End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Dialysis and kidney transplantation are treatments for severe kidney failure, also called kidney (or renal) failure, stage 5 chronic kidney disease, and end-stage kidney (or renal) disease. There are two types of dialysis: hemodialysis and peritoneal dialysis.

In the US, African Americans (AAs) are four times more likely to develop end stage renal disease (ESRD) but half as likely to receive a kidney transplant as whites. Patient interest in kidney transplantation is a fundamental step in the kidney transplant referral process. Our aim was to determine the factors associated with the willingness to receive a kidney transplant among chronic kidney disease (CKD) patients in a predominantly minority population.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Kidney transplantation is the treatment of choice for most patients with end-stage renal disease (ESRD) [1,2]. A successful kidney transplant improves quality of life and reduces the mortality risk for the majority of patients when compared with maintenance dialysis.

The lifespan of a transplant kidney has significantly improved over the last 30 years. Between 1986 and 1995, 75 percent of the transplanted kidneys still functioned five years after the transplant. Between 2006 and 2015, this number had already risen to 84 percent. However, an international study led by kidney specialist Maarten Naesens of KU Leuven shows that the progress is stagnating.

 

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A transplanted kidney’s lifespan is 15 to 20 years on average. If the kidney stops working, the patient is back on the waiting list for a new one. However, a second or even a third transplant is more complex, as finding a new good match between donor and recipient becomes increasingly difficult. In practice, this often results in patients having to undergo dialysis treatment for a long time, or even for the rest of their lives. To avoid this, extending the lifespan of transplant kidneys should be prioritized.

Professor Maarten Naesens of KU Leuven and University Hospitals Leuven says, “The data of more than 100,000 recipients of transplant kidneys across Europe from 1986 until 2016 shows that we have made considerable progress in the last 30 years. Between 1986 and 1995, 87 percent of the transplanted kidneys still functioned one year after the transplant. After five years, that was still 75 percent. Between 2006 and 2015, this number had risen to 92 percent one year after the transplantation and 84 percent five years after.”

This is good news, but Naesens says, “For the most part, this progress was made in the period 1986 to 2000. Unfortunately, we haven’t seen much progress in the last 15 years. The data confirms what we already noticed in the hospital. This is especially striking compared to other fields in medicine. Against expectations, the stagnation has nothing to do with the changing profile of donors and recipients, at any rate. On average, they have become older with more concomitant diseases in past years. But even if we take this into account, it doesn’t explain why the lifespan of a transplant kidney has stagnated.” So the question is: what is the cause?End-Stage-Renal Disease and Kidney Transplantation Essay Paper

The explanation can be found in the way we treat patients, concludes Naesens: “The medication currently used to prevent a kidney from being rejected by the recipient’s immune system dates back to the 1990s. Our scientific knowledge has, of course, increased in the last 15 years, but this hasn’t resulted in better medicines. This means that there is a clear need for innovation when it comes to kidney transplants.”

Patients with ESRD often have significant comorbidities. It is important that potential kidney transplant recipients are carefully evaluated in order to detect and treat coexisting illnesses, which may affect perioperative risk and survival after transplantation, as well as transplant candidacy [3,4]. (See “Patient survival after renal transplantation”.) The evaluation should be as efficient and cost effective as possible.

This topic will review the evaluation of a potential renal transplant recipient. The evaluation of the renal transplant donor is discussed separately. (See “Evaluation of the living kidney donor candidate”.)

Issues related to patient survival following transplantation, risk factors associated with graft failure, and the kidney transplant waitlist are discussed elsewhere. (See “Patient survival after renal transplantation” and “Risk factors for graft failure in kidney transplantation” and “The kidney transplant waiting list in the United States”.)

Kidney transplantation or renal transplantation is the organ transplant of a kidney into a patient with end-stage renal disease. Kidney transplantation is typically classified as deceased-donor (formerly known as cadaveric) or living-donor transplantation depending on the source of the donor organ.

When your kidneys fail, treatment is needed to replace the work your own kidneys can no longer do.  There are two types of treatment for kidney failure — dialysis or transplant. Many people feel that a kidney transplant offers more freedom and a better quality of life than dialysis.  In making a decision about whether this is the best treatment for you, you may find it helpful to talk to people who already have a kidney transplant. You also need to speak to your doctor, nurse and family members.End-Stage-Renal Disease and Kidney Transplantation Essay Paper,MNNBHBHBBB
What is a kidney transplant?
When you get a kidney transplant, a healthy kidney is placed inside your body to do the work your own kidneys can no longer do.
On the plus side, there are fewer limits on what you can eat and drink, but you should follow a heart-healthy diet. Your health and energy should improve.  In fact, a successful kidney transplant may allow you to live the kind of life you were living before you got kidney disease. Studies show that people with kidney transplants live longer than those who remain on dialysis.
On the minus side, there are the risks of surgery.  You will also need to take anti-rejection medicines for as long as your new kidney is working, which can have side effects.  You will have a higher risk for infections and certain types of cancer.
Although most transplants are successful and last for many years, how long they last can vary from one person to the next. Many people will need more than one kidney transplant during a lifetime.End-Stage-Renal Disease and Kidney Transplantation Essay Paper
What is a “preemptive” or “early” transplant?
Getting a transplant before you need to start dialysis is called a preemptive transplant.  It allows you to avoid dialysis altogether.  Getting a transplant not long after kidneys fail (but with some time on dialysis) is referred to as an early transplant. Both have benefits.  Some research shows that a pre-emptive or early transplant, with little or no time spent on dialysis, can lead to better long-term health.  It may also allow you to keep working, save time and money, and have a better quality of life.
Who can get a kidney transplant?
Kidney patients of all ages—from children to seniors—can get a transplant.
You must be healthy enough to have the operation. You must also be free from cancer and infection. Every person being considered for transplant will get a full medical and psychosocial evaluation to make sure they are a good candidate for transplant.  The evaluation helps find any problems, so they can be corrected before transplant.  For most people, getting a transplant can be a good treatment choice.
What if I’m older or have other health problems?
In many cases, people who are older or have other health conditions like diabetes can still have successful kidney transplants.  Careful evaluation is needed to understand and deal with any special risks.  You may be asked to do some things that can lessen certain risks and improve the chances of a successful transplant.  For example, you may be asked to lose weight or quit smoking.
If you have diabetes, you may also be able to have a pancreas transplant.  Ask your healthcare professional about getting a pancreas transplant along with a kidney transplant.
How will I pay for a transplant?
Medicare covers about 80% of the costs associated with an evaluation, transplant operation, follow-up care, and anti-rejection medicines.  Private insurers and state programs may cover some costs as well. However, your post-transplant expenses may only be covered for a limited number of years. It’s important to discuss coverage with your social worker, who can answer your questions or direct you to others who can help. Click here to learn more about insurance and transplant.  End-Stage-Renal Disease and Kidney Transplantation Essay Paper
Getting a Transplant

How do I start the process of getting a kidney transplant?

Ask your healthcare provider to refer you to a transplant center for an evaluation, or contact a transplant center in your area.   Any kidney patient can ask for an evaluation.

How does the evaluation process work?

Medical professionals will give you a complete physical exam, review your health records, and order a series of tests and X-rays to learn about your overall health. Everything that can affect how well you can handle treatment will be checked. The evaluation process for a transplant is very thorough. Your healthcare team will need to know a lot about you to help them—and you—decide if a transplant is right for you. One thing you can do to speed the process is to get all the testing done as quickly as possible and stay in close contact with the transplant team.  If you’re told you might not be right for a transplant, don’t be afraid to ask why—or if you might be eligible at some future time or at another center. Remember, being active in your own care is one of the best ways to stay healthy.
If someone you know would like to donate a kidney to you, that person will also need to go through a screening to find out if he or she is a match and healthy enough to donate.
If it’s your child who has kidney disease, you’ll want to give serious thought to getting a transplant evaluation for him or her. Because transplantation allows children and young adults to develop in as normal a way as possible in their formative years, it can be the best treatment for them.
If the evaluation process shows that a transplant is right for you or your child, the next step is getting a suitable kidney. (See “Finding a Kidney” below.)

What does the operation involve?

You may be surprised to learn that your own kidneys generally aren’t taken out when you get a transplant. The surgeon leaves them where they are unless there is a medical reason to remove them. The donated kidney is placed into your lower abdomen (belly), where it’s easiest to connect it to your important blood vessels and bladder. Putting the new kidney in your abdomen also makes it easier to take care of any problems that might come up.End-Stage-Renal Disease and Kidney Transplantation Essay Paper
The operation takes about four hours. You’ll be sore at first, but you should be out of bed in a day or so, and home within a week. If the kidney came from a living donor, it should start to work very quickly. A kidney from a deceased donor can take longer to start working—two to four weeks or more. If that happens, you may need dialysis until the kidney begins to work.
After surgery, you’ll be taught about the medicines you’ll have to take and their side effects.  You’ll also learn about diet. If you’ve been on dialysis, you’ll find that there are fewer restrictions on what you can eat and drink, which is one of the benefits of a transplant.

What are anti-rejection medicines?

Normally, your body fights off anything that isn’t part of itself, like germs and viruses. That system of protection is called your immune system. To stop your body from attacking or rejecting the donated kidney, you will have to take medicines to keep your immune system less active (called anti-rejection medicines or immunosuppressant medicines).   You’ll need to take them as long as your new kidney is working.  Without them, your immune system would see the donated kidney as “foreign,” and would attack and destroy it.
Anti-rejection medicines can have some side effects.  It is important to talk to your healthcare provider about them, so that you know what to expect.  Fortunately, for most people, side effects are usually manageable.  Changing the dose or type of medicine can often ease some of the side effects.
Besides the immunosuppressive medicines, you will take other medicines as well. You will take medicines to protect you from infection, too.  Most people find taking medicines a small trade for the freedom and quality of life that a successful transplant can provide.
After Your Transplant

What happens after I go home?

Once you are home from the hospital, the most important work begins—the follow-up.  For your transplant to be successful, you will have regular checkups, especially during the first year.  At first, you may need blood tests several times a week.  After that, you’ll need fewer checkups, but enough to make sure that your kidney is working well and that you have the right amount of anti-rejection medication in your body.
What if my body tries to reject the new kidney?
One thing that you and your healthcare team will watch for is acute rejection, which means that your body is suddenly trying to reject the transplanted kidney. A rejection episode may not have any clear signs or symptoms. That is why it is so important to have regular blood tests to check how well your kidney is working.  Things you might notice that can let you know you are having  rejection are fevers, decreased urine output, swelling, weight gain, and pain over your kidney.
The chances of having a rejection episode are highest right after your surgery. The longer you have the kidney, the lower the chance that this will happen.  Unfortunately, sometimes a rejection episode happens even if you’re doing everything you’re supposed to do. Sometimes the body just doesn’t accept the transplanted kidney. But even if a rejection episode happens, there are many ways to treat it so you do not lose your transplant.  Letting your transplant team know right away that you think you have symptoms of rejection is very important.

How often do rejection episodes happen?

Rejections happen much less often nowadays. That’s because there have been many improvements in immunosuppressive medicines.  However, the risk of rejection is different for every person.  For most people, rejection can be stopped with special anti-rejection medicines. It’s very important to have regular checkups to see how well your kidney is working, and make sure you are not having rejection.
How soon you can return to work depends on your recovery, the kind of work you do, and your other medical conditions.  Many people can return to work eight weeks or more after their transplant.  Your transplant team will help you decide when you can go back to work.
People who have not had satisfactory sexual relations due to kidney disease may notice an improvement as they begin to feel better.  In addition, fertility (the ability to conceive children) tends to increase.  Men who have had a kidney transplant have fathered healthy children, and women with kidney transplants have had successful pregnancies. It’s best to talk to your healthcare practitioner when considering having a child.
Women should avoid becoming pregnant too soon after a transplant.  Most centers want women to wait a year or more.  All pregnancies must be planned.  Certain medications that can harm a developing baby must be stopped six weeks before trying to get pregnant.  Birth control counseling may be helpful.  It’s important to protect yourself against sexually transmitted diseases (STDs).  Be sure to use protection during sexual activity.

Will I need to follow a special diet?

In general, transplant recipients should eat a heart-healthy diet (low fat, low salt) and drink plenty of fluids.  If you have diabetes or other health problems, you may still have some dietary restrictions.  A dietitian can help you plan meals that are right for you.
Finding a Kidney
Where do donated kidneys come from?
A donated kidney may come from someone who died and donated a healthy kidney. A person who has died and donated a kidney is called a deceased donor.
Donated kidneys also can come from a living donor. This person may be a blood relative (like a brother or sister) or non-blood relative (like a husband or wife). They can also come from a friend or even a stranger.
When a kidney is donated by a living person, the operations are done on the same day and can be scheduled at a convenient time for both the patient and the donor. A healthy person who donates a kidney can live a normal life with the one kidney that is left. But the operation is major surgery for the donor, as well as the recipient. As in any operation, there are some risks that you will need to consider.
Is it better to get a kidney from a living donor?
Kidneys from living or deceased donors both work well, but getting a kidney from a living donor can work faster and be better.  A kidney from a living donor may last longer than one from a deceased donor.End-Stage-Renal Disease and Kidney Transplantation Essay Paper
To get a deceased donor kidney, you will be placed on a waiting list once you have been cleared for a transplant.  It can take many years for a good donor kidney to be offered to you.  From the time you go on the list until a kidney is found, you may have to be on some form of dialysis. While you’re waiting, you’ll need regular blood tests to make sure you are ready when a kidney is found. If you’re on dialysis, your center will make the arrangements for these tests. Your transplant center should know how to reach you at all times.  Once a kidney become available, the surgery must be done as soon as possible.
Are there disadvantages to living donation?
A disadvantage of living donation is that a healthy person must undergo surgery to remove a healthy kidney.  The donor will need some recovery time before returning to work and other activities.  However, recent advances in surgery (often called minimally invasive or laparoroscopic surgery) allow for very small incisions.  This means shorter hospital stays and recovery time, less pain, and a quicker return to usual activities.  Living donors often experience positive feelings about their courageous gift.
What are the financial costs to the living donor?
The surgery and evaluation is covered by Medicare or the recipient’s insurance.  The living donor will not pay for anything related to the surgery.  However, neither Medicare nor insurance covers time off from work, travel expenses, lodging, or other incidentals.  The National Living Donor Assistance Program (www.livingdonorassistance.org) or other programs may help cover travel and lodging costs.

A kidney transplant is a surgical procedure during which a patient receives a donated kidney to replace their diseased kidney. This is done as a treatment for end stage kidney disease, which is kidney disease that is so severe that it will shorten the lifespan of the individual because the kidneys are no longer able to do their job well enough to prevent illness.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

The Kidneys

A healthy human body has two kidneys that work together to filter the blood and remove toxins from the body. The kidneys work to maintain the appropriate amount of fluid in the blood and also filter excess salts, electrolytes and minerals out of the blood.

The kidneys make urine with what is filtered from the blood. This urine is then eliminated from the body first by moving out of the kidneys through the ureters to collect in the bladder, then exiting the body through the urethra during urination.

Without the kidneys, water is not eliminated from the body, which can cause fluid overload making it difficult to breathe and causing serious swelling throughout the body. It also makes the work of the heart much more difficult, and if it continues without treatment, this excess water can lead to death.

Along with the excess water comes disturbances in how much salt, potassium, magnesium and other electrolytes remain in the blood. Imbalances in these substances can cause issues with the function of the heart and other serious complications.

Kidney Disease

Individuals whose kidneys are no longer functioning well enough to support the needs of their body will need dialysis or a kidney transplant to prevent death. Kidney disease is usually a progressive issue, and worsens over time, so the individual is typically well aware of their worsening kidney disease and is able to take steps to prevent the disease from progressing rapidly.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

One common cause of kidney disease and the eventual need for dialysis is poorly-controlled diabetes. For an individual who is diabetic and has kidney disease, getting glucose levels under control can add years to the functional lifespan of the kidneys, or even prevent the need for dialysis and transplant entirely.

For other individuals, kidney disease worsens over time despite medical interventions and lifestyle changes. Despite everyone’s best efforts, the kidneys become too diseased to function well.

Rarer still is when sudden kidney issues, called acute renal failure, lead to permanent kidney disease. In these cases the damage is sudden and cannot be recovered. This may happen due to a trauma or as a side effect of a major illness.

There are many stages of kidney disease, ranging from mild disease to severe and life-threatening conditions. End stage kidney disease is the final step in kidney disease. This is the level of disease that requires dialysis treatments, transplant or death will eventually occur.

Kidney Transplant

The process of being listed on the transplant recipient wait list is neither quick nor easy, but the effort is well worth it when a new kidney becomes available.

The process to be approved to be on the transplant list will start early in the disease process, when your kidney problem is first noticed, and a referral to a nephrologist—kidney doctor—is made. Your nephrologist may be able to treat your disease for many years, but when it worsens and it becomes clear that dialysis and the need for a transplanted kidney are becoming a reality, you can be referred to a transplant center.

The transplant center will then determine if you are appropriate for a kidney transplant. Many questions will need to be answered, starting with the most basic issue of whether or not a kidney transplanted is needed by doing lab tests that determine how the kidneys are functioning. If there is a need for a kidney transplant, many more questions will need to be answered.

These issues range from whether or not the individual is a good candidate for a transplant, if they are healthy enough to tolerate the surgery and the stress the surgery will place on the body and if the reward of the transplant outweighs the potential risk of transplant surgery and recovery.

Answering these questions, though lab work, physical examinations and other testing is the starting point. After that, additional tests are done to determine the patient’s genetic fingerprint, so that a donated organ that is a good genetic match can be selected to reduce the risk of rejection.

The recipient will also undergo evaluations to determine if they have emotional and mental capacity to tolerate the wait for a transplant, the process of receiving a transplant and have the ability to take care of themselves and manage their health after surgery.

Many transplant centers will not provide any type of organ transplant to patients who are not independent in their day to day needs.

A history or current issues with addiction can also exclude potential recipients from the transplant process, at least on a temporary basis. For example, if the patient abused cocaine and it caused kidney damage, they will not be transplanted if they continue to abuse cocaine. If they are continuing to use the drug they will not be placed on the transplant list until they are free of drug abuse for a length of time that is determined by the transplant center.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

The financial aspects of transplant will also be addressed by the transplant center, making sure the patient has the ability and insurance necessary to pay for the transplant process from first visit to the medication needed to prevent rejection after surgery.

The Transplant List

Once the patient is determined to be appropriate for an organ transplant they are placed on the transplant list by the transplant center. This means they are added to a national database run by UNOS that allows donors and recipients to be matched when an organ becomes available.

