Kidney transplant or ral transplant is the organ transplant of a kidney into a patit with d-stage kidney disease (ESRD). Kidney transplant is typically classified as deceased-donor (formerly known as cadaveric) or living-donor transplantation depding on the source of the donor organ. Living-donor kidney transplants are further characterized as getically related (living-related) or non-related (living-unrelated) transplants, depding on whether a biological relationship exists betwe the donor and recipit. The first successful kidney transplant was performed in 1954 by a team including Joseph Murray, the recipit’s surgeon, and Hartwell Harrison, surgeon for the donor. Murray was awarded a Nobel Prize in Physiology or Medicine in 1990 for this and other work.
Before receiving a kidney transplant, a person with ESRD must undergo a thorough medical evaluation to make sure that they are healthy ough to undergo transplant surgery. If they are deemed a good candidate, they can be placed on a waiting list to receive a kidney from a deceased donor.
Once they are placed on the waiting list, they can receive a new kidney very quickly, or they may have to wait many years; in the United States, the average waiting time is three to five years.
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During transplant surgery, the new kidney is usually placed in the lower abdom (belly); the person's two native kidneys are not usually tak out unless there is a medical reason to do so.
People with ESRD who receive a kidney transplant gerally live longer than people with ESRD who are on dialysis and may have a better quality of life.
However, kidney transplant recipits must remain on immunosuppressants (medications to suppress the immune system) for as long as the new kidney is working to prevt their body from rejecting it.
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Kidney transplant rejection can be classified as cellular rejection or antibody-mediated rejection. Antibody-mediated rejection can be classified as hyperacute, acute, or chronic, depding on how long after the transplant it occurs. If rejection is suspected, a kidney biopsy should be obtained.
It is important to regularly monitor the new kidney's function by measuring serum creatinine and other labs; this should be done at least every three months.
One of the earliest mtions about the possibility of a kidney transplant was by American medical researcher Simon Flexner, who declared in a reading of his paper on Tdcies in Pathology in the University of Chicago in 1907 that it would be possible in the th-future for diseased human organs substitution for healthy ones by surgery, including arteries, stomach, kidneys and heart.
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In 1933 surgeon Yuriy Vorony from Kherson in Ukraine attempted the first human kidney transplant, using a kidney removed six hours earlier from a deceased donor to be reimplanted into the thigh. He measured kidney function using a connection betwe the kidney and the skin. His first patit died two days later, as the graft was incompatible with the recipit's blood group and was rejected.
It was not until 17 June 1950, wh a successful transplant was performed on Ruth Tucker, a 44-year-old woman with polycystic kidney disease, by Dr. Richard Lawler at Little Company of Mary Hospital in Evergre Park, Illinois.
Although the donated kidney was rejected t months later because no immunosuppressive therapy was available at the time—the developmt of effective antirejection drugs was years away—the interving time gave Tucker's remaining kidney time to recover and she lived another five years.
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Dr. John P. Merrill (left) explains the workings of a th-new machine called an artificial kidney to Richard Herrick (middle) and his brother Ronald (right). The Herrick twin brothers were the subjects of the world's first successful kidney transplant, Ronald being the donor.
A kidney transplant betwe living patits was undertak in 1952 at the Necker hospital in Paris by Jean Hamburger, although the kidney failed after three weeks.
The first truly successful transplant of this kind occurred in 1954 in Boston. The Boston transplantation, performed on 23 December 1954 at Brigham Hospital, was performed by Joseph Murray, J. Hartwell Harrison, John P. Merrill and others. The procedure was done betwe idtical twins Ronald and Richard Herrick which reduced problems of an immune reaction. For this and later work, Murray received the Nobel Prize for Medicine in 1990. The recipit, Richard Herrick, died eight years after the transplantation due to complications with the donor kidney that were unrelated to the transplant.
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In 1955, Charles Rob, William James Jim Dempster (St Marys and Hammersmith, London) carried out the first deceased donor transplant in United Kingdom, which was unsuccessful.
In July 1959, Fred Peter Raper (Leeds) performed the first successful (8 months) deceased donor transplant in the UK. A year later, in 1960, the first successful living kidney transplant in the UK occurred, wh Michael Woodruff performed one betwe idtical twins in Edinburgh.
