for the transplantation over a certain time before surgery.

Then, the organ(s) are surgically removed from the donor and further examined. Depending on the condition of the organ, they are authorized to be transplanted and transported to the recipient. While the organs are removed, the organ recipient is prepared for surgery to transplant the “new” organ as fast as possible. Only special transplantation centers are allowed to transplant organs. However, organ removal is allowed in far more hospitals.

In kidney transplantation, normally, both “old” kidneys remain in the body to make the surgery less invasive. Thus, the patient has three kidneys after transplantation. Normally, the “new” kidney is not implanted not at the usual location, but it is placed into the patient's pelvis. There, the renal artery and vein are linked to the iliac blood vessels to supply the kidney with blood which can then be filtered to urine. Its ureter is it connected with urinary bladder.^[3] This surgical technique is beneficial to a placement at the usual location: The distance between the “new” kidney and the bladder is smaller, the blood vessel connection is less complicated and the transplanted organ is now easier to examine (palpation, examination via ultrasound and biopsy).

The kidney has the longest so-called cold ischemia time of all transplantable organs with a duration of 24 to 36 hours. This is the time after the removal of the organ to the transplantation into the recipient. In other words, the time in which no blood and, thus, no oxygen or nutrients circulate through the organ. While the organ is transported to the recipient, it is conservated and cooled to prevent possible damages. The temperature in the transport box is kept constant at four degrees Celsius (39,2 degrees Fahrenheit). The organ is either transported by car or by a chartered plane for long distances. In cases of living donation, removal and transplantation is usually performed in the same hospital. Donated organs are constantly accompanied and guarded.

After surgery, patients are monitored on a special hospital ward for transplanted patients. There, after-care and physiotherapy take place. For surgery, a bladder catheter is placed in the patient. The bladder catheter remains until the sutures have healed and is removed normally after one week and when the kidney function is sufficient. It is used for monitoring and evaluation of the urine production of the transplanted kidney. Sometimes, it may take some time until the new transplanted organ functions properly. In these cases, dialysis still needs to be performed for a while. Furthermore, a stabilizing ureter stent (due to its form often called double-j-stent) is often placed in the ureter and is removed after about six weeks.

Often, pharmaceutical therapy has to be adapted, e. g. blood pressure levels changes. Furthermore, from now on the patients have to take immunosuppressive drugs for the rest of their lives to prevent a rejection reaction of the body against the new organ which possibly can damage the donated organ.

Usually, patients are treated stationary in the hospital for about two weeks after the transplantation. Then, if no complications appeared, they can start a rehabilitation treatment which lasts about three weeks in a special hospital. After that, the patients should go to regular monitoring appointments with a specialist to ensure kidney function and health. The transplanted organ functions approximately 14 years. If the organ was donated by a living donor, this prognostic timespan increases.

Please, look up the legal situation concerning organ donation and transplantation in your own country! Laws and procedures might differ. 

Discuss treatment options with your treating physician!