The “transplant list” is actually a very large database of over 114,000 individuals waiting for a variety of types of organ transplants. When an organ becomes available for transplantation, a complex mathematical algorithm is used to create the unique list of the potential recipients for that organ. Thousands of these lists are generated on a monthly basis, each one is unique to a specific organ being donated by a specific donor.

Only individuals who are appropriate for that organ will appear on the list. A recipient who is too big or too small or a blood type that is incompatible will not appear on that list.

Contraindications
There are some issues that typically prevent an individual from receiving a transplant. How these are handled are unique to the surgeon and the transplant center, and may be different from center to center or even from one surgeon to another.

A contraindication at one transplant center may not prevent an individual from being listed at a different transplant center, these are not rules, they are general guidelines of suitability for recipients. Some of these would only prevent transplantation temporarily.

For example, a current infection would only prevent transplant surgery while the infection is present. The patient would be eligible for a transplant as soon as they are well. A positive drug screening that shows the potential recipient has been using cocaine, on the other hand, could cause a delay of years in the process.

Active infection
Severe disease of another organ (for some a multi-organ transplant is available, including a heart-kidney or a kidney-pancreas)
Active addiction to drugs that may include illegal drugs, alcohol, and/or nicotine
Cancer that is current, or likely to return.
Inability to manage their own health regimen
Dementia
Severe vascular disease
A life-ending disease in addition to kidney disease
Severe pulmonary hypertension

Types of Kidney Donation

Deceased Donor Transplant

Most donated organs become available for transplantation when a person becomes brain dead, and the donor or their family members elect to donate their organs to a waiting recipient. This type of donation is called a deceased donor transplant.

Living Donor Transplant

In some cases, a healthy friend or family member will donate a kidney to a loved one, as the human body can remain well with one healthy kidney. This is called a living donor. In some cases, a living donor decides to donate to a waiting recipient they do not know out of kindness, this type of donor is referred to as an altruistic donor.

Not every donor kidney is fit for every person waiting for an organ. In order for a kidney donor and a recipient to match, they must be approximately the same body size. In some cases a kidney from a child might be appropriate for a small adult female, but would not be adequate for a large adult, depending on the size of the child. Similarly, a large kidney would be too big for a young child in need of transplantation.

The donor and recipient need to match genetically, and the better that match the better the outcome from surgery over the long term. A zero antigen mismatch is the technical term for a kidney donor-recipient match that is exceptional. This type of match, which is most often seen between relatives, can reduce the amount of anti-rejection medication the recipient needs in the years after surgery.

Barriers to Living Donor Transplantation

If a loved one wants to donate a kidney, they may or may not be able to do so for a wide variety of reasons. Some donors may find out, after starting testing, that they have kidney disease too. Others find out that they are the wrong blood type or have a health condition that makes the donation too risky.

Some of the more common issues that prevent living donation include:

Kidney disease including some types of kidney stones. This is a particular risk when siblings are donating to a sibling with kidney disease, the donating sibling may also find out they have kidney disease.
Uncontrolled blood pressure, diabetes, heart disease or lung disease
History of bleeding problems: bleeding too easily or blood clots
Poorly controlled psychiatric issues
Obesity
Cancer
Communicable diseases, such as HIV  End-Stage-Renal Disease and Kidney Transplantation Essay Paper

For some people, their loved one wants to donate a kidney but cannot due to blood type or another issue of compatibility. Modern medicine makes it possible for donation to occur anyway, with the pairing of matched donors and recipients.

For example, Mr. Smith needs a kidney and Mrs. Smith would like to give him one but they are not compatible. In another area of the state, Mrs. Brown needs a kidney and Mr. Brown would like to donate his, but they are not compatible. A computer program is used to determine that an exchange can take place, where Mr. Brown gives his kidney to Mr. Smith and Mrs. Brown receives Mrs. Smith’s kidney.

These paired exchanges are becoming more common, and the “chains” of donor and recipient matches are getting longer. As of December of 2017 the longest chain, known as the “UAB chain”, was at a record 88 transplants, meaning 88 donors gave a kidney to a person in the chain they did not know, and 88 recipients in the chair received a kidney from someone they did not know.

Kidney Transplant Surgery
Finding a Surgeon and Surgery Center

Most transplant centers have multiple surgeons who are competent to perform a given transplant procedure, but not all transplant centers do all types of transplants. Many centers do offer kidney transplants, but less offer heart or lung transplants, so the nature of your issue and your location may determine where you seek treatment.

You may have many centers to choose from or the nearest transplant center may be a significant distance away from your home, which may limit your options.

The Procedure

The kidney transplant procedure starts with the donor’s surgery, during which the kidney is removed. Once the kidney is determined to be healthy and of high enough quality to be transplanted into a recipient, the process begins for the recipient. They will be sent to the hospital where labs are drawn, IVs are placed and other preparations are made for surgery.

The surgery begins with general anesthesia being given, typically by an anesthesiologist, and the placement of an endotracheal tube.

Once the patient is asleep, the incision is made in the abdomen, where the new kidney will be placed. For most individuals, the native kidneys—kidneys the patient was born with—will remain in place unless they are causing circulation problems or other issues that require their removal.

The kidney is sewn into place by one or two surgeons, with great care to make sure blood flows well through the kidney, and that the kidney begins to make urine within minutes of being connected to the blood supply.

Once the kidney is in place and actively making urine, the surgery is completed and the incision can be closed. The entire process takes two to three hours in most cases.

In the vast majority of surgeries only one kidney is transplanted as one kidney is more than capable of filtering the blood of the recipient. If the donated kidneys are very small, both may be transplanted into the recipient to make sure that the kidneys are able to filter well enough to keep the recipient well.

Risks

In addition to the general risks of surgery and the risks associated with anesthesia, kidney transplant surgery has unique risks. These risks vary from person to person, but also increase with age and the severity of illness.

Risks of kidney transplant include but are not limited to:

Bleeding–the kidney filters the blood, so bleeding has the potential to be severe in rare cases.
Blood clots
Stroke
Anoxic brain injury, or brain damage due to a lack of oxygen
Death. All surgeries have a risk of death, but the risk is higher than typical with kidney transplantation due to the complex nature of procedure and care after surgery.
Acute rejection. The donor’s body does not accept the donated kidney.End-Stage-Renal Disease and Kidney Transplantation Essay Paper
Recovery

The typical patient returns home within a week of surgery with kidney function that is good enough that dialysis is no longer needed. Most individuals are able to return to their normal activities within a month or two of surgery.

Some patients experience immediate kidney function that is excellent, others have a delay in kidney function that may make dialysis a necessity until the kidney reaches its full potential. In rare cases, the kidney never works well enough to allow the patient to stop having dialysis treatments.

Organ rejection can be a serious issue after transplant surgery. This occurs when the body identifies the new organ as a foreign body and tries to reject it. To prevent this, many medications can be used, and some individuals never have an issue with rejection.

Rejection episodes are most common in the six months after surgery but are possible at any time after transplant surgery. When rejection happens, the faster it is identified and treated the better the outcome.

Prognosis

For the kidney recipient, the patient is up to seven times less likely to die than when they were on dialysis. Ninety percent of recipients, whether they received an organ from a living or deceased donor, are alive three years after surgery. At ten years after surgery, 67 percent of deceased donor recipients and 90 percent of living donor recipients are alive.

For those that are not, it is important to remember that these statistics show all causes of death including natural causes, car crashes, heart attacks and many others that may not be kidney or transplant related.

Of the transplant recipients living 10 years after their kidney transplant, 81 percent of deceased donor recipients and 90 percent of living donor recipients have a kidney functioning well enough to stay off of dialysis.

A kidney transplant is a complex and serious surgery that can take months of preparation, testing and frequent doctor visits just to turn around and wait for years for an organ to become available.
For most, the frequent dialysis treatments and all of the time spent wondering and waiting if an organ will become available is absolutely worth it when a kidney becomes available. Transplant surgery leads to a dramatic change in the feelings of fatigue and exhaustion that come with dialysis and kidney disease, a change that is often notable and dramatic before leaving the hospital.

Tests before the operation

Someone who is called into the hospital for a transplant is not guaranteed to receive it. Before the operation can go ahead, it is necessary to check that you are well enough to have the operation and will not reject the transplant kidney.

1. Physical examination – A thorough physical examination by a doctor is carried out. The purpose of this is to check that it is safe to proceed with the operation. For example, if the patient has a heavy cold, it may considered too much of a risk to have an anaesthetic. If the patient ‹fails’ this assessment they will be sent home and put back on the waiting list.

2. The cross-match – This test is the final hurdle before the operation. The cross-match is a blood test that checks there are no antibodies (substances that normally help the body to fight infection) that would react with the donor kidney. Very high levels of such antibodies in the blood mean that the new kidney could be rejected as soon as it is put in, even if it seems a good match.

A cross-match is done by mixing a sample of the recipient’s blood with cells from the donor’s lymph nodes or spleen or blood. If there is no reaction (i.e., the recipient’s blood does not start attacking the donor’s cells), it is assumed that the new kidney will not be destroyed immediately after it is transplanted. This is called a negative cross-match, and means that the operation can go ahead. There can still be some rejection a few days later which is caused by white blood cells and not the antibodies tested for in the cross-match.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

If the cross-match is positive (ie there is a reaction between the recipient’s blood and the donor’s cells), the recipient will usually be sent home and put back on the waiting list. This can be very disappointing, but it is much better to return to dialysis for a while than to be given a kidney that does not work and which may make the recipient extremely ill. If the crossmatch test is only slightly positive, it may be possible to go ahead with a slightly increased risk of rejection.

Virtual cross-match: Most centres offer transplants based on a virtual cross match. This is based on antibodies a cross match could be predicted and if it is negative the surgeon will proceed with the transplant saving critical cold time (kidney in ice).

Chronic kidney disease is a major health concern in this country afflicting more than eight million Americans. When kidney function declines to a certain level, patients have end-stage renal disease and require either dialysis or transplantation to sustain their life. Currently more than 340,000 people are on dialysis, with 106,000 new patients added in 2006. Over 140,000 people are living with a functioning kidney transplant (source: www.usrdsrg). The prevalence of these two populations of end-stage renal disease has tripled in the last 20 years. Medicare expenditure for end-stage renal disease is expected to exceed $28 billion in 2010.

In 2006, 10,659 patients received a deceased donor kidney transplant and 6,432 patients received a live donor kidney transplant. However, more than 74,000 people are currently on the national waiting list for a deceased donor kidney transplant (source: www.usrds.org). Despite the increasing numbers of kidney transplants performed each year, the waiting list continues to grow. Twelve people die each day awaiting a kidney transplant.

Normal Kidney Function

The kidneys are organs whose function is essential to maintain life. Most people are born with two kidneys, located on either side of the spine, behind the abdominal organs and below the rib cage. The kidneys perform several major functions to keep the body healthy.

Filtration of the blood to remove waste products from normal body functions, passing the waste from the body as urine, and returning water and chemicals back to the body as necessary.
Regulation of the blood pressure by releasing several hormones.
Stimulation of production of red blood cells by releasing the hormone erythropoietin.

The normal anatomy of the kidneys involves two kidney bean shaped organs that produce urine. Urine is then carried to the bladder by way of the ureters. The bladder serves as a storehouse for the urine. When the body senses that the bladder is full, the urine is excreted from the bladder through the urethra.

Kidney Disease

When the kidneys stop working, renal failure occurs. If this renal failure continues (chronically), end-stage renal disease results, with accumulation of toxic waste products in the body. In this case, either dialysis or transplantation is required.

Common Causes of End-Stage Renal Disease
Diabetes mellitus
High blood pressure
Glomerulonephritis
Polycystic Kidney Disease
Severe anatomical problems of the urinary tract
Treatments for End-stage Renal Disease

The treatments for end-stage renal disease are hemodialysis, a mechanical process of cleaning the blood of waste products; peritoneal dialysis, in which waste products are removed by passing chemical solutions through the abdominal cavity; and kidney transplantation.

However, while none of these treatments cure end-stage renal disease, a transplant offers the closest thing to a normal life because the transplanted kidney can replace the failed kidneys. However, it also involves a life-long dependence on drugs to keep the new kidney healthy. Some of these drugs can have severe side effects.

Some kidney patients consider a transplant after beginning dialysis; others consider it before starting dialysis. In some circumstances, dialysis patients who also have severe medical problems such as cancer or active infections may not be suitable candidates for a kidney transplant.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Kidney Transplantation

Kidneys for transplantation come from two different sources: a living donor or a deceased donor.

The Living Donor

Sometimes family members, including brothers, sisters, parents, children (18 years or older), uncles, aunts, cousins, or a spouse or close friend may wish to donate a kidney. That person is called a “living donor.” The donor must be in excellent health, well informed about transplantation, and able to give informed consent. Any healthy person can donate a kidney safely.

Deceased Donor

A deceased donor kidney comes from a person who has suffered brain death. The Uniform Anatomical Gift Act allows everyone to consent to organ donation for transplantation at the time of death and allows families to provide such permission as well. After permission for donation is granted, the kidneys are removed and stored until a recipient has been selected.

Transplant Evaluation Process

Regardless of the type of kidney transplant-living donor or deceased donor-special blood tests are needed to find out what type of blood and tissue is present. These test results help to match a donor kidney to the recipient.

Blood Type Testing

The first test establishes the blood type. There are four blood types: A, B, AB, and O. Everyone fits into one of these inherited groups. The recipient and donor should have either the same blood type or compatible ones, unless they are participating in a special program that allow donation across blood types. The list below shows compatible types:

If the recipient blood type is A Donor blood type must be A or O
If the recipient blood type is B Donor blood type must be B or O
If the recipient blood type is O Donor blood type must be O
If the recipient blood type is AB Donor blood type can be A, B, AB, or O

The AB blood type is the easiest to match because that individual accepts all other blood types.

Blood type O is the hardest to match. Although people with blood type O can donate to all types, they can only receive kidneys from blood type O donors. For example, if a patient with blood type O received a kidney from a donor with blood type A, the body would recognize the donor kidney as foreign and destroy it.

Tissue Typing

The second test, which is a blood test for human leukocyte antigens (HLA), is called tissue typing. Antigens are markers found on many cells of the body that distinguish each individual as unique. These markers are inherited from the parents. Both recipients and any potential donors have tissue typing performed during the evaluation process.

 

 

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To receive a kidney where recipient’s markers and the donor’s markers all are the same is a “perfect match” kidney. Perfect match transplants have the best chance of working for many years. Most perfect match kidney transplants come from siblings.

Although tissue typing is done despite partial or absent HLA match with some degree of “mismatch” between the recipient and donor.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Crossmatch

Throughout life, the body makes substances called antibodies that act to destroy foreign materials. Individuals may make antibodies each time there is an infection, with pregnancy, have a blood transfusion, or undergo a kidney transplant. If there are antibodies to the donor kidney, the body may destroy the kidney. For this reason, when a donor kidney is available, a test called a crossmatch is done to ensure the recipient does not have pre-formed antibodies to the donor .

The crossmatch is done by mixing the recipient’s blood with cells from the donor. If the crossmatch is positive, it means that there are antibodies against the donor. The recipient should not receive this particular kidney unless a special treatment is done before transplantation to reduce the antibody levels. If the crossmatch is negative, it means the recipient does not have antibodies to the donor and that they are eligible to receive this kidney.

Crossmatches are performed several times during preparation for a living donor transplant, and a final crossmatch is performed within 48 hours before this type of transplant.

Serology

Testing is also done for viruses, such as HIV (human immunodeficiency virus), hepatitis, and CMV (cytomegalovirus) to select the proper preventive medications after transplant. These viruses are checked in any potential donor to help prevent spreading disease to the recipient.

Phases of Transplant

Pre-transplant Period

This period refers to the time that a patient is on the deceased donor waiting list or prior to the completion of the evaluation of a potential living donor. The recipient undergoes testing to ensure the safety of the operation and the ability to tolerate the anti-rejection medication necessary after transplantation. The type of tests varies by age, gender, cause of renal disease, and other concomitant medical conditions. These may include, but are not limited to:

General Health Maintenance: general metabolic laboratory tests, coagulation studies, complete blood count, colonoscopy, pap smear and mammogram (women) and prostate (men)
Cardiovascular Evaluation: electrocardiogram, stress test, echocardiogram, cardiac catheterization
Pulmonary Evaluation: chest x-ray, spirometry
Potential Reasons of Excluding Transplant Recipient
Uncorrectable cardiovascular disease
History of metastatic cancer or ongoing chemotherapy
Active systemic infections
Uncontrollable psychiatric illness
Current substance abuse
Current neurological impairment with significant cognitive impairment and no surrogate decision maker

Transplant Surgery

The transplant surgery is performed under general anesthesia. The operation usually takes 2-4 hours. This type of operation is a heterotopic transplant meaning the kidney is placed in a different location than the existing kidneys. (Liver and heart transplants are orthotopic transplants, in which the diseased organ is removed and the transplanted organ is placed in the same location.) The kidney transplant is placed in the front (anterior) part of the lower abdomen, in the pelvis.

The original kidneys are not usually removed unless they are causing severe problems such as uncontrollable high blood pressure, frequent kidney infections, or are greatly enlarged. The artery that carries blood to the kidney and the vein that carries blood away is surgically connected to the artery and vein already existing in the pelvis of the recipient. The ureter, or tube, that carries urine from the kidney is connected to the bladder. Recovery in the hospital is usually 3-7 days.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Complications can occur with any surgery. The following complications do not occur often but can include:

Bleeding, infection, or wound healing problems.
Difficulty with blood circulation to the kidney or problem with flow of urine from the kidney.

Kidneys for transplant come from a living donor or a deceased (cadaver) donor. When a kidney is transplanted from a living donor, the donor’s remaining kidney enlarges to take over the work of two. As with any major operation, there is a chance of complication. But kidney donors have the same life expectancy, general health and kidney function as others.

Any healthy person can safely donate a kidney. The donor must be in excellent health, well informed about transplantation and able to give informed consent. Costs for living donor surgery, hospitalization, diagnostic tests and evaluation usually are paid by the recipient’s insurance. Travel and living expenses are not covered. Insurance coverage will be discussed during the transplant evaluation.

If you have a potential living donor, he or she will undergo an evaluation and discuss the possibility of organ donation. Tests will be performed to ensure that the donor and recipient are compatible. In some families, several people are compatible donors. In other families, none are suitable.

Since 1999, UCSF has been using a procedure, called laparoscopic donor nephrectomy, to remove kidneys from living donors. We have performed more than 850 of these procedures, making our program one of the most experienced in the country. The procedure uses tiny incisions and a scope or camera, similar to one used to remove a gall bladder. The procedure has a shorter recovery period and the complication rate is very low. In addition, the quality and function of the transplanted kidneys are excellent.