In November 1994, the Sultan Qaboos University Hospital, in Oman, performed successfully the world's youngest cadaveric kidney transplant. The work took place from a newborn of 33 weeks to a 17-month-old recipit who survived for 22 years (thanks to the couple of organs transplanted into him).
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Until the routine use of medication to prevt and treat acute rejection, introduced in 1964, deceased donor transplantation was not performed. The kidney was the easiest organ to transplant: tissue typing was simple; the organ was relatively easy to remove and implant; live donors could be used without difficulty; and in the evt of failure, kidney dialysis was available from the 1940s. As explained in Thomas Starzl's 1992 memoir, these factors explain why Starzl's team and others began with kidney transplantation as the first type of solid organ transplantation to translate to clinical practice before attempting to move on to liver transplantation, heart transplantation, and other types.
The major barrier to organ transplantation betwe getically non-idtical patits lay in the recipit's immune system, which would treat a transplanted kidney as a 'non-self' and immediately or chronically reject it. Thus, having medication to suppress the immune system was esstial. However, suppressing an individual's immune system places that individual at greater risk of infection and cancer (particularly skin cancer and lymphoma), in addition to the side effects of the medications.
The basis for most immunosuppressive regims is prednisolone, a corticosteroid. Prednisolone suppresses the immune system, but its long-term use at high doses causes a multitude of side effects, including glucose intolerance and diabetes, weight gain, osteoporosis, muscle weakness, hypercholesterolemia, and cataract formation. Prednisolone alone is usually inadequate to prevt rejection of a transplanted kidney. Thus, other, non-steroid immunosuppressive agts are needed, which also allow lower doses of prednisolone. These include: azathioprine and mycopholate, and ciclosporin and tacrolimus.
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The indication for kidney transplantation is d-stage ral disease (ESRD), regardless of the primary cause. This is defined as a glomerular filtration rate below 15 ml/min/1.73 m
. Common diseases leading to ESRD include rovascular disease, infection, diabetes mellitus, and autoimmune conditions such as chronic glomerulonephritis and lupus; getic causes include polycystic kidney disease, and a number of inborn errors of metabolism. The commonest 'cause' is idiopathic (i.e. unknown).
Diabetes is the most common known cause of kidney transplantation, accounting for approximately 25% of those in the United States. The majority of ral transplant recipits are on dialysis (peritoneal dialysis or hemodialysis) at the time of transplantation. However, individuals with chronic kidney disease who have a living donor available may undergo pre-emptive transplantation before dialysis is needed. If a patit is put on the waiting list for a deceased donor transplant early ough, this may also occur pre-dialysis.
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Contraindications to receive a kidney transplant include both cardiac and pulmonary insufficicy, as well as hepatic disease and some cancers. Concurrt tobacco use and morbid obesity are also among the indicators putting a patit at a higher risk for surgical complications.
Kidney transplant requiremts vary from program to program and country to country. Many programs place limits on age (e.g. the person must be under a certain age to ter the waiting list) and require that one must be in good health (aside from kidney disease). Significant cardiovascular disease, incurable terminal infectious diseases and cancer are oft transplant exclusion criteria. In addition, candidates are typically screed to determine if they will be compliant with their medications, which is esstial for survival of the transplant. People with mtal illness and/or significant ongoing substance abuse issues may be excluded.
HIV was at one point considered to be a complete contraindication to transplantation. There was fear that immunosuppressing someone with a depleted immune system would result in the progression of the disease. However, some research seem to suggest that immunosuppressive drugs and antiretrovirals may work synergistically to help both HIV viral loads/CD4 cell counts and prevt active rejection.
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As candidates for a significant elective surgery, pottial kidney donors are carefully screed to assure good long term outcomes. The screing includes medical and psychosocial componts. Sometimes donors can be successfully screed in a few months, but the process can take longer, especially if test results indicate additional tests are required. A total approval time of under six months has be idtified as an important goal for transplant cters to avoid missed opportunities for kidney transplant (for example, that the intded recipit becomes too ill for transplant while the donor is being evaluated).
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