The procedure will be described in detail by the surgeon prior to surgery. The operation usually takes three hours. Most patients undergoing laparoscopic surgery for kidney donation require a hospital stay of only two to three days. After discharge from the hospital, the donor is seen for follow-up care in the transplant clinic. If the donor resides outside the San Francisco region, he or she should stay in the area for at least a week after discharge. Donors who undergo laparoscopic surgery often return to work within three to four weeks after the procedure.

Living Donor Kidney Transplantation

Living donor kidney transplants are the best option for many patients for several reasons:

Better long-term results
No need to wait on the transplant waiting list for a kidney from a deceased donor
Surgery can be planned at a time convenient for both the donor and recipient
Lower risks of complications or rejection, and better early function of the transplanted kidney

Any healthy person can donate a kidney.  When a living person donates a kidney the remaining kidney will enlarge slightly as it takes over the work of two kidneys.  Donors do not need medication or special diets once they recover from surgery.  As with any major operation, there is a chance of complications, but kidney donors have the same life expectancy, general health, and kidney function as most other people.  The kidney loss does not interfere with a woman’s ability to have children.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Potential Barriers to Living Donation

Age < 18 years unless an emancipated minor Uncontrollable hypertension History of pulmonary embolism or recurrent thrombosis Bleeding disorders Uncontrollable psychiatric illness Morbid obesity Uncontrollable cardiovascular disease Conronic lung disease with impairment of oxygenation or ventilation History of melanoma History of metastatic cancer Bilateral or recurrent nephrolithiasis (kidney stones) Chronic Kidney Disease (CKD) stage 3 or less Proteinuria > 300 mg/d excluding postural proteinuria
HIV infection

If a person successfully completes a full medical, surgical, and psychosocial evaluation they will undergo the removal of one kidney.  Most transplant centers in the United States use a laparoscopic surgical technique for the kidney removal.  This form of surgery, performed under general anesthesia, uses very small incisions, a thin scope with a camera to view inside of the body, and wand-like instruments to remove the kidney.  Compared with the large incision operation used in the past, laparoscopic surgery has greatly improved the donor’s recovery process in several ways:

Decreased need for strong pain medications
Shorter recovery time in the hospital
Quicker return to normal activities
Very low complication rate

The operation takes 2-3 hours.  Recovery time in the hospital is typically 1-3 days.  Donors often are able to return to work as soon as 2-3 weeks after the procedure.

Occasionally the kidney needs to be removed through an open incision in the flank region.  Prior to the use of the laparoscopic technique, this surgery was the standard for the removal of the donated kidney.  It involves a 5-7 inch incision on the side, division of muscle and removal of the tip of the twelfth rib.  The operation typically lasts 3 hours and the recovery in the hospital averages 4-5 days with time out of work of 6-8 weeks.

Although laparoscopy is increasingly used over open surgery, from time to time, the surgeon may elect to do an open procedure when individual anatomic differences in the donor suggest that this will be a better surgical approach.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

The quality and function of the kidneys recovered with either technique work equally well. Regardless of technique all donors will require lifelong monitoring of their overall health, blood pressure and kidney function.

Special Programs For Living Donor Transplantation

Many patients have relatives or non-relatives who wish to donate a kidney but are not able to because their blood type or tissue type does not match.  In such cases, the donor and recipient are said to be “incompatible.”

See also: National Kidney Registry

Live Donor to Deceased Donor Waiting List Exchange

This program is a way for a living donor to benefit a loved one, even if their blood or tissue types do not match.  The donor gives a kidney to another patient who has a compatible blood type and is at the top of the kidney waiting list for a “deceased donor” kidney.  In exchange, that donor’s relative or friend would move to a higher position on the deceased donor waiting list, a position equal to that of the patient who received the donor’s kidney.

For example, if the donor’s kidney went to the fourth patient on the deceased donor waiting list, the recipient would move to the fourth spot on the list for his or her blood group and would receive kidney offers once at the top of the list.

Paired Exchange Kidney Transplant (or “Family Swap”)

This program is another way for a living donor to benefit a loved one even if their blood or tissue types do not match. A “paired exchange” allows patients who have willing but incompatible donors to “exchange” kidneys with one another-the kidneys just go to different recipients than usually expected.

An example of how this works would be if Mary wanted to give her sister Susan a kidney, but differences in blood type made it impossible, and Kevin wanted to give his sister Sarah a kidney, but differences in blood type made that impossible (see picture below).  A paired exchange would be arranged so that Mary would donate to Sarah and Kevin would donate to Susan.  The two pairs can thus “exchange” kidneys so that both donors give kidneys and both patients receive kidneys.

That means that two kidney transplants and two donor surgeries will take place on the same day at the same time.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Blood Type Incompatible Kidney Transplant

This is a program that lets patients receive a kidney from a living donor who has an incompatible blood type.  To be able to receive such a kidney, patients must undergo several treatments before and after the transplant to remove the harmful antibodies that can lead to rejection of the transplanted kidney.

A special process called plasmapheresis, which is similar to dialysis, is used to remove these harmful antibodies from the patient’s blood.

Patients require multiple treatments with plasmapheresis before transplant, and may require several more after transplant to keep their antibody levels down.  Some patients may also need to have their spleens removed at the time of transplant surgery to lower the number of cells that produce antibodies.  The spleen, a spongy organ about as big as a person’s fist, produces blood cells.  Located in the upper left part of the abdomen under the rib cage, the spleen can be removed laparoscopically.

Positive Crossmatch and Sensitized Patient Kidney Transplant

This program makes it possible to perform kidney transplants in patients who have developed antibodies against their kidney donors-a situation known as “positive crossmatch.”

The process is similar to that for blood type-incompatible kidney transplants.  Patients receive medications to decrease their antibody level or they may undergo plasmapheresis treatments to remove the harmful antibodies from their blood.  If their antibody levels to their donors are successfully reduced, they can then go ahead with the transplants.

Blood type-incompatible kidney transplants and positive crossmatch/sensitized patient kidney transplants have been very successful in the United States and internationally. Success rates are close to those for transplants from compatible living donors and are better than success rates for deceased donor transplants.

When most people think about getting an organ transplant, they focus on the obvious physical aspects: the illness, the operation, and the healing. They’re less likely to think about the emotional impact. But that can be profound too, both for you and the people around you.

Nearly all people who receive a transplant, experts say, feel elated and experience a sense of relief and hope after a surgery that goes well. But with time, that initial optimism may be tinged with other feelings. You may start to worry about your condition coming back. You may be afraid of organ rejection. Or you may fixate on the uncertainty of the future.

It’s perfectly natural to have these feelings. But if these worries take over your life, you need to do something about it.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Guilt After an Organ Transplant

Guilt is a common reaction people have after a transplant. Patients often report thinking a lot about the donor and feeling guilty about benefiting from the donor’s death. This feeling can be especially strong for people who became very ill while waiting and prayed or hoped for an organ to become available. After the procedure, some get the feeling that they had been wishing for someone else to die.

The long term success of a kidney transplant depends on many things. You should:

Be seen by your transplant team on a regular basis and follow their advice
Take your anti-rejection medications daily in the proper dose and at the right times, as directed by the transplant team, to keep your body from rejecting your new kidney.
Follow the recommended schedule for lab tests and clinic visits to make sure that your kidney is working properly.
Follow a healthy lifestyle including proper diet, exercise, and weight loss if needed
Rejection and Transplant Medicine
What is rejection?

Rejection is the most common and important complication that may occur after receiving a transplant. Since you were not born with your transplanted kidney, your body will think this new tissue is “foreign” and will try to protect you by “attacking” it. Rejection is a normal response from your body after any transplant surgery. You must take anti-rejection medicine exactly as prescribed to prevent rejection.

Are there different types of rejection?

There are two common types of rejection:

Acute Rejection – Usually occurs anytime during the first year after transplant and can usually be treated successfully.
Chronic Rejection – Usually occurs slowly over a long period of time. The causes are not well understood and treatment is often not successful.
What are anti-rejection medications?

Anti–rejection (immunosuppressant) medications decrease the body’s natural immune response to a “foreign” substance (your transplanted kidney). They lower (suppress) your immune system and prevent your body from rejecting your new kidney.

Why do I need to take anti-rejection medication?

Kidney rejection is hard to diagnose in its early stages. Rejection is often not reversible once it starts. You should never stop taking your anti-rejection medication no matter how good you feel and even if you think your transplanted kidney is working well. Stopping or missing them may cause a rejection to occur.

How should I take anti-rejection medication?

Here are some tips to help you take your anti-rejection (immunosuppressant) medication as directed:

Make taking your medicine part of your daily routine
Use digital alarms and alerts to remember when to take your medication. Be creative because it is easy to forget, especially once you are feeling wellKnow all of your medications by name and dose. Know the reason for taking each medication. Click here for form.End-Stage-Renal Disease and Kidney Transplantation Essay Paper
Ask for and review all written instructions for any change in medication dose or frequency
Tell your transplant team of problems and concerns about medications during every clinic visit
If a doctor other than a member or your transplant team gives you a prescription, notify the transplant team before taking. Certain medications can interfere with your anti-rejection medications and keep them from working.
Continue to take your anti-rejection medication no matter how great you feel, even if you think your transplanted kidney is working well. Stopping them may cause rejection to occur.
Do anti-rejection medications have side-effects?

Anti-rejection (immunosuppressant) medications have a number of possible side-effects which are usually manageable for most patients. Blood levels of anti-rejection medications will be checked regularly to prevent rejection and lessen side-effects. If side-effects do occur, your doctor may change the dose or type of medications.

What are the side-effects of anti-rejection medications?

Some of the most common side-effects of anti-rejection (immunosuppressant) medications include high blood pressure, and weight gain, an increased chance of having infections, and increased risk of some forms of cancer.

What are the types of anti-rejection medications?

There are 3 groups of anti-rejection (immunosuppressant) medications:

Induction agent – Powerful anti-rejection medication used before the transplant in the operating room, or immediately after the transplant surgery
Maintenance agents – Anti-rejection medications you will take daily for as long as you have your transplanted kidney
Rejection agents: Medications which are used for the treatment for rejection episodes
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Infection
Why is infection a concern after kidney transplant?

The anti-rejection medicines that help keep your body from rejecting your transplanted kidney also lower your immune system. Because your immune system is lowered, viral and other infections can be a problem.

What is the best way to stay healthy?

Finding and treating infections as early as possible is the best way to keep you and your transplanted kidney healthy. Exposure to diseases such as the flu or pneumonia can make you very sick. Receiving vaccines as determined by your transplant team can help you stay healthy. It is also important to frequently wash your hands or use an antimicrobial gel during cold and flu season.

What problems should I report to my doctor?

You should report any of the following problems to your doctor as soon as possible:

Sores, wounds, or injuries; especially those that don’t heal
Urinary tract infection symptoms such as frequent urge to urinate, pain or burning feeling when urinating, cloudy or reddish urine, or bad smelling urine
Respiratory infection symptoms such as cough, nasal congestion, runny nose, sore or scratchy throat, or fever
How can I avoid getting infections?

To avoid getting infections you should:

Wash your hands regularly
Maintain good hygiene habits especially around pets
Avoid close contact with people who have contagious illnesses
Avoid close contact with children recently vaccinated with live vaccines (see section on Vaccines). Also, no one in the household should get the nasal influenza vaccine
Practice safe food handling. For more information on safe food handling go to USDA: Basics for Handling Food Safely
Inform your doctor well in advance of any travel plans
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Vaccines
Can a vaccine be harmful after kidney transplant?

Vaccines help your body protect you from infection. Some vaccines are not good for you when you have a transplant. For example, you should avoid all “live vaccines.” Check with your transplant team before receiving any vaccines or boosters.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

What are some general rules for getting vaccines such as Hepatitis B, live vaccines, or a flu shot?

You should:

Get Hepatitis B vaccine before transplant
Avoid all live vaccines
Avoid the nasal influenza vaccine
Wait at least 3-6 months after transplant before getting a flu shot; then get a yearly booster (injection only)
What if someone I know receives a live vaccine?

You should avoid direct contact with anyone who has received a live vaccine. Examples include:

Children who have received oral polio vaccine for 3 weeks
Children who have received measles or mumps vaccines
Adults who have received attenuated (a-TEN-yoo-ated) varicella vaccine to prevent zoster (attenuated means weaker strength)
Children or adults who have received the nasal influenza vaccine
What if I travel to another country?

Contact your transplant physician if you plan to travel to another country. You may need to receive certain vaccines to prevent diseases that are common to the area.

Which vaccines are safe to get?

Always talk to your transplant coordinator before getting any vaccines or boosters. The following vaccines are recommended:

Diphtheria-pertussis-tetanus
Haemophilus influenzea B
Hepatitis A (for travel or other risk)
Hepatitis B (receive before transplant)
Pneumovax (single booster at 5 years)
Inactivated polio
Influenza types A and B (booster every year)
Meningococcus (if at high risk)
Typhoid Vi
Which vaccines should I avoid?

You should NOT receive the following “live” vaccines:

Varicella zoster
Bacillus Calmette-Guerin (BCG)
Smallpox
Intranasal influenza
Live oral typhoid Ty21a and other newer vaccines
Measles (except during an outbreak)
Mumps
Rubella
Oral polio
Live Japanese B encephalitis vaccine
Yellow fever
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New-Onset Diabetes After Transplant
What is new-onset diabetes after transplant or NODAT?

Even if you did not have diabetes before, you may develop diabetes after transplant. This type of diabetes is called new-onset diabetes after transplant or NODAT. This can occur as a side effect of the medications that you need to prevent rejection of your new kidney.

What are my chances of having new-onset diabetes after transplant?

Your chances of having new-onset diabetes after transplant will be higher if you are obese. Your chances are also increased if others in your family have diabetes.

Why should I worry about diabetes?

Having a high blood sugar level due to diabetes or due to NODAT can cause serious damage to your heart, blood vessels, eyes, feet, and nerves.

How can I find out about my blood sugar?

Blood sugar levels will be closely watched while you are in the hospital after the transplant and in the outpatient clinic. If needed, your doctors will help you develop a plan to keep your blood sugar under control. If you are on corticosteroid medication (such as prednisone), your blood sugar levels will improve as the dose of this medication is decreased in the first 2 months after transplant.

If I have diabetes, how can I control my blood sugar?

Your transplant team will help you manage your blood sugar. High blood sugar is usually done with:

A carbohydrate-controlled diet
Exercise, as allowed by your doctor
Diabetes medications

Heart Disease
What are my chances of getting heart disease after a kidney transplant?

People with kidney transplants are at greater risk for heart disease. There are many causes for heart disease including: smoking, diabetes, overweight, hypertension, high cholesterol and blood lipids, and number of years on dialysis.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

How can I lower my chances of getting heart disease?

Here are some important things for you to do now to lower your chances for getting heart disease later (see information on each topic):

Control high blood pressure
Manage cholesterol and blood lipids
Stop smoking
Exercise, as allowed by your doctor
Maintain a healthy weight by following a healthy diet
If you have diabetes, work to keep it well controlled
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High Blood Pressure
What are my chances of having high blood pressure after a kidney transplant?

If you had high blood pressure before getting your new kidney, it may continue after your transplant. High blood pressure might also occur as a side-effect of anti-rejection medications, organ rejection and/or obesity (from weight gain after transplant).

Should I check my blood pressure?

You should check your blood pressure as directed by your transplant team. The target blood pressure for people with a kidney transplant is less than 130/80.

How can I control my blood pressure?

Your doctor will help you manage your blood pressure. High blood pressure is usually controlled with:

Weight control including regular exercise
A low salt diet
Blood pressure medication
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High Cholesterol and Blood Lipids
What are my chances of having high cholesterol and blood lipids after kidney transplant?

Many people may have higher cholesterol and lipid levels in the blood after transplant due to medication side-effects , weight gain, poor diet, family history, or lack of exercise. Kidney-related issues that cause protein in the urine (proteinuria) can also increase blood lipids.

Why should I worry about high cholesterol and blood lipids?

High blood lipids can lead to clogged blood vessels. When this occurs it increases risk of heart disease and stroke.

How can I control my cholesterol and blood lipids?

Your doctor will help you manage your cholesterol and blood lipids. Controlling high cholesterol and blood lipids is usually done with:

A heart healthy diet
More exercise as allowed by your doctor
Lipid lowering medication
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Stop Smoking
Why should I stop smoking?

Smoking cigarettes significantly increases your risk for heart disease, cancer and lung disease. It may also decrease the amount of time your new kidney will work.

How can I get help to stop smoking?

Ask your doctor about medication to help you quit smoking if you are having a problem quitting on your own. Also ask your transplant team about programs in your area. There are also online programs and Apps you may want to try. Here are some examples:

BeTobaccoFree.gov
NCI QuitPal App
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Healthy Weight
What are my chances of gaining weight after kidney transplant?

It is very likely that you will gain weight after your kidney transplant. Weight gain after transplant is common due to medication side-effects and a less strict diet (as compared to the diet for dialysis).

Why should I worry about gaining too much weight?

Gaining too much weight can lead to having too much total body fat. This is known as obesity. Obesity increases the risk of heart disease and new-onset diabetes after transplant (NODAT).

How can I keep a healthy weight?

Your transplant team will include a dietitian. Your doctor and dietitian will help you develop a plan to keep a healthy weight. To control weight, work with your dietitian to reduce calories. Also, you should exercise regularly as allowed by your doctor

If I have Medicare, can I ask my doctor for a Medical Nutrition Therapy referral to see a registered dietitian?

Medicare covers Medical Nutrition Therapy services prescribed by a doctor for patients with diabetes or chronic kidney disease, and includes transplant patients. The services provided by a registered dietitian include:

An initial assessment of your nutrition and lifestyle
Nutrition counseling
Information on managing lifestyle factors that affect your diet
Follow-up visits to check progress on managing your diet

Cancer
What are my chances of getting cancer after a kidney transplant?

Your chances are greater than those without a transplant. The immune system is very important to keep your body from getting cancer. Anti-rejection (immunosuppressive) medications decrease your immune function and may decrease the body’s defenses for certain types of cancer. There are things that you can do to lower your chances of getting cancer.

How do I know if I am at increased risk for skin cancer?

Skin cancer is the most common type of cancer and can cause death. If you have fair skin, live in a high sun exposure area or have a history of skin cancer you may have a higher chance for getting skin and lip cancer. There are also certain anti-rejection medication that may increase your risk more than others.

How can I lower my chances of getting skin cancer?

To lower your chances of getting skin cancer you should:

Avoid direct sunlight
Avoid tanning booths
Wear UVA and UVB sunscreen protection
Be aware of any changes in your skin. Preform self-examines of your skin and lips regularly. Tell your doctor if you notice a strange lump, bump, sore, ulcer, or colored area on the skin
Follow the advice of your transplant team and kidney doctor for further skin care. Your doctor may recommend going to a dermatologist (skin doctor) for a yearly exam
What other cancer screening should I talk to my doctor about?End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Women – Discuss risk of cervical, breast and colon cancer with your doctor regularly and keep up with recommended exams

Men – Discuss risk of prostate and colon cancer with your doctor regularly and keep up with recommended exams

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Bone Disease
What are my chances of having bone disease after kidney transplant?

Bone disease (also known as chronic kidney disease-mineral and bone disorder or CKD-MBD) may continue even after your kidney transplant. CKD-MBD occurs due to medication side-effects, previous kidney disease, diabetes, smoking, lack of exercise, menopause, or number of years on dialysis.

Why should I care about bone disease?

Bone disease can cause weak and brittle bones and increase your chance for fractures.

How can I find out if I have bone disease?

To check your bone health your doctor will test your blood levels of calcium, phosphorus, parathyroid hormone (PTH) and vitamin D.

How can I lower my chances of having bone disease?

Weight bearing exercise such as walking, biking and using weights is a good way to increase bone and muscle strength. If your blood level of vitamin D is low your doctor may prescribe a vitamin D supplement.

Can I take bone density medications?

Bone density medications are not commonly used after kidney transplant. If your doctor suggests this option a bone biopsy may be needed to check your bone health before starting this medication.

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Anemia
What are my chances of having anemia after a kidney transplant?

Following a kidney transplant you may have anemia (low red blood cell count) due to the surgery, medication side-effects, infection, abnormal breakdown of red blood cells, or organ rejection. Blood pressure medication can cause your body to make fewer red blood cells.

Why should I care about anemia?

Mild anemia can cause minor problems like feeling tired and having pale skin. If left untreated, anemia can cause a lack of oxygen to organs and lead to serious health problems such as heart failure.

What should I do if I have anemia?

If you have anemia your doctor may prescribe an iron supplement or other medications. There are many choices for iron pills; if you do not tolerate one iron supplement, ask about other choices. Your doctor will work with you to decide on the best treatment. It is also important to eat a healthy diet.

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Gout
What is gout?

Gout is a condition that occurs when high blood uric acid levels cause crystals to build up in the joints, causing painful swelling.

What are my chances of having a high blood uric acid level (hyperuricemia) after kidney transplant?

Your body may have a hard time getting rid of uric acid (a normal waste product in blood) after your kidney transplant. This is often due to side-effects from medications, such as cyclosporine, leading to a high uric acid level in blood.

What do I do if I have high blood uric acid levels or gout?

Your doctor will help you manage high blood uric acid levels or gout. This is usually done with:

Medication (avoid non-steroidal anti-inflammatory drugs (NSAIDS) whenever possible)
A diet that limits certain foods and beverages including red meat, seafood, sugared soft drinks and alcohol (especially beer)
Keeping a healthy weight
Controlling high blood pressure, high blood lipid levels and diabetes, if present
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Sexual Activity and Fertility
What happens to sexual function after kidney transplant?

Most sexual functions return after a successful transplant if the problem was due to kidney disease or dialysis. You and your spouse or significant other should talk to your transplant team about any problems with sexual function, or if you have questions about safe sex, contraception or pregnancy.

If I am a woman of child bearing age, can I become pregnant after kidney transplant?

Women of child bearing age should consult with their transplant physician regarding pregnancy and/or contraception. If you are thinking about becoming pregnant, talk to your transplant team. Before becoming pregnant you should:

Wait at least 1 year after your transplant
Wait until your kidney function is stable
See an obstetrician who specializes in high risk pregnancies
Learn about the risks and benefits of breastfeeding. If you are interested in breastfeeding, it is very important to discuss the medications you are taking with your obstetrician. Some medicines can be passed on through your breast milk and can be harmful to your baby.
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Mental Health
What if I feel anxiety or depression after kidney transplant?

Anxiety and depression are common following kidney transplant. You may even become overwhelmed because of all the new things and changes that are happening to you following your transplant. This is a normal feeling for some transplant recipients.

What are the causes of depression and anxiety?

Depression and anxiety may be due to prior health problems, sleep disorders, or stress from the transplant itself. For example, it is normal to worry about the health of the living donor or the tragedy the deceased donor’s family felt. Some anti-rejection medications may also cause depression or mood swings until the dose is decreased.

What should I do if I feel anxiety or depression?

Discuss these issues with your transplant team to determine if treatment is needed. They can plan the right treatment for you to help you through this period.

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Healthy Lifestyle
Why is a healthy lifestyle important after kidney transplant?

A healthy lifestyle is important for many reasons. Many conditions such as new onset diabetes after transplant (NODAT), high cholesterol, and high blood pressure can be improved through living a healthy lifestyle. A healthy lifestyle also helps bring about a feeling of wellness.

How do I follow a healthy lifestyle?

Your transplant team will help you make the right choices to develop and live a healthy lifestyle. You should:

Return to your normal routine, such as work, school or housework.
Increase physical activity with regular exercise. Check with your doctor before you start an exercise program.
Eat a proper diet. A dietitian can help you make the right heart healthy food choices for a healthy lifestyle.
Lose weight, as needed, to reach and maintain a healthy weight. Consult with your dietitian and transplant team for a healthy weight loss diet. Fad diets should be avoided. Once you get to your healthy weight you will feel better.
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Patient Assistance Programs
What if I have Medicare and need help paying for my transplant medications?

If you have Medicare and are having trouble paying for your prescriptions there is extra help available. You should apply for “Extra Help” with Medicare Prescription Drug Plan Costs through the Social Security Administration. Learn more and apply online. Or call Social Security at 1-800-772-1213 or visit your local social security office.

Are there any other prescription assistance programs?

Yes, here are some websites that allow you to search for prescription assistance programs by medicine:

The Partnership for Prescription Assistance or call at 1-888-4PPA-NOW (1-888-477-2669)End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Helps qualifying patients without prescription drug coverage get the medicines they need for free or nearly free.

Good search tool when looking for prescription assistance programs.

RxAssist Patient Assistance Program Center

RxAssist can help you learn about ways to use pharmaceutical company programs and other resources to help reduce your medication costs.

Needy Meds

This program helps people obtain prescription assistance and offers a discount card for those eligible. It can help people save up to 80% on the cost of their medications.

Do drug companies offer prescription assistance programs?

Yes, many drug companies offer prescription assistance programs for their medications to those who qualify. Click here to see some common medications and companies for kidney transplant.

Do any states offer prescription assistance programs?

Yes. Check with your transplant social worker to see if your state offers a prescription assistance program and to see if you qualify.

How can I find out about other community resources and medication assistance programs?

Call NKF Cares, sponsored by the National Kidney Foundation. This patient hot line offers help for people affected by kidney disease, or those with questions on organ donation or transplantation. Speak with a trained professional who will answer your questions and listen to your concerns. Call toll-free at 1-855-NKF-Cares (1-855-653-2273).

Living-donor renal transplants are further characterized as genetically related (living-related) or non-related (living-unrelated) transplants, depending on whether a biological relationship exists between the donor and recipient.

Exchanges and chains are a novel approach to expand the living donor pool. In February 2012, this novel approach to expand the living donor pool resulted in the largest chain in the world, involving 60 participants organized by the National Kidney Registry.[1] In 2014 the record for the largest chain was broken again by a swap involving 70 participants

Kidney transplant is the best therapy to manage end-stage kidney failure. The main barriers limiting this therapy are scarcity of cadaveric donors and the comorbidities of the patients with end-stage kidney failure, which prevent the transplant. Living kidney donor transplant makes it possible to obviate the problem of scarcity of cadaveric donor organs and also presents better results than the cadaveric transplant. The principal indication of living kidney donor transplant is preemptive transplant. This will allow the patient to avoid the complications of dialysis and it has also been demonstrated that it has better results than the transplant done after dialysis has been initiated. Priority indications of living donor transplant are also univitelline twins and HLA identical siblings. We will also have very favorable conditions when the donor is young and male. On the contrary, the living donor transplant will have worse results if the donors are over 60-65 years and the recipients are young, this possibly being a relative contraindication. There is an absolute contraindication for the living donation when the recipient has diseases with high risk of aggressive relapse in the grafts: focal and segmental hyalinosis that have had early relapse in the first transplant; atypical hemolytic uremic syndrome due to deficit or malfunction of the complement regulatory proteins; early development of glomerulonephritis due to anti-glomerular basement membrane antibody in patients with Alport Syndrome; primary hyperoxaluria.

El trasplante renal es la mejor terapia para hacer frente a la insuficiencia renal terminal. Las principales barreras que limitan esta terapéutica son la escasez de donantes fallecidos y las comorbilidades de los enfermos con insuficiencia renal terminal, que impiden el trasplante. El trasplante renal de vivo permite obviar el problema de la escasez de órganos de donante fallecido y además presenta mejores resultados que el trasplante de cadáver. La principal indicación del trasplante renal de vivo es el trasplante anticipado (preemptive). Éste permitirá al paciente librarse de las complicaciones de la diálisis y, además está demostrado que tiene mejores resultados que el trasplante realizado cuando ya se ha iniciado la diálisis. Son también indicaciones prioritarias de trasplante renal de vivo los gemelos univitelinos y los hermanos HLA idénticos. Además, tendremos condiciones muy favorables cuando el donante es joven y hombre. Por el contrario, el trasplante de vivo tendrá peores resultados si los donantes son mayores de 60-65 años y los receptores son jóvenes, pudiendo constituir esto una contraindicación relativa. Existe contraindicación absoluta para la donación de vivo cuando el receptor presenta enfermedades con alto riesgo de recidiva agresiva en los injertos: la hialinosis segmentaria y focal que han tenido una recidiva precoz en un primer trasplante; el síndrome hemolítico-urémico atípico por déficit o mala función de las proteínas reguladoras del complemento; el desarrollo precoz de una glomerulonefritis por anticuerpos antimembrana basal glomerular en pacientes con síndrome de Alpont, o la hiperoxaluria primaria.

When patients are faced with end-stage renal failure, the best treatment option, without a doubt, is kidney transplantation before starting any form of dialysis. The scarcity of organs from cadaveric donors and the comorbidity of these patients, which contraindicates transplantation, prevent this treatment from being routinely performed prior to dialysis. Living-donor kidney transplantation can meet this objective perfectly, as it does not depend on waiting times imposed by cadaveric donation. In recent years, the expansion of genetically unrelated living donation has facilitated living-donor kidney transplantation as spouses, distant relatives, friends and even Good Samaritans have increased the pool of potential living donors. The results of this type of living-donor transplant have been better than those of cadaveric-donor transplants and the same as those for related living donors, despite worse HLA compatibility  End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Overall, living-donor kidney transplantation offers better survival than transplantation from cadaveric donors.1,3 The 2008 OPTN-UNOS (Organ Procurement and Transplantation Network-United Network for Organ Sharing) registry contains data from 159,119 transplants from cadaveric donors and 83 471 from living donors reported during the 20-year-period between 1988 and 2007. According to this data, the actuarial graft survival rates at 15 years were 25%-29% for cadaveric-donor transplantation and 42% for living-donor transplantation.1 The main reasons for these numbers are that living donors are thoroughly studied and selected from healthy individuals and they organs are not exposed to haemodynamic instability, sepsis, or nephrotoxic agents, as are those of cadaveric donors during brain death. Moreover, they do not suffer the deleterious effects of brain death and they have short cold ischaemia times before implantation.

These factors make living-donor transplantation the preferred option for treating end-stage kidney failure. However, not all patients have relatives or close friends who are willing to donate a kidney, and in many cases, although a donor may be available, the donor may not be optimal for ensuring long-term survival of the graft. Therefore, due to the morbidity to which the donor is exposed, we are obliged to ensure maximum success of the transplant in the short and long term when indicating this procedure.

Rather than discuss donor diseases that contraindicate living donation, which will be covered in a separate chapter on donor studies, this article deals with the situations that affect donor-recipient pairs in which the procedure is or is not recommended, according to the short and long-term results.

In general, provided that factors such as age and weight differences between donor and recipient are the same, living-donor kidney transplantation offers better short- and long-term graft survival rates than those from cadaveric donors. Therefore, if a patient has a living donor of a similar age, this option is preferable to cadaveric-donation.

However, if the living donor is elderly (e.g., older than 60 or 65 years) and the recipient is young (under 40 years), the results will be worse in terms of long-term graft survival and renal function, even if the donor still has perfect renal function with no cardiovascular risk. Although there is no absolute contraindication, there is a relative one and, in any case, the donor and recipient need to know this information.

Transplantation is the best option for a patient with onset of end-stage kidney failure, as long as the patient has no contraindications for transplantation (uncontrolled cancer, atherosclerosis with unresolved ischaemia in different locations, atherosclerosis that makes vascular anastomosis impossible and uncontrolled active infections). We will therefore describe in detail the circumstances in which living-donor kidney transplantation is better, similar and worse than cadaveric-donor transplantation, in terms of long-term survival (Table 1). Very few studies have addressed this issue from this perspective. In general, most studies on transplantation mix living- and cadaveric-donor transplantations, which makes it difficult to draw conclusions.

PRE-DIALYSIS TRANSPLANTATION

Kidney transplantation prior to dialysis, also known as pre-emptive kidney transplantation, is the optimal treatment strategy for dealing with end-stage kidney failure. Unfortunately, Spain has a high rate of cadaveric donors and living kidney donation is often associated with unnecessary morbidity for the healthy individual. The pre-dialysis nephrologists (except for the paediatric ones) are therefore not sufficiently aware of this treatment so as to convincingly present this option to patients with onset of end-stage kidney failure.

The benefits of pre-emptive kidney transplantation are clearly documented in kidney transplantation registries and the various studies of a particular centre (Table 2). The initial results on pre-emptive kidney transplants published in the nineties with both living and cadaveric donors showed better graft survival than those performed after starting dialysis.4 With pre-emptive transplantation, dialysis-associated morbidity is avoided, there is a low incidence of delayed graft function, the risk of acute rejection is lower, there is lower mortality and graft survival is improved. This was demonstrated by the analysis of 73 103 first transplants in adults from 1988 to 1997 in the United States Renal Data System Registry. The analysis showed that death with functioning a graft and death-censored graft survival were better in pre-emptive transplants and in patients who spent less time on dialysis.5

It has been speculated that the improved results of pre-emptive transplantation may be due to patients with better residual function. However, recent studies found no relationship between residual function at the time of pre-emptive transplantation and function at six months after transplantation,6 or in the annual decline in graft function when comparing pre-emptive and non-pre-emptive transplant patients.7This suggests that the function achieved by the graft in pre-emptive transplantation is independent of its residual function, and that the improved survival of these transplants is independent of this function. These data support policies for indicating pre-emptive transplantation when dialysis is indicated, with no need to indicate it until compromised glomerular filtration begins to cause symptoms. From a practical standpoint, pre-dialysis nephrology visits should indicate pre-emptive living-donor transplantation when they believe, due to chronic and symptomatic renal function deterioration, that it is necessary to perform an arteriovenous fistula or a peritoneal catheter implantation in order to start haemodialysis or peritoneal dialysis (generally when the glomerular filtration rate is below 15ml/min). Obviously, transplantation will spare the need for performing these procedures. Nevertheless, from the earliest stages of kidney failure, patients should be made aware of the possibility for pre-emptive living-donor transplantation so that they can identify potential donors among relatives and friends.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

Time on dialysis waiting for a transplant is associated with worse graft evolution, both for living and cadaveric donations. An analysis of living-donor graft survival in recipients older than 18 years used data from the U.S. Renal Data System from 1994 to 1997, and compared the evolution of 1819 pre-emptive living-donor transplants with 6662 living-donor transplants in patients who had already started dialysis. The analysis reported that graft survival at three years (uncensored for death) was 90% for pre-emptive transplant patients and 81% for those that had already started dialysis.8

We compared the evolution of 2405 paired kidneys (from the same donors) recorded in the U.S. Renal Data System database between 1988 and 1998. They were transplanted to patients with more than two years and less than six months on dialysis, and graft survival (non-adjusted and censored for patient deaths) at five and ten years was significantly worse in recipients of paired kidneys who were on dialysis for more than two years (58% and 29%, respectively) when compared to recipients who were on dialysis for less than six months (78% and 63%, respectively; P<.001 each one). For living-donor transplants, the adjusted survival rate at 10 years was 75% for pre-emptive transplants, compared to 49% for transplants in patients on dialysis for more than 24 months. In conclusion, time on dialysis is a modifiable risk factor for transplant evolution. Better survival outcome for living-donor transplantation may partly be due to it being performed sooner, and the patient waiting less time on dialysis. In fact, this study showed that survival for cadaveric-donor transplant patients who waited less than six months on dialysis was equivalent to living-donor transplant patients who have been on dialysis for more than two years.9 The American registry data showed that 25% of living-donor kidney transplants between 1994 and 2002 were pre-emptive transplants. Moreover, among recipients of cadaveric-donor kidney transplants, 7% received them pre-emptively. Pre-emptive transplants had better graft and patient survival. Pre-emptive transplant recipients had a lower incidence of post-transplant dialysis and acute rejection episodes prior to hospital discharge. Therefore, those patients with an appropriate living donor, should be transplanted before starting dialysis or, if dialysis has already begun, as soon as possible.10 According to the Australian registry, data on 2739 first kidney transplants (between 1980 and 2004) in recipients under 30 years old showed that for adolescents, time on dialysis affects graft survival at five and ten years. In contrast, pre-emptive transplantation achieved the best results, as it reduced the risk of graft loss by 50% in the long term.11 As for the results of a single centre for living-donor kidney transplantation, some cases have been reported showing better or equal results for pre-emptive transplants compared to those performed in patients already on dialysis. Among those that report better results for pre-emptive transplantation, of note is a Korean series that compared 63 pre-emptive living-donor kidney transplants with 359 living-donor transplants performed after starting dialysis. They found that graft survival rates at 10 years were significantly better in the pre-emptive group than in the dialysis group (94% compared to 76%), although patient survival rates were no different in for time period (98% compared to 91%).12 A French study of 44 pre-emptive transplants (16% living donor) also found a 93% graft survival rate compared to 77% for a group of 419 (2% living donor) performed on patients on dialysis. This was recorded at the end of a follow-up that varied between 46 months for the pre-emptive group and 63 months for the post-dialysis group.13 Among those that found no differences was a single Iranian centre that compared 300 pre-emptive living-donor kidney transplants with 300 living-donor transplants in patients on dialysis. Survival at five years both for graft (84% for pre-emptive compared to 89% for post-dialysis) and patient (93% compared to 97%) were comparable.14 An Egyptian centre reported that of 1279 living-donor transplants performed between March 1976 and March 2001, 82 (6.4%) were pre-emptive. Results at five years for these last two centres were similar to the 1197 transplants in patients who had already started dialysis, but pre-emptive transplantation eliminated the complications, inconvenience and cost of dialysis.15 A single centre Indian study compared 43 pre-emptive living-donor kidney transplants with 83 living-donor control transplants that were performed after starting dialysis, between 1989 and 1996. Survival rates at one and two years were similar for both the graft (pre-emptive: 82.8% and 77.3%; controls: 82% and 78%, respectively) and patient (pre-emptive: 92% and 89.5%; controls: 91% and 89.5%, respectively). As such, pre-emptive transplantation eliminated the inconvenience of dialysis and was much less costly.16 In summary, most of the studies described above show the superiority of pre-emptive living-donor kidney transplantation over other transplantation methods. Even though some single centres that analysed fewer patients did not show differences between pre-emptive transplants and those performed after dialysis had started, in every case, pre-emptive transplantation succeeded in avoiding dialysis and all the inconvenience it entails. LIVING-DONOR KIDNEY TRANSPLANTATION IN PATIENTS ON DIALYSIS In many cases, the willingness of a living donor (relative or not) arises when the candidate for transplant on dialysis remains on the waiting lists indefinitely, with little chance of receiving a cadaveric-donor kidney transplant. The results of living-donor transplantation have improved decade by decade since the sixties, despite the expansion of living-donor acceptance criteria (mainly donation by the elderly or genetically unrelated individuals). The reasons for this improvement are the development of new immunosuppressants that control acute rejection better, new antibiotic and antiviral drugs that treat infections in these patients and the improved treatment of cardiovascular problems with the early detection and treatment of coronary artery disease and cerebrovascular events. When approaching living-donor kidney transplantation in a patient on dialysis, one should understand the factors that determine worse evolution in order to avoid them as much as possible. The factors that worsened long-term survival in 2540 living-donor transplants performed at the University of Minnesota from 1963 to 1998 included: delayed graft function in living-donor transplants, acute rejection, the combination of these two conditions, pre-transplant cardiovascular disease, smoking, dialysis and a donor age over 55 years.17 Advantages and disadvantages of living-donor transplantation according to donor and recipient characteristics:End-Stage-Renal Disease and Kidney Transplantation Essay Paper Cadaveric donor quality has declined in recent years due to the effectiveness of road and workplace safety policies, which have drastically reduced the deaths of young people in traffic and job accidents. There is evidence that one of the main factors affecting long-term graft survival is donor age. It is crucial for young patients (under 60 years old) to find donors of similar age to ensure long-term graft survival. Meeting this criterion is difficult and waiting times for receiving this type of cadaveric-donor graft are very long. Living donor of a similar age as the recipient This condition (young living donor for young recipient) ensures better survival than if the recipient receives a kidney from an elderly cadaveric donor. In addition, the patient will have the general advantages of a living-donor transplant such as shorter cold ischaemia time and immediate renal function. All of these conditions, as well as HLA compatibility if patient and donor are related, will create the ideal situation for a long survival. Elderly living donor Sometimes living donors are elderly, as in the case of parents. Kidney transplants from elderly cadaveric donors have worse survival rates because the grafts have a lower nephron mass, are senescent and are more susceptible to ischaemic attacks and acute rejection events. What has been described here for cadaveric donors may also apply to living donors, although it has not been widely studied in medical literature. In these circumstances (elderly living donors and young recipients), transplantation is not contraindicated but the donor and the recipient must understand that survival rates are lower. In contrast with elderly cadaveric-donors and young recipient, this combination entails some advantages, such as shorter cold ischaemia times and better HLA compatibility. There are no studies comparing graft survival in young people with young cadaveric donors and elderly living donors, but data from various registries and centres seem to show that survival would be greater with young cadaveric donors. Nevertheless, living-donor transplantation would avoid the delay in graft function and therefore improve the evolution of this type of pairing. It is unclear what to advise a patient when taking into account that the time on dialysis negatively influences the survival of patients and future grafts.5,9,18Therefore, clinicians must balance all these factors when making decisions and informing patients of them. An American registry, in an analysis of 73 073 first kidney transplants performed between 1995 and 2003, showed that elderly (>55 years) living-donor transplants were conducted pre-emptively on elderly white female recipients. In addition, they were performed more often between spouses than between relatives and even more so when the husband was the donor. Glomerular filtration at one year was inversely proportional to the age of the living donor at the time of donation. The multivariate analysis on graft loss risk with living donors between 55 and 64 years old was similar to that of cadaveric donors under 55 years, and it was higher when the living donor was between 65 and 69 years (HR=1.3; 95% CI: 1.1-1.7) or were over 70 years (HR=1.7; 95% CI: 1.1-2.6). The conclusion is that donors younger than 65 years may be living donors with advantages over younger cadaveric donors despite achieving worse glomerular filtration rates at one year than younger living-donor transplants.19

These data are consistent with the UK Transplant Registry, which analysed the factors affecting long-term graft and patient survival. They studied data from 3142 living-donor transplants (71% genetically related and 29% unrelated) performed between 2000 and 2007 inclusive. They found that HLA (-A, -B, and -DR) incompatibility did not have a negative effect, but those patients who received a graft from donors who were over 59 years had lower survival rates. Furthermore, being a female recipient was also an independent risk factor for worse survival End-Stage-Renal Disease and Kidney Transplantation Essay Paper

A multivariate analysis of a Norwegian registry with 739 living-donor kidney transplants performed between 1994 and 2004 also found that donor age over 65 years was a risk factor for graft loss for all time periods after transplantation.21 In these latter studies, the age of the donor was not adapted to the recipient’s.

An observational study analysed a cohort of kidney transplant recipients aged 60 years or older who underwent transplantation between 1996 and 2005 and were included in The Organ Procurement Transplant Network/United Network for Organ Sharing American registry. The study focused on the results for living donors over 55 years old. In these elderly recipients of kidneys from living donors over 55 years old, although there was lower graft survival at three years compared to those who received kidneys from younger living donors, patient survival was similar. Furthermore, graft and patient survival rates were greater than in recipients who received kidneys from cadaveric donors of any age. This was especially noticeable when compared to kidney transplants from expanded criteria donors.22 Therefore, being an elderly kidney transplant candidate is the ideal situation to have an elderly living donor.

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Female living donor or low-weight donor

In kidney transplantation, donor age and graft size are known factors that influence the long-term evolution of the graft.23-26 Women tend to have smaller kidneys with 17% less nephrons than men. The number of nephrons per kidney is positively correlated with the weight of the kidney and negatively correlated with the age of the individual.24 It has been reported that kidneys from female donors that are transplanted to men have worse evolution.20,27-29

Kwon et al30 assessed the impact of age and sex on the results of living-donor kidney transplantation. Their series of 614 living-donor kidney transplants were divided into four groups according to the four combinations of sex between donor and recipient. The group with the worst survival was female donors whose kidneys were transplanted to male recipients. Graft survival at five years was 75% compared to 83%-85% for the other three groups. A risk factor analysis performed as part of the study found that factors that influence worse long-term graft evolution were donor age, female sex, acute rejection and HLA incompatibilities.

Lankarani et al came to similar conclusions when analysing a series of 2649 first unrelated living-donor transplants. They observed worse survival rates for transplants from female donors to male recipients, and among young people who received kidneys from older donors. They found that using kidneys from young donors (under 40 years) and avoiding female donors for males is the optimal condition for living-donor transplantation.31

Other analyses suggest that the negative effect female donors have on male recipients not only has to do with the difference in the number of transplanted nephrons but is also related to the fact that the female graft would trigger a greater immunological response.21,32 Female sex has even been suggested to be a risk factor for early acute rejection.21

Overall, current evidence tells us that when the donor is an elderly female and the recipient is a young male, we do not have the most appropriate circumstances for ensuring good medium and long-term results. Therefore, this donor-recipient pairing would be a relative contraindication for living-donor kidney donation. As such, if living-donor transplantation is decided upon using this type of donor, it should only be performed after comprehensively informing the donor and the recipient about the risks.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

In general, these unfavourable conditions would be less important for pre-emptive transplantation. The advantages of not implementing dialysis probably outweigh, at least in part, the disadvantages of these types of donor-recipient pairs.

DISEASES WITH HIGH RATES OF RECURRENCE IN KIDNEY TRANSPLANTATION 

Patients with kidney diseases with high rates of recurrence after transplantation are absolutely contraindicated for living-donor kidney donation. The diseases may be relative contraindications in the first transplant but if there is a recurrence of primary kidney disease, and this is the cause of graft loss, the contraindication is absolute for the second transplant. The processes that are absolutely contraindicated are segmental or focal hyalinosis with early recurrence in the first transplant, atypical haemolytic-uraemic syndrome due to deficit or dysfunction of complement regulatory proteins,33,34 early development of glomerulonephritis due to anti-glomerular basement membrane antibodies in patients with Alport’s syndrome and primary hyperoxaluria. In these circumstances, living-donor kidney transplantation is contraindicated although cadaveric-donor transplantation or double transplantation of liver and kidney may be a good treatment option.

There are many other diseases that recur in the transplant35 and if the rates of graft loss due to these recurrences are high, the clinician must consider setting a relative contraindication for living-donor transplantation. Table 3 summarises the diseases susceptible to recurrence.

This is without doubt the ideal situation for living-donor transplantation since it almost guarantees a definitive solution to the recipient’s kidney problem with little or no immunosuppression. The first kidney transplantation between humans was performed successfully between monozygotic twins and although this was before immunosuppressants were available, the genetic similarities guaranteed long-term graft survival.36,37

The results of these transplants between identical twins have been recently evaluated in the U.S.A and Britain.38 Transplant data came from U.S.A and British registries for the 1988-2004 period. In the U.S.A, 120 cases were found while Britain had 12. Graft survival was excellent at one, three and five years (99.17%, 91.84% and 88.96%, respectively in the U.S.A, and 83.3%, 83.3% and 75%, respectively in the British group). It was noteworthy that a large number of patients maintained some form of immunosuppression, usually because of doubts about whether the twins were monozygotic. Thus, genetic studies to determine whether twins are monozygotic help eliminate immunosuppression.39

A HLA-identical sibling is another favourable situation for living-donor transplantation, although it is not as immunologically neutral as monozygotic twins. An analysis by De Mattos et al of 108 living-donor transplants between HLA-identical siblings performed at their institution between 1977 and 1993, observed an acute rejection incidence of 46%, although it should be noted that modern immunosuppression was not used. Patients who had acute rejection had worse long-term evolution (69% at five years compared to 88% in the overall series), as well as those patients who suffered kidney failure due to diseases that could potentially recur in the transplant.40 To summarise, monozygotic twins, and to a lesser extent HLA-identical siblings, are an ideal situation for living-donor kidney transplantation and under these circumstances transplantation is especially indicated.

These patients may benefit from living donations from HLA-identical siblings, those that share a haplotype or parents. If there are positive crossmatches with all relatives then the ideal situation would be to enter into a hyper-immunised patient kidney transplant programme sharing cadaveric donors or crossover living-donor kidney transplant programmes. Prior to this, patients can be administered desensitisation treatments to see whether the crossmatch with living donors comes back negative.

PANCREAS AND KIDNEY TRANSPLANTATION CANDIDATES

The best treatment for patients with type 1 diabetes mellitus and end-stage kidney failure is simultaneous transplantation of pancreas and kidney, and the ideal situation is pre-emptive transplantation with organs from the same cadaveric donor. Unfortunately, the shortage of pancreas donors is very pronounced, given that the selection criteria specify very young donors with hardly any acute comorbidity. This means that patients spend long periods on dialysis waiting for a simultaneous transplant.End-Stage-Renal Disease and Kidney Transplantation Essay Paper

An alternative to simultaneous transplantation of pancreas and kidney for type 1 diabetics with kidney failure is sequential transplantation of a kidney from a living donor followed by a pancreatic transplant from a cadaveric donor. This treatment strategy makes pre-emptive living-donor transplantation possible and avoids the morbidity of dialysis. Poommipanit et al in their analysis of the Organ Procurement Transplant Network/United Network of Organ Sharing Database reported results from this strategy, comparing 807 pancreatic transplants performed after a living-donor kidney transplant with 5580 transplants performed simultaneously with organs from cadaveric donors. Patient and kidney survival were greater in transplants performed after a living-donor kidney transplant, although hospital stays and pancreatic transplant survival were favourable to simultaneous transplantation.41

This greater patient and kidney graft survival was confirmed by other studies in which patients who received a pancreas after the living-donor kidney transplant had better patient and kidney graft survival than those who never received a pancreatic transplant.42 In some studies, even living-donor kidney transplantation in diabetic patients achieved better kidney graft survival than simultaneous transplantation of pancreas and kidney. This was due to the time saved from dialysis in these diabetic patients with high cardiovascular risk.43

To summarise, living-donor transplantation in type 1 diabetic patients should be seen as a priority, without conflicting with the latter indication for pancreatic transplantation after the living-donor kidney transplant. If it is put into practice, kidney transplantation should be located primarily in the left iliac fossa to facilitate later surgery for pancreatic transplantation in the right iliac fossa.

Patients must meet certain basic criteria in order to be considered a potential transplant candidate. These criteria are different depending upon the type of organ(s) needed. These basic criteria are just the initial indicators. All patients must be fully evaluated by the transplant team to determine if transplantation is the best treatment option.

The following patients may be considered potential candidates for kidney transplantation:

Patients with End-Stage Kidney Disease on dialysis.
Patients with advanced chronic kidney disease (stage IV or V with calculated or estimated GFR <20ml/min. Patients with chronic kidney disease (stage IV with GFR <30ml/min) that also need another organ transplant. Patients with chronic kidney disease that have type 1 Diabetes that has not responded to medical treatment may also be considered for a combined kidney-pancreas transplant. There may be times when transplantation is not the best treatment option for patients. Patients will be considered on an individual basis to determine whether the benefits of transplantation will outweigh the risks. Documentation of chronic kidney disease (CKD) and its stage are crucial for correct coding, which affects hospital revenue and severity of illness classification. Precise diagnosis and reporting of CKD stage improve the accuracy of our national health care database used for research and for projections of national health care needs. The 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease published by the National Kidney Foundation (NKF) is the authoritative, consensus standard for the diagnosis, classification and management of CKD. The guideline identifies five stages of CKD (listed in Table 1), which are defined by either glomerular filtration rate (GFR) decreased to less than 60 mL/min/1.73 m2 or by presence of certain kidney damage markers (listed in for more than three months. Image by Thinkstock The diagnosis of CKD stage 1 or 2 requires the presence of one or more of the markers of kidney damage. Therefore, a patient with a GFR greater than or equal to 60 mL/min/1.73 m2 does not have CKD if there are no markers of kidney damage. Stages 3, 4, and 5 are based on GFR cutoffs alone, although such patients may also have markers of kidney damage. Lab reports of creatinine values typically include the calculated GFR for both African-American and non-African-American patients. The calculated GFR is proportional to serum creatinine but also depends on age, race, and gender. The NKF recommends using the CKD-EPI Creatinine Equation, published in 2009, to estimate GFR (available on the NKF website). It is not necessary to perform a 24-hour urine collection to measure creatinine clearance, even though this may be a more precise measure of GFR if done correctly. The stage of CKD can only be correctly assigned when GFR and therefore creatinine levels are at a stable baseline. Staging cannot be performed when the creatinine is in flux, such as during an inpatient admission. Renal function must be stabilized before staging. The currently preferred clinical terminology of "chronic kidney disease" or CKD should be used in diagnostic documentation. Clinicians should avoid nonspecific, imprecise terminology such as "renal insufficiency" or "chronic renal insufficiency (CRI)" as the correct codes for CKD will not be assigned. End-stage renal disease (ESRD) represents the culmination of progressive stage 5 CKD. It has been a long-standing clinical practice to classify patients with CKD who require either dialysis or transplantation as ESRD. However, ICD-10-CM defines ESRD (code N18.6) as "dialysis-dependent stage 5 CKD." Dialysis dependence means that the requirement for dialysis is expected to last three months or more. A significant conflict exists between the clinical documentation standards and ICD-10-CM coding practices for a patient who has had a kidney transplant. Clinically, transplant patients are considered to have ESRD even though the transplanted kidney may be functioning well. On the other hand, ICD-10-CM requires the transplant status code Z94.0 plus a code for the current CKD stage of the transplanted kidney. All transplant patients are considered to have CKD so any of the five stages will apply, based on the GFR. As an example, the code for a patient with a GFR of 50 mL/min/1.73 m2 after transplant would be N18.3 (CKD-3) and Z94.0. The code for ESRD (N18.6) cannot be assigned because it requires chronic dialysis dependence If the transplant patient eventually became dependent on dialysis again, code N18.6 could then be assigned together with Z94.0. In summary, correct documentation of CKD stage is crucial for accurate coding, hospital reimbursement, and severity of illness classification. Clinicians should always review the calculated GFR associated with the creatinine level on clinical lab reports and remember that CKD stage can only be determined when renal function (GFR and creatinine levels) are stable, unless a recent baseline measurement is available.End-Stage-Renal Disease and Kidney Transplantation Essay Paper CKD stages are defined by either a GFR below 60 mL/min/1.73 m2or by the presence of certain kidney damage markers for more than three months. ESRD is defined clinically as either dialysis dependence or kidney transplant status, but the ICD-10-CM definition requires dialysis dependence. Transplant patients are identified with the transplant status code (Z94.0) plus a code for the current CKD stage of the transplanted kidney. Ask Dr. Pinson Q: A patient with alcohol dependency was admitted for alcohol intoxication with confusion and disorientation. Blood alcohol level was 412 mg/dL. Subsequently he began experiencing signs and symptoms of delirium tremens (DTs) and was transferred to the ICU. In your opinion, is it appropriate to query for toxic encephalopathy due to alcohol intoxication? A: Clinicians should be aware of the coding implications of toxic encephalopathy due to alcohol. Yes, a clarification query may be submitted. Without a query, the code assignment would be: 1. Principal diagnosis code: F10.229, alcohol dependence with intoxication (present on admission [POA] indicator = yes) 2. Secondary diagnosis code: F10.231, alcohol dependence with withdrawal delirium (DTs) (POA = no, since it occurred after admission) The diagnosis-related group (DRG) is 897. If the patient's condition is clarified as toxic encephalopathy due to alcohol, then the code assignment would change to: 1. Principal diagnosis code: T51.0X4A, toxic effect of ethanol, initial encounter (POA = yes) 2. Secondary diagnosis codes: G92, toxic encephalopathy (POA = yes), followed by F10.229 (POA = yes), then F10.231 (POA = no) The resulting DRG is 917. Clinicians should also be aware that documentation of "alcoholic encephalopathy" results in assignment of code G31.2 for a chronic degenerative brain condition (Wernicke-Korsakoff) rather than acute encephalopathy due to alcohol. Q: I was disappointed by your column "Linking Severe Sepsis and Hyperlactatemia" in the June 2018 ACP Hospitalist. You seem comfortable with preserving the Sepsis-2 definition, instead of adopting the 2016 Sepsis-3 criteria that I believe should be embraced by the medical community. Hyperlactatemia is not one of the Sequential Organ Failure Assessment (SOFA) organ dysfunction parameters in the Sepsis-3 definition. A: Thank you for your concern about the Sepsis-2/Sepsis-3 controversy. The June edition of Coding Corner was written in response to a specific question from a reader working at a facility where, whether we agree with it or not, the Sepsis-2 definition is still used—a not uncommon situation at this time. The article was devoted to the diagnostic, documentation, and coding nuances of hyperlactatemia pursuant to the ICD-10-CM Official Guidelines for Coding and Reporting, the Surviving Sepsis Campaign (SSC), CMS's Hospital Inpatient Quality Reporting (IQR) system, and Sepsis-2. I believe we agree on the authoritativeness of Sepsis-3. As I wrote in the June article: "Another issue is that Sepsis-2 definitions and criteria (systemic inflammatory response syndrome [SIRS] due to infection) are no longer the authoritative clinical diagnostic standard for sepsis recognized by SSC, having been replaced by Sepsis-3, which was published in February 2016 and adopted by SSC in March 2017. Appeals of auditor denials based on Sepsis-2 criteria are unlikely to be successful, but all such cases should be reviewed for the possibility of using Sepsis-3 diagnostic criteria as the basis for appeal." It is widely recognized that the SIRS criteria are overly sensitive, leading to overdiagnosis of sepsis in patients who are not truly "septic." We should also acknowledge that many of our colleagues do not yet trust the sensitivity of Sepsis-3 and qSOFA without prospective outcomes research and are concerned about underrecognition of truly septic patients. Lastly, the CMS IQR measure for management of severe sepsis still follows selected SIRS diagnostic and severe sepsis criteria (not Sepsis-3/SOFA), so clinicians must utilize these Sepsis-2 criteria for initiating a severe sepsis management bundle to demonstrate quality care. This is certainly an unsettled period in the evolution of our definitions, diagnostic tools, and effective management of sepsi Chronic Kidney Disease Stage 5—End Stage Renal Disease SHARE THIS PAGE Kidney failure and need for dialysis or transplant, eGFR less than 15End stage renal disease (ESRD), or renal failure, is the end stage of kidney function—not the end stage of life. Also called stage 5 of CKD, ESRD indicates that both kidneys are no longer working sufficiently to keep your body healthy and chemically balanced. If you haven't already decided on an ESRD treatment, discuss your options with your doctor so you can make an informed decision when the time comes. Possible kidney failure signs and symptoms:Uremia, fatigue, shortness of breath, nausea, vomiting, abnormal thyroid levels, swelling in hands/legs/eyes/lower back or lower back pain. Stage 5 kidney failure life expectancy:How long can you live with stage 5 kidney failure? While there's no cure for kidney disease, there are treatment options for kidney failure that can help people live well for decades. Treatment goals: Be ready to start the treatment option that best fits your lifestyle: Home peritoneal dialysis Home hemodialysis In-center hemodialysis Kidney transplant Supportive care without dialysis (palliative care) Continue to treat any other medical conditions and/or complications. What you can do: Meet with your insurance coordinator to help you understand your insurance coverage options. Meet regularly with your kidney doctor to monitor your progression. Continue to see your primary care physician (PCP) for new symptoms or changes/worsening of existing conditions. The Department of Nephrology at Fortis Hospital, provides comprehensive, high quality, multi-disciplinary, compassionate and evidence-based care across the range of kidney-related diseases. We provide clinical services in all areas of nephrology including: clinical nephrology, kidney transplantation, haemodialysis, hemodialfiltration, sustained low efficiency dialysis (SLED), CRRT, Plasmapheresis, peritoneal dialysis, ABO incompatible and pediatric transplantation and critical care nephrology. Our physicians are highly trained and our division is consistently among the highest-ranked programs across the country. We offer comprehensive clinical services, and innovative training programs. Our kidney specialists work closely with other specialty divisions and departments to integrate patient care and our nephrologists also involve patients and their families in decision-making and education to promote understanding of the diagnosis and treatment plans. Specialty Outpatient Care Our cardiologists, nurses and technologists are trained in preventing, diagnosing and treating: Blocked heart arteries (coronary artery disease) Congestive heart failure Heart palpitations High blood pressure High cholesterol (lipid abnormalities) Valve and vascular diseases Cardiac rhythm disorders Our staff will provide an initial consultation and follow-up care for advanced cardiac interventional procedures, electrophysiology services and peripheral vascular interventions in collaboration with the Arrythmia Institute. We also offer echocardiography, electrocardiograms, event recorders, exercise stress testing, Holter monitors, evaluations for pacemakers and implantable cardioverter defibrillators (ICDs), noninvasive vascular testing and nuclear cardiology expertise, in an outpatient setting. Accreditations We are nationally accredited by the Intersocietal Accreditation Commission (IAC, formerly ICANL/ICAEL) for the following: Nuclear Stress Testing/PET scan (IAC Nuclear/PET) Stress Echocardiography (IAC Stress Echocardiography) Echocardiography (IAC Echocardiography) Carotid Ultrasound (IAC Vascular testing) Abdominal Aorta Ultrasound (IAC Vascular testing) Upper and Lower Extremity Arterial testing (IAC Vascular testing) Each accreditations are earned by establishing high standards of quality patient care, careful evaluation of laboratory procedures, and review by an outside board for compliance with nationally accredited standards. Accreditation is re-evaluated every three years for continued compliance. What is kidney transplantation If you are diagnosed with failing kidneys before you need dialysis, treatment can sometimes prevent (or certainly delay) their complete failure. But when your kidneys finally stop working effectively, then you will treatment to replace the work that they do - either a transplant or dialysis. While dialysis is able to get rid of waste products from your body, it does not replace all the functions of your own kidneys. A transplant does. These necessary functions include: continuous removal of waste products of metabolism continuous removal of excess fluid production of a natural hormone called erythropoietin, to prevent anaemia. (If you become very anaemic, exertion will leave you short of breath) conversion of vitamin D in food into an active compound, which helps to keep bones healthy. (All patients with kidney failure develop some bone disease) excretion of some drugs helping to control blood pressure Your kidneys are normally undertaking these functions continuously, day and night, year in year out, without you even having to think about it. It has been shown that kidney transplantation gives better quality and quantity of life than dialysis treatment, so it is in your best long-term interest, provided that you are fit enough to undergo it. How am I assessed for kidney transplantation? If kidney transplantation is something that you wish to consider, you should speak to your kidney doctor (nephrologist) and about whether this is an option for you as soon possible.  This allows time for you to receive all the information that you will need and to be referred for transplant assessment. If you are suitable for a transplant and you wish to have one, the aim is to minimise time on dialysis or, where possible, to avoid it all together. Assessment does not depend on age or ethnic background but on whether you are fit enough to have the operation, recover from the surgery and manage living living with a transplant . So if you have evidence of heart disease, chest condition or other problems, special investigations will be undertaken to assess whether the risks to you are too great for transplantation. There will be discussion between the transplant surgeon, your kidney doctor (nephrologist), specialists in other disciplines if necessary (such as a cardiologist or chest physician) and your GP, as well as yourself, before making a decision. If you are considered fit for transplantation, sucessfully completed your assessment (including checking your tissue type and whether you have had certain virus infections -Hepatitis B and C, HIV, Cytomegalovirus) and understand the benefits and risks to you, you could either be put on the transplant waiting list or receive a kidney from a living donor. Living donation Most living donors are usually close family members or friends but an increasing number of people volunteer to donate anonymously to a someone they do not know- so called 'altruistic donors'. You will also be asked whether you have any family or friends who would consider being a living kidney donor for you and it is important to consider this carefully and well ahead of when you need a transplant to allow time for possible donors to be assessed for their suitability to donate.  Living donor transplantation gives the transplanted kidney a better chance of long-term survival, compared to transplants from patients who have died (deceased donor transplants). A living donor kidney transplant can also be planned in advance so that you may be able to avoid starting dialysis at all or reduce the amount of time that you need to wait for a transplant. Whilst it is is difficult to ask a loved one to go through an operation for your benefit, you should think carefully before rejecting this form of kidney donation or declining offers that are made to you.  In many ways, it is likely to be in your best interests to accept and, for people close to you, it is an opportunity for them to do something life-changing for you. Whilst there are risks as well as benefits to living donor transplantation, these will be fully discussed with you and your donor, so that you can both make the best decision for you. If your potential donor is not compatible with you (blood group or HLA (tissue-type)) you could consider entering into the UK living kidney sharing scheme or discuss the options for antibody removal to make a transplant possible. There are many options that you may not be aware of and it is really important that you have an opportunity to discuss these with different members of the hospital team- your kidney doctor, specialist nurses, surgeons and counsellors or psychologists- all of whom are there to help and support you. Inevitably emotion also plays a part in the decision-making about living donor kidney transplantation, but the transplant will only go ahead if your donor is fit and healthy, you are suitable for a transplant and you both want it to happen. Useful information about living donation: Interactive information documents and short films Living donation in Scotland Legal information Statistics How long will I wait for my new kidney? Once you are accepted for transplantation, you will go on a national transplant list. The national transplant list is held by NHS Blood and Transplant (NHSBT), a government-funded body which co-ordinates organ donation and transplantation in the UK and holds the details of all patients in every transplant centre in the UK. Whenever a kidney donation from a deceased donor takes place, the donor HLA type (tissue type) is registered with NHSBT and a computer search is made to see which patients have the best match – so a kidney donor in Aberdeen may be best matched to a recipient in Plymouth or Liverpool, and the kidneys would be sent to these transplant centres for specifically identified individuals. Your waiting time for a kidney will depend on a number of factors, including waiting time on the list and how well matched you are to the donor, and age matching of the donor and recipient. Some people have been very fortunate and received a transplant within a few weeks of joining the waiting list, whereas others have had to wait for a long time, but the average length of time is 2.5 years If your origin is from outside the UK, or you have an unusual HLA type, the waiting time is likely to be longer because the chances of matching with the pool of UK donors will be less. Don't forget that for deceased donor transplantation, someone has to die before he or she becomes a donor, so it is impossible for doctors to predict when a suitable matched kidney will become available. Also, there are always more people in need of a kidney transplant than the number of donors available. Will my blood group and tissue type affect the wait? Blood group: In the first instance, your blood group determines whether you can receive a donor kidney. There are four blood groups: O, A, B and AB. The blood group has to be compatible (though not necessarily the same) as follows: Donor blood group Recipient blood group O (47% donors) - universal donor A, B, AB, O A (40% of donors) A, AB B (9% of donors) B, AB AB (4% of donors) AB - universal recipient Kidneys from donors in blood group O ("universal donors") can be given to anyone in other blood groups, and patients in blood group AB can receive kidneys from donors in any other blood group ("universal recipients"). Blood group B is uncommon in the UK (about 9% of donors) but is quite common (40%) in the Indian, Pakistani and Bangladeshi populations. Blood group and tissue matching differences are the main reasons for the difficulty in Asian dialysis patients receiving a kidney transplant from UK donors. Human Leucocyte Antigen (HLA/Tissue type) We all inherit a set of chromosomes from our father and mother, making two sets of chromosomes altogether. Amongst these chromosomes there are so-called HLA (human leucocyte antigen) genes which are within the genetic material of virtually all the cells which make up the body. There are three principle transplantation genes that are particularly important: HLA 'A', HLA 'B' and HLA 'DR'. There are many different HLA 'A', 'B' and 'DR' genes and so it is difficult to get two people perfectly alike, but it is possible to achieve a good enough match for a successful transplant. The larger the group of patients and donors, the more chance there is of a good or perfect match between donor and recipient. That is why deceased donor kidneys are shared throughout the UK. It has been shown in many studies that good matching between deceased donor and recipient leads to longer kidney survival, and hence is in the best interests of everyone. In a situation where there is a shortage of donor organs, it makes sense to maximise the benefit in prolonging kidney survival. In living donor kidney transplantation, matching has less impact on the outcome of transplants because living kidneys are donated by healthy people in ideal circumstances, which all contribute to success. However, for younger people and children who may need another transplant during their lives, a closer match for a first transplant is preferred. Who would donate my new kidney? There are three types of donor: Donation after brain stem death (DBD) donor, previously known as heart-beating donor. This is the traditional form of deceased organ donor and hence better known. Usually the donor has undergone a sudden, serious event such as a brain haemorrhage, a head injury following a road accident, or another event which has led to them being placed on a ventilator (breathing machine), being unable to breathe unaided. Tests are carried out to establish whether or not the patient will ever recover adequate brain function, particularly a capacity to breathe independently again. If tests confirm that brain damage has been extensive and irretrievable the patient can be considered as a potential organ donor and the Organ Donor Register will be checked. It is at this stage that the family are informed and the subject of organ donation is raised. Nearly all relatives will consent to organ donation when their loved one is on the Organ Donor register, particularly when a Specialist Nurse for Organ Donation (SNoD) is involved but the overall consent rate for organ donation is only 63%. The donor is then transferred to the operating theatre where the respective organs are cooled with a special fluid to help preserve the organs, the ventilator is stopped and the organs removed.. Donation after circulatory death (DCD) donor, previously known as non heart- beating donor. These again are patients who have an irreversible brain injury and are usually on an Intensive Care Unit or in an Emergency Department. They will usually be on a ventilator to keep the heart and lungs working, but do not meet the tests for brain stem death. If there is no prospect of recovery they may be considered as a potential donor and the Organ Donor Register checked before talking to the family. If consent is given, the patient will be disconnected from the ventilator and if the heart stops within a suitable period of time they are transferred to theatre and the same procedure performed as for a DBD donor. The number of DCD donors has increased significantly in recent years and accounts for 40%  of all deceased donors. The long term results for kidney transplants are as good as for DBD donors. Living kidney donation has been discussed previously. After rigorous testing to make sure that the donor is suitable, the kidney is transplanted into you. The kidney is functioning very well before removal and the process for removal and transplanting into you is much shorter. Any damage caused by the removal process is therefore minimised, and usually the kidney starts working immediately, hence this type of transplant results in the best long-term outcome. The nature of living donor transplantation means that it is a daytime activity on a scheduled operating theatre list, whereas deceased donor transplantation tends to be an emergency procedure. What happens in the transplant operation? The operation itself takes anywhere between one-and-a-half and three hours, although if there are difficulties it may take even longer. The key factor is not the length of the operation but the care with which it is performed. Technical factors within you and any anatomical abnormalities in the donor kidney will dictate the length of the procedure. The kidney is placed in the groin in your lower abdomen and can be put on either side. Your own kidneys will be left in place. The kidney's vein is joined to your own iliac vein (which drains the blood from your leg), and the kidney's artery is joined onto the iliac artery (which supplies your leg with blood). Once these blood vessels have been connected, the circulation to your kidney is released; the kidney becomes pink and may start to work more or less straight away. Indeed, urine may pass out of the ureter, the tube that joins the kidney to the bladder. The ureter is then joined to the bladder to complete the operation and sometimes a plastic tube called a stent will be placed through this join and this will require removal 4-6 weeks later in a minor operation. Often, a drainage tube is placed near the kidney, to drain out any blood or other fluid from the operation site. A catheter in your bladder drains the urine into a bag for monitoring. In addition to these tubes you will return to the ward with one or two intravenous infusions and often a PCA (Patient Controlled Analgesia), which is a morphine infusion for pain control which you can adjust yourself. After the operation, you and your kidney will be monitored carefully. Your kidney may be scanned by ultrasound to check on the circulation, and to make sure that the ureter does not become obstructed. How will I be monitored after the operation? Immediately following the transplant, and sometimes before, you will start taking immunosuppressive medication to help prevent your body from rejecting the new kidney. The medicines that you are given to prevent rejection may not be entirely effective, and break-through "acute rejection" may occur, usually within the first six weeks after transplantation. Thereafter, the rejection episodes are much less common and are usually triggered by external factors and, most particularly, if you do not take your immunosuppressive drugs. Once your kidney is working and is stable, you will be discharged home. Some transplant units have a policy of sending you home as soon as you have recovered from the operation, whether the kidney is working or not. In these units you will be monitored very closely as an outpatient until the kidney starts to function. In those that keep you in hospital until the kidney starts to work, after you have been discharged from hospital you will also be monitored closely in the outpatient clinic, but probably less frequently. This monitoring will require you to go to the hospital or the transplant unit up to three times a week initially so that blood tests can be performed, and your immunosuppressive drug levels can be monitored. It is important to remember that worsening of your kidney function does not necessarily mean you have rejection; there may be other factors such as obstruction to urine flow in your ureter or bladder, or high levels of immunosuppressive drugs. Follow-up clinic appointments are important to monitor your kidney function, your blood pressure and your general well-being. Many centres ask for you to monitor your own blood pressure at home as well as your urine output and temperature. Most often you will be given a book in which to record these measurements, and all your prescribed drugs will also be recorded in the book. It is vital that you bring this book with you every time you attend the hospital. The dosage of your drugs will be readjusted with time. What long-term monitoring is needed? If you are well and the kidney function is stable, you will usually be discharged home between one and two weeks after the transplant. After the first six to eight weeks following transplantation you will be monitored once a week, and then in time less frequently. Once you are several years after your transplant, you will generally be seen on a three to six monthly basis – but you will never be discharged. Despite many years of function, kidneys do deteriorate and the purpose of the outpatient appointment is to monitor the function of your kidney and those factors that will improve the long-term survival of the kidney and your life. These include your weight, blood pressure, the lipids (fats) in your blood, bone disease, heart disease, prescribed drugs and so on. Attendance at outpatient clinics is essential. A lot has been invested in you, not only by your family and your transplant team but also the donor family who have given their loved one's kidney to you, and it is your responsibility to treasure that gift. Not taking immunosuppressive drugs as prescribed is a problem which is probably far more common than even doctors are aware of. Every transplant centre has patients who lose their transplant because of this completely avoidable factor. If the drugs that you are taking are causing some problems, talk to your doctors about changing them rather than stop taking them. Your doctor will not insist that you take a drug which you find unpalatable, or causes unacceptable side effects. Monitoring you after transplant is a partnership between you the patient, the transplant unit staff and your GP. If you feel depressed, or have other problems, then every transplant centre has an "open door" policy so that you can contact transplant unit staff at any time to discuss your concerns. Most patients use this facility at some time or other. Your GP is responsible for the overall care for you and your family, so he or she is very important in monitoring and managing your general health. Many patients and their GPs are happier for much of the care after transplant to be controlled by the transplant centre. However, there is a three-way partnership between you, your GP and the transplant centre staff to try and maintain your good health. The transplant centre should be in regular contact with your GP via your discharge letters and clinic letters, informing the GP of changes in drug prescription, your kidney function and general health. High blood pressure is a common feature of kidney failure, both before and after transplantation, and the management of this is often a shared partnership between the GP and the hospital doctors. It is important that you participate in this by measuring your blood pressure yourself if you have a machine, or have your blood pressure checked by the nurse at the GP practice. Many GPs and hospital transplant centres run "healthy lifestyle" clinics which are there to monitor and advise you on improving your general health. Some patients are more comfortable in attending the transplant centre clinic rather than going to their GP if they have a problem. This is understandable and arrangements usually allow for this. However, your GP is the first port of call in an emergency situation. In some areas, GPs will prescribe your immunosuppressive drugs for you, but in other areas your drugs will be supplied by the hospital. Home delivery service of the immunosuppressive drugs has become more available in some areas, and this may be appropriate for you once you are stabilised on a settled dose of your medication. What are the survival rates of kidney transplants? Kidney survival time Survival rates Deceased donor kidneys Live donor At 1 year 85-90 90-95 At 5 years 70 80 At 15 years 50 60 Whilst your medical team would like your kidney to last forever - and some kidneys indeed survive for more than 30 years - unfortunately this does not usually happen. Therefore, transplantation plays only one part in the management of your kidney failure, with dialysis being the counterpart. How am I notified when a transplant becomes available for me? You will receive a telephone call, usually from the Recipient Co-ordinator or a nurse from the Transplant Unit, informing you that a kidney has been accepted for you, and asking you to come into hospital. Sometimes the kidney is already in your transplant unit but at other times it will be transported from another UK transplant centre. The telephone call may come at any time, including the middle of the night. There is clearly no way of predicting in advance when the call will come; in fact, most patients are easier to get hold of in the middle of the night than during the day! Am I guaranteed to receive the kidney? The first thing that will happen when you arrive at the hospital is a blood test which will be sent to the tissue typing laboratory for the "cross match" test. This test is absolutely essential to see whether your blood has any antibodies that react against the donor. The cross match test takes at least four hours to perform, and longer if more complex tests have to be undertaken. Sometimes if your antibody status is clearly known it is possible to go ahead with the operation without waiting for the test to come back., After you arrive you will be seen by a doctor who will assess whether you are fit enough to undertake the transplant, and you will have more blood tests (usually done at the same time as blood taken for cross match testing), an ECG and chest x-ray. Once the all-clear is given, the operating theatre will be contacted about proceeding with the transplant. Very occasionally a combined discussion between the doctors on the transplant team and the anaesthetist will result in you not going ahead with the transplantation because of medical problems. What are the risks involved in transplantation? There are a number of complications related to the transplant operation itself and then the more general risks attached to transplantation which are detailed below. As the operation involves joining blood vessels together and the ureter to the bladder there are risks of leaking or blocking. If the blood vessels leak this causes bleeding which may require a blood transfusion or more uncommonly a further operation. If the blood vessels block this is more serious as the kidney will lose its blood supply and will usually have to be removed. Thankfully this only happens in around 1 in 50 occasions and will usually happen in the first week. If the ureter leaks or blocks this may require treatment in the X-ray department or a further operation. Most living donor kidneys will work immediately, but 20-40% of deceased donor kidneys may take a few days or weeks to work and dialysis can be required in the meantime. Your transplant surgeon will be able to explain these risks in more detail. Infection - The anti-rejection immunosuppressive drugs partially suppress your immune system, which fights infection in the body, so you will be more prone to infection than you were on dialysis. Infections frequently involve the urinary tract and the transplant centre will undertake regular urine tests. Repeated urine infections can damage your kidney and, if they occur, you may be prescribed a regular low dose of antibiotic, which is changed every few months. Virus infections such as flu or the common cold may last longer than normal. A virus you may not have heard of is cytomegalovirus, CMV for short. Half of the UK population has had CMV infection, and the virus then lives inside the body. Blood tests will detect whether you have had the virus infection or not. If you have not, and you receive a kidney from someone who has had the infection, then there is a 1 in 2 chance that the virus may be passed to you through the kidney. The virus can cause a variety of medical problems, some serious. However, virus transmission can be detected early and effective drug treatment started to prevent serious disease. In some centres, doctors prefer to give you anti-viral drugs for three to six months. Death - unfortunately, there is a risk of death in a small percentage of people following transplantation, usually due to two main factors: a heart attack or other complication of the heart severe infection These risks are increased in those with existing heart disease and infection problems. The older you are, the greater the risk. Your transplant surgeon and physician will balance the risk of transplantation with the benefits, and decide with you whether it is too great a risk. It is important to remember the risk of death is not just at the time of the transplant operation itself, but also the recovery period afterwards, during which time you may require intensive anti-rejection therapy. Cancer - The immunosuppressive drugs can increase the risk of developing certain cancers, the most common being skin cancer. It is particularly important to avoid excessive exposure to the sun by avoiding sunbathing. Most skin cancer is treated by localised excision More serious is the risk of cancer of the immune system (lymphoma). The risk of developing this form of cancer exists during the lifetime of the transplant whilst you are taking immunosuppressive drugs, but the overall risk is small. Higher risk kidneys and donors All donor kidneys carry some risk, but some are higher risk than others. Despite careful assessment all kidneys carry a very small risk of passing on an infection or a cancer. Higher risk donors are those aged over 50; those with mild high blood pressure (hypertension); those with diabetes and with no evidence of kidney disease; and those kidneys with long storage times. These kidneys may have a higher failure rate in the long term, but the evidence is that you are better-off with a kidney transplant, even from a higher risk donor, than staying on dialysis. Kidneys from DCD donors often have delayed function but the outcome in the long-term is good. What will happen if I live a long way from the transplant unit? Many of you will live closer to your old dialysis unit than the transplant centre. The kidney doctor, who looked after you pre-transplant, will be kept up-to-date about your progress following transplantation. Increasingly, more of the kidney doctors in the dialysis units outside of the transplant centres are becoming more involved in taking care of transplant patients. In some areas, such kidney doctors will look after you following the first few months after transplantation and others some time later. However, the transplant centre and the kidney doctors will keep in touch with each other in order to monitor your progress. If your kidney function starts to deteriorate, then further investigations, including transplant biopsy, may be done in the transplant centre rather than in the renal unit. However, this will vary depending on what arrangements have been made in your area. How soon will I be mobile after a transplant? It is important to get mobile as soon as possible after a transplant in order to reduce the risk of thrombosis in the veins in your legs. So the nursing staff will usually get you out of bed the day after the transplant, even if it is just sitting in a chair. Once the drain, catheter and intravenous drips have been removed - generally within five days of your transplant - you should be walking around the ward comfortably. In general, it is important for you to keep fit and healthy, and exercise is an essential component of your recovery. This exercise could merely be walking outside rather than any planned fitness activity. Exercise will aid your recovery as well as maintaining your health, and there is no reason why you could not get back to normal activity by six weeks after transplantation, provided your post-transplant recovery has not been difficult. In the long-term, even strenuous exercise should not cause you any harm. However contact sports such as rugby would best be avoided since there is more risk of injury to the transplanted kidney than to your own kidneys due to its position. Do you have to remove my own kidneys to get the transplant in? It is unlikely that your own kidneys will be removed at any time unless they are causing you problems or will interfere with the transplant. For example, if you are getting repeated water infections from diseased kidneys, or they are causing persistent high blood pressure despite taking many drugs, then your kidneys may be removed. The position of your own kidneys make transplantation at that site difficult therefore the transplanted kidney is actually placed in the lower abdomen just above the thigh and close to the blood vessels supplying your legs. The kidney can be comfortably accommodated in this position. The kidney transplant is usually easy to feel on examining your abdomen compared to your own kidneys, which are well hidden underneath the rib cage. How will I know if I am rejecting my new kidney? Acute rejection usually occurs within the first three months after transplantation, and especially within the first six weeks. Your immune system will recognise the kidney as "foreign" and will react against it despite the immunosuppressive drugs given to you. Doctors can recognise this by the increase in serum creatinine and urea in the blood tests, and you will recognise it by the reduction in the amount of urine you pass and sometimes when the kidney feels tender. Most often acute rejection is confirmed by performing a kidney transplant biopsy. When can I return to work? The whole purpose of transplantation is to allow you to lead a normal life, which includes the ability to work and earn a living. The precise time at which you can return to (or search for) work depends on the type of job you have, the length of time you are in hospital or receive anti-rejection treatment and how well you have coped with transplantation and its aftermath. If you have a desk job which does not involve heavy physical work, then you can return to work within six weeks to two months following transplantation. If you have a physical job, then you may need three months before returning to work. If you have a physically demanding job, employers will often be sympathetic and ease you back in with a less demanding job initially. Am I restricted in my diet after a transplant? If your kidney is working well, then you can eat any food you like. Indeed, one of the problems after transplantation is that you may put on a considerable amount of weight because the restrictions on your diet no longer apply. There are many instances of patients putting on 2-3 stone in weight! Clearly this has a very negative impact on health generally - blood pressure, blood lipids (fats which are related to increased heart and blood vessel disease), increased pressure on bones and other problems. Therefore, maintaining a healthy diet is important for you. If you need advice, the dietician who gave you information before your transplant will also give you further information afterwards. Will my sex life be affected? Sexual activity is often unsatisfactory when you are on dialysis. After transplantation, as you start to feel better, there may well be a steady improvement in your sex life. In women, menstrual periods may return and therefore the ability to have children. It is extremely rare to have children whilst on dialysis and so transplantation is certainly an avenue by which women are able to start or complete a family, but you are recommended to have a chat with your transplant doctor when you are ready to do so. However, conceiving a child within the first 12 months after transplantation is generally discouraged. You first need to recover from the transplant operation and any problems associated with it. Can I go on holiday? One of the benefits of transplantation is the fact that you do not need to dialyse when going away on holiday. Relaxing on holiday with your family either at home or abroad is certainly one of the exciting prospects following transplantation. Transplant centres generally do not like you to travel abroad in the first year following transplantation but thereafter, provided you take precautions, there is no reason why you cannot go abroad. The critical factor is whether you are exposing yourself to a risk of infection. Certainly dialysis patients and transplant patients who have gone abroad have contracted Hepatitis B and other infections, so if you are travelling outside the Western European countries, it is advisable to use bottled water only (even to clean your teeth). You should also make sure you have enough tablets to take with you. What happens if I lose my kidney? Losing your kidney transplant means that you will need to go back onto dialysis and this will be discussed with you in the phase leading up to your needing dialysis, just as before when your own kidneys were failing. You will need to readjust to the more restricting requirements of dialysis in order to keep well. Your kidney doctor (nephrologist) will take over your management once again and will discuss your future dialysis options with you. Peritoneal dialysis and haemodialysis both remain possibilities. After a period of recovery, you will be reassessed to see if you are suitable for another kidney transplant. If you have lost your kidney suddenly soon after transplantation, or you were not well during the period you had your transplant, you may not feel that you want another. In general,  the survival of the first transplant is better than the second, the second is better than the third. But some patients even have the opportunity to have a fourth transplant. There will be a reluctance to give you a second opportunity to have a transplant if you are the cause of your kidney loss by not taking your immunosuppressive medication or attending clinics. Don't forget, there are not enough kidneys to meet the demand, and it is only fair to the donor and his or her family, to other patients on the transplant waiting list (some of whom will have been waiting for many years longer than you), and to the transplant team that the life of the kidney should be preserved for as long as possible. When a kidney transplant is given to you, you and the transplant team have responsibilities. They will look after you to the best of their ability as their part, and you must take your medication without fail for as long as your kidney works, as part of yours. Conclusion A kidney transplant is the most successful treatment for kidney failure, but there are no 100% guarantees. Hopefully this information will help you understand more about the benefits and risks and you should discuss this further with your nephrologist and transplant surgeon.End-Stage-Renal Disease and Kidney Transplantation Essay Paper End-stage Renal Disease The kidneys are two bean shaped organs whose function is essential to life.  The kidneys are located on either side of the spine behind the abdominal organs and below the rib cage.  The kidneys perform several major functions: Filtration of the blood to remove waste products from normal body functions, passing the waste from the body as urine, and returning water and chemicals back to the body as necessary. Regulation of the blood pressure by releasing several hormones. Stimulation of production of red blood cells by releasing the hormone erythropoietin. The kidneys produce urine, which is then carried to the bladder by the ureters. The bladder serves as a storehouse for the urine. When the body senses that the bladder is full, the urine is excreted from the bladder through the urethra. Chronic Kidney Disease In chronic kidney disease, also known as CKD, there is an accumulation of toxic waste products in the body resulting in  permanent damage to the kidneys. While the kidneys may work well enough for a person to live, the condition is irreversible and often worsens over time until the kidneys fail known as end-stage renal disease (ESRD) . Causes Diabetes and high blood pressure are the leading causes of chronic kidney disease and kidney failure. The disease can also be caused by a physical injury to the kidney or by other diseases. When the kidneys are damaged, they do not effectively remove wastes and extra water from the blood. Symptoms In its early stages, CKD is often silent producing few if any symptoms. CKD often develops so slowly, in fact, that many people are unaware of it until the disease is very advanced or must be rushed to the hospital for life-saving dialysis.  CKD runs in families. There is an increased risk of developing the disease if a first-degree relative (mother, father, sister, or brother) has kidney failure. Risks of Developing CKD Diabetes High Blood pressure Kidney failure in a first-degree relative Some racial groups are at increased risk for CKD African Americans are nearly four times as likely to develop kidney failure as white Americans. American Indians have nearly three times the risk compared to whites. Hispanic Americans have nearly twice the risk of non-Hispanic whites. If a person has one of these risk factor, they should be screened for kidney disease which is done through simple blood and urine tests. Diagnosis Since early CKD has no symptoms, the diagnosis is made using standard medical tests. Blood Pressure: High blood pressure can lead to kidney damage, and it can also be a sign that kidney damage has already occurred. If blood pressure is high, controlling it is essential to ensure the kidneys remain healthy. Blood Test: The glomerular filtration rate (GFR) measures how efficiently the kidneys are filtering waste from the blood. The new method of calculating GFR requires only a measurement of the creatinine (kree-AT-ih-nin) in a blood sample. Creatinine is a waste product in the blood created by the normal breakdown of muscle cells during activity. When kidneys are not working well, creatinine builds up in the blood. Urine Test: Measuring the amount of a protein called albumin in the urine can show a kidney problem. A large amount of protein in the urine is known as proteinuria and is a sign of kidney damage. A dipstick in a sample of your urine is used for this test. The color of the dipstick indicates the level of protein.End-Stage-Renal Disease and Kidney Transplantation Essay Paper A test that can show smaller amounts of protein or albumin in the urine is called a microalbumin test and also uses a dipstick in the urine.  Your doctor may also do a calculation of the protein-to-creatinine or albumin-to-creatinine ratio. Healthy kidneys move creatinine from the blood into the urine. A ratio greater than 30 milligrams of albumin per 1 gram of creatinine indicates that the kidneys are leaking helpful substances from the blood and failing to filter out harmful substances. This test should be used in people at high risk, especially those with diabetes. If your first laboratory test shows high levels of protein, another test should be done 1 to 2 weeks later. If the second test also shows high levels of protein, you have persistent protein in the urine (proteinuria) and should have additional tests to test your kidney function. A 24-hour urine collection is no longer necessary. Small samples of urine and blood, which can easily be taken in the doctor's office, are all the new methods require. Several organizations offer free screenings for kidney disease. You may be able to have your kidney function measured at a local health fair. The National Kidney Foundation's KEEP (Kidney Early Evaluation Program) initiative offers blood and urine testing, on-site consultation with a physician, and referral and followup services for people whose test results are outside the normal range. The American Kidney Fund's MIKE (Minority Intervention and Kidney Education) Program offers educational sessions and medical screenings. The American Association of Kidney Patients' Finding Your Strength program offers education about your kidneys, tests to expect, and ways to stay healthy with CKD. Contact information for these and other organizations appears in the For More Information section at the end of this fact sheet. What can I do to slow down or avoid kidney failure? Learning about reduced kidney function allows you to take steps to keep your kidneys healthy as long as possible. You can control many of the things that can make CKD worse and may lead to kidney failure. If you have diabetes, control your blood glucose, also called blood sugar. Studies show that keeping tight control of blood glucose can delay or prevent kidney failure. If you have high blood pressure, keep your blood pressure below 140/90 mm Hg. If you have high blood pressure with CKD, keep your blood pressure below 130/80 mm Hg. Blood pressure medicines called ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) protect the kidneys better than other medicines. You may need a combination of two or more drugs to keep your blood pressure below 130/80. In many cases, a medicine that lowers blood pressure by increasing urination, called a diuretic, should also be part of the plan. If you have CKD, don't eat too much protein. Protein breaks down into the waste products the kidneys must excrete. Reducing those waste products by eating less protein means the kidneys don't have to work so hard. But eating too little protein can lead to poor nutrition. Work with a dietitian to make sure you get the right amounts of protein and other nutrients. What can I do to avoid the complications of CKD? CKD can lead to many other health problems well before kidney failure occurs. Anemia. Anemia develops when the kidneys fail to produce enough erythropoietin, or EPO, the hormone that directs the bones to make red blood cells. Anemia can cause heart problems. Bone problems. Healthy kidneys help keep your bones strong by balancing the levels of calcium and phosphorus in the blood. CKD can lead to bone problems by throwing those minerals out of balance. Acidosis. The kidneys also maintain the acid/base balance in the blood. Kidney problems may lead to acidosis, a condition in which the blood is too acidic. Acidosis can disrupt body functions. Cardiovascular disease (CVD). Patients with CKD are more likely to die from a heart attack or stroke than from kidney failure. Even a small loss of kidney function can double a person's risk of developing CVD. If you have CKD, you will need to have regular checkups to monitor blood levels of creatinine, urea nitrogen, potassium, phosphorus, parathyroid hormone, hemoglobin, and cholesterol. If your blood tests show abnormal levels of any of these substances several times, your doctor will prescribe medicines. For example, if you have anemia indicated by low levels of hemoglobin on repeated tests, your doctor can prescribe a synthetic form of EPO (erythropoietin) to help your body make more red blood cells.End-Stage-Renal Disease and Kidney Transplantation Essay Paper End Stage Renal Disease (Kidney Failure) Chronic kidney disease may eventually result in complete kidney failure. This is the last stage of CKD (Stage 5), also referred to as end-stage renal disease (ESRD). When the kidneys totally fail, either dialysis or a kidney transplant is required. Common Causes of End-Stage Renal Disease Diabetes mellitus High blood pressure Glomerulonephritis Polycystic Kidney Disease Severe anatomical problems of the urinary tract Dialysis Hemodialysis, a mechanical process of cleaning the blood of waste products Peritoneal dialysis, in which waste products are removed by passing chemical solutions through the abdominal cavity Kidney Transplantation Dialysis does not cure end-stage renal disease. A transplant offers the closest thing to a normal life because the transplanted kidney can replace the failed kidneys.  However, a kidney transplant also involves a life-long dependence on drugs to keep the new kidney healthy.  Some of these drugs can have severe side effects. Some kidney patients consider a transplant after beginning dialysis; others before starting dialysis.  Dialysis patients who also have severe medical problems such as cancer or active infections may not be suitable candidates for a kidney transplant. A Growing Problem CKD is a growing problem in the United States of which kidney failure is only one piece. Experts estimate that 20 million Americans have significantly reduced kidney function; even a small loss of kidney function can double a person's risk of developing cardiovascular disease. Many of these people will experience heart attacks or strokes before they become aware of their kidney disease. So identifying and treating CKD early can help prevent heart problems as well as postpone kidney failure. Available treatments for end‐stage renal disease (ESRD) include dialysis and kidney transplantation (1, 2). Increasing prevalence of ESRD, together with stable or declining rates of organ donation have led to a critical shortage of kidneys available for transplantation (3, 4). The median interval between placement on a transplant waiting list and receipt of a kidney transplant from a deceased donor has dramatically increased in recent years, and currently ranges between 3 and 7 years for North American patients with kidney failure, depending on region of residence (5). At the same time, the age and comorbidity of patients who are treated with dialysis continues to increase (6). Individual studies indicate that kidney transplantation is associated with lower mortality and improved quality of life compared with chronic dialysis treatment (7, 8). However, factors that are associated with greater or lesser benefit from transplantation are poorly described. In addition, there has been little or no systematic exploration of how the relative benefits of transplantation (compared to dialysis) have varied over time, given that contemporary dialysis patients are older and sicker (6), but must wait longer to receive a kidney transplant than those in previous years (3, 9). We did a systematic review to summarize the anticipated clinical benefit associated with kidney transplantation (compared with dialysis) in the current era. We also aimed to identify characteristics associated with especially large or small relative benefit, compared to dialysis. Materials and Methods Data sources and searches This systematic review is reported according to published guidelines (10). An expert librarian conducted a comprehensive search to identify all relevant studies regardless of publication status. Nonenglish articles were included where an appropriate translator was available. Three electronic databases, MEDLINE (1950–February 25, 2010), EMBASE (1980–February 25, 2010), and all evidence‐based medicine reviews (September 7, 2007) were searched. The detailed search strategies are included in the Supporting Information. A content expert and a methodologist screened each citation or abstract. Any study considered potentially relevant by at least one reviewer was recovered for further review.End-Stage-Renal Disease and Kidney Transplantation Essay Paper Study selection The full text of each potentially relevant study was independently assessed by two reviewers for inclusion in the review using predetermined eligibility criteria on a preprinted form. Studies were eligible for inclusion if they reported important clinical outcomes (mortality, cardiovascular events, hospitalization and quality of life [QoL]) in both a chronic dialysis population and a kidney transplantation population. Pediatric studies (age < 16 years) and studies including multi‐organ transplantation were excluded. Studies had to include at least 30 participants in each relevant treatment modality group. This minimum sample size was set to improve the efficiency of the work without an appreciable loss of power and to minimize bias (robust calculations of standard deviation and to prevent small study bias). Multigroup cohort studies were included; crossover, case‐control and cross‐sectional studies were excluded with one exception—we included cross‐sectional studies when QoL was reported. Disagreements were resolved by discussion and consultation with a third party. Reviewers agreed on study selection for 89% of the articles (κ= 0.66). Data extraction and risk of bias assessment We assessed and reported risk of bias in included studies using items from the Downs and Black checklist (11). These include items of study design (selection of participants, allocation of participants and outcome definitions), statistical analysis (calculation of sample size and adjustment for potential confounding) and results (losses to follow up). Post hoc, we included three items specifically relevant to the time‐to‐event analyses in these studies: (1) selected time of origin (e.g. dialysis initiation or transplantation) and destination (e.g. modality failure, death), (2) adjustment for prior time spent on renal replacement therapy and (3) modeling time‐dependency of modality (i.e. attributing the time on dialysis for eventual transplant recipients and graft failure patients to the dialysis hazard). Two reviewers independently assessed each included study, and resolved disagreements with the aid of a third party. The following properties were extracted from each study: characteristics (country, data source, era of accrual, duration of follow‐up, special subgroups or populations, sample size and setting), participants (age, gender, race, body mass index, socio‐economic status and comorbidities), renal replacement modality (living or deceased donor, hemodialysis, peritoneal dialysis, etc.) and results (both unadjusted and adjusted, covariates, interactions and subgroups). The following outcomes were considered: all‐cause mortality, cardiac events (limited to myocardial infarction, stroke, heart failure and to the aggregate of any cardiac event), hospitalization (incidence, rate, mean counts; limited to infection and all‐cause) and QoL. Specifically, the following QoL instruments were included: European quality of life‐5 dimensions (EQ‐5D), time trade off (TTO), standard gamble, health utility index (HUI), Finnish 15 dimensions (15D), Medical Outcomes Study 36‐Item Short‐Form Health Survey (SF‐36), kidney disease quality of life (KDQoL), Karnofsky, sickness impact profile (SIP), general health questionnaire (GHQ), and World Health Organization quality of life (WHO‐QoL). A second reviewer checked the data for accuracy. Data synthesis and analysis Because identified studies were expected to be observational and, therefore, both methodologically and clinically diverse, we decided a priori not to statistically combine results. To facilitate comparison, we present individual study summary statistics in unpooled metagraphs using R software. Dichotomous outcomes (e.g. mortality) are summarized using the unadjusted risk ratio and all available adjusted ratios (i.e. hazard ratio [HR], risk ratio, odds ratio, rate ratio; depending on what was reported). Continuous outcomes (e.g. QoL) are summarized using the mean difference. Given the presence of large heterogeneity, we did not formally assess for the presence of publication bias (12). We planned a priori to examine the following subgroups for evidence of effect modification on the association between transplantation and mortality: diabetic patients, elderly patients, patients with chronic infections (human immunodeficiency virus, hepatitis B or hepatitis C) and patients with cardiovascular disease. We were primarily interested in the results of formal tests for effect modification in the primary studies. Unfortunately, we did not identify eligible studies for all of these subgroups. However, using multivariable meta‐regression models (weighted least squares linear regression), we examined whether era (midyear of the interval for inclusion of participants), restricting analyses to dialysis patients who were active on the kidney transplantation waiting list, or elements of study design (prospective, retrospective or registry) modified the relationship between unadjusted mortality and modality. To minimize participant overlap (and ensure independence of data) between studies in our meta‐regression analyses, we restricted our pool of studies to unique combinations of region (or registry) and era of accrual. More current studies were given precedence; studies with special populations were excluded (e.g. hepatitis positive). Kidney disease has become more prevalent over the years, one in nine Americans has chronic kidney disease, resulting in the need for a kidney transplant. Kidney failure is caused by variety of factors resulting in damage of the nephrons, which are the most important functioning unit of the kidneys. Kidney failure can be broken down into three groups: acute, chronic, end-stage. Once kidney failure is irreversible, dialysis or transplantation is the only method of survival. To avoid a kidney transplant, one needs to be aware of the pre-disposing factors, signs and symptoms, available treatments, and proper diet. 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). End-Stage-Renal Disease and Kidney Transplantation Essay Paper CKD patients from an outpatient nephrology clinic at a safety-net hospital (n = 213) participated in a cross-sectional survey from April to June, 2013 to examine the factors associated with willingness to receive a kidney transplant among a predominantly minority population. The study questionnaire was developed from previously published literature. Multivariable logistic regression analysis was used to determine factors associated with willingness to undergo a kidney transplant. Respondents were primarily AAs (91.0 %), mostly female (57.6 %) and middle aged (51.6 %). Overall, 53.9 % of participants were willing to undergo a kidney transplant. Willingness to undergo a kidney transplant was associated with a positive perception towards living kidney donation (OR 7.31, 95 % CI: 1.31–40.88), willingness to attend a class about kidney transplant (OR = 7.15, CI: 1.76–29.05), perception that a kidney transplant will improve quality of life compared to dialysis (OR = 5.40, 95 % CI: 1.97–14.81), and obtaining information on kidney transplant from other sources vs. participant's physician (OR =3.30, 95 % CI: 1.13–9.67), when compared with their reference groups. It is essential that the quality of life benefits of kidney transplantation be known to individuals with CKD to increase their willingness to undergo kidney transplantation. Availability of multiple sources of information and classes on kidney transplantation may also contribute to willingness to undergo kidney transplantation, especially among AAs. When the kidneys are no longer working effectively, waste products, electrolytes, and fluid build up in the blood. Dialysis takes over a portion of the function of the failing kidneys to remove the fluid and waste products. Kidney transplantation can even more completely take over the function of the failing kidneys. This article discusses these therapies, including the advantages, disadvantages, and care required for kidney transplantation and dialysis. You and your family should discuss all of the options with your healthcare provider to make an informed decision.End-Stage-Renal Disease and Kidney Transplantation Essay Paper WHEN WILL DIALYSIS OR KIDNEY TRANSPLANTATION BE NEEDED? As the kidneys lose their ability to function, fluid, waste products, and electrolytes begin to build up in the blood. Dialysis should begin before kidney disease has advanced to the point where life-threatening complications occur. This usually takes many months or years after kidney disease is first discovered, although sometimes severe kidney failure is discovered for the first time in people who were not previously known to have kidney disease. (See "Patient education: Chronic kidney disease (Beyond the Basics)".) If you have advanced kidney disease and you plan to start dialysis, it is best to begin dialysis treatments while you still feel well and have only mild symptoms of kidney failure. Such symptoms include nausea, loss of appetite, loss of energy, vomiting, difficulty concentrating, and others. You and your doctor will decide when to begin dialysis after considering a number of factors, including your kidney function (as measured by blood and urine tests), overall health, and personal preferences. Most patients will have symptoms of kidney failure and thus generally plan to start dialysis when their kidney function is approximately 5 to 10 percent of normal. KIDNEY TRANSPLANTATION Kidney transplantation is considered the treatment of choice for many people with severe chronic kidney disease because quality of life and survival (life expectancy) are often better than in people who are treated with dialysis. However, there is a shortage of organs available for donation. Many people who are candidates for kidney transplantation are put on a transplant waiting list and require dialysis until a kidney is available. A kidney can be transplanted from a relative, an unrelated person (such as a spouse or friend), or from a person who has died (deceased or cadaver donor); only one kidney is required to survive. In general, organs from living donors function better and for longer periods of time than those from donors who are deceased. Some people with kidney failure are not candidates for a kidney transplant. Older age and severe heart or vascular disease may mean that it is safer to be treated with dialysis rather than undergo kidney transplantation. Other conditions that might prevent a person from being eligible for kidney transplantation include:End-Stage-Renal Disease and Kidney Transplantation Essay Paper ●Active or recently treated cancer ●A chronic illness that could lead to death within a few years ●Dementia ●Poorly controlled mental illness ●Severe obesity (a body mass index greater than 40) (calculator 1 and calculator 2) ●Inability to remember to take medications ●Current drug or alcohol abuse ●History of poor compliance with medications or dialysis treatments ●Limited or no health insurance Some people with human immunodeficiency virus (HIV) infection may be eligible for kidney transplantation if their disease is well controlled. People with other medical conditions are evaluated on a case-by-case basis to determine if kidney transplantation is an option. Advantages — Kidney transplantation is the treatment of choice for many people with end-stage kidney disease. A successful kidney transplant can improve your quality of life and reduce your risk of dying. In addition, people who undergo kidney transplantation do not require hours of dialysis treatment. Ideally, patients who are eligible to get a kidney transplant do so before ever starting on dialysis. Disadvantages — Kidney transplantation is a major surgical procedure that has risks both during and after the surgery. The risks of the surgery include infection, bleeding, and damage to the surrounding organs. Even death can occur, although this is very rare. After kidney transplantation, you will be required to take medications and have frequent monitoring to minimize the chance of organ rejection; this must continue for your entire lifetime. The medications can have significant side effects. HEMODIALYSIS In hemodialysis, your blood is pumped through a dialysis machine to remove waste products and excess fluids. You are connected to the dialysis machine using a surgically created path called a vascular access, also known as a fistula or graft. Sometimes, a catheter inserted into a large vein in the neck is used for hemodialysis treatments, although it is better to have a fistula or graft. This allows blood to be removed from the body, circulate through the dialysis machine, and then return to the body. Hemodialysis can be done at a dialysis center or at home. When done in a center, it is most commonly done three times a week and takes between three and five hours per session. In-center hemodialysis can also be done with an overnight treatment three times per week. Home dialysis is generally done three to six times per week and takes between 3 and 10 hours per session (sometimes while sleeping). More detailed information about hemodialysis is available separately. (See "Patient education: Hemodialysis (Beyond the Basics)".) Advantages — It seems that neither hemodialysis nor peritoneal dialysis have clear advantages over the other in terms of survival. The choice between the two types of dialysis is generally based upon other factors, including your preferences, home supports, and underlying medical problems. You should begin with the type of dialysis that you and your doctors think is best, although it is possible to switch to another type as circumstances and preferences change. Disadvantages — Low blood pressure during treatments is the most common complication of hemodialysis and can be accompanied by lightheadedness, shortness of breath, abdominal cramps, nausea, or vomiting. Treatments and preventive measures are available for these potential problems. In addition, the access can cause a blood stream infection or get clogged up and need surgery or other procedures to open it up. Many patients who receive hemodialysis in a center are either unable to work or choose not to work due to the time required for travel and the dialysis treatments. Sometimes, nighttime overnight hemodialysis treatments in a dialysis facility may make it easier to both work and have hemodialysis. PERITONEAL DIALYSIS Peritoneal dialysis is typically done at home. To perform peritoneal dialysis, the abdominal cavity is filled with dialysis fluid (called dialysate) through a catheter (a flexible tube). The catheter is surgically inserted into the abdomen near the umbilicus (belly button). (See "Patient education: Peritoneal dialysis (Beyond the Basics)".) The fluid is held within the abdomen for a prescribed period of time (called a dwell), usually several hours. The lining of the abdominal cavity (the peritoneal lining) acts as a membrane to allow excess fluids and waste products to diffuse from the bloodstream into the dialysate. The used dialysate in the abdomen is then drained out and discarded. The abdominal cavity is then filled again with fresh dialysate solution. This process is called an exchange. Peritoneal dialysis treatments may be done by hand four to five times during the day or by using a machine (called a cycler) while you sleep. Some people use a cycler at night and also do one or two exchanges during the day. Advantages — Advantages of peritoneal dialysis compared with hemodialysis include more uninterrupted time for work, family, and social activities. Many people who use peritoneal dialysis are able to continue working, at least part time, especially if exchanges are done during sleep. Disadvantages — People who use peritoneal dialysis must be able to understand how to set the equipment up and use their hands to connect and disconnect small tubes. If you cannot do this, a family or household member may be able to do it. Disadvantages of peritoneal dialysis include an increased risk of hernia (weakening of the abdominal muscles) from the pressure of the fluid inside the abdominal cavity. In addition, you can gain weight, and you have an increased risk of infection at the catheter site or inside the abdomen (peritonitis), although this is quite rare. WHICH THERAPY IS BEST FOR ME? Kidney transplantation is the optimal treatment for most patients who do not have one of the reasons to be ineligible for transplant that were mentioned above (see 'Kidney transplantation' above). Patients who are not candidates for kidney transplantation or who must wait for a kidney can usually be treated with either hemodialysis or peritoneal dialysis.End-Stage-Renal Disease and Kidney Transplantation Essay Paper Choosing between peritoneal dialysis and hemodialysis is a complex decision that is best made by you, your doctor, and often other family members or caregivers after careful consideration of a number of important factors. For example, hemodialysis involves rapid changes of the fluid balance in the body and cannot be tolerated by some patients. Some patients are not suitable candidates for kidney transplantation, while others may not have the home supports or abilities needed to do peritoneal dialysis. Your overall medical condition, personal preferences, and home situation are among the many factors that should be considered. It is possible to switch from one type of dialysis to the other if preferences or conditions change over time. NOT STARTING DIALYSIS Some people choose not to start dialysis at all. You and your family should discuss the risks and benefits of long-term dialysis with your doctors. Most people with kidney disease who have no or few other chronic illnesses are encouraged to start dialysis or get a kidney transplant; the chance of having a high quality of life for an extended period of time is usually excellent. However, you may have compelling reasons for electing not to start dialysis; this is often due to advanced age and having other medical conditions that might limit long-term life expectancy that would not be prolonged by starting dialysis. Try to feel comfortable discussing your wishes with your family and healthcare team with the goals of death with dignity and life with quality. WHERE TO GET MORE INFORMATION Your healthcare provider is the best source of information for questions and concerns related to your medical problem. This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below. Patient level information — UpToDate offers two types of patient education materials. The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Chronic kidney disease (The Basics) Patient education: Polycystic kidney disease (The Basics) Patient education: Hemodialysis (The Basics) Patient education: Preparing for hemodialysis (The Basics) Patient education: Peritoneal dialysis (The Basics) Patient education: Choosing between dialysis and kidney transplant (The Basics) Patient education: Planning for a kidney transplant (The Basics) Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Hemodialysis (Beyond the Basics) Patient education: Chronic kidney disease (Beyond the Basics) Patient education: Peritoneal dialysis (Beyond the Basics) Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. End-Stage-Renal Disease and Kidney Transplantation Essay Paper