Pediatric kidney transplantation part 14

Those doctors will make sure your child's other organs are working well and that your child can safely undergo anesthesia for the transplant operation. Some centers will also have your child be seen by an infectious disease specialist.

The "palliative care team" is another important team that is often included. This team helps you make decisions that are best for your child and your family.

In addition to determining your child's medical eligibility for transplant it is also the responsibility of the transplant team to assess ability to adhere to a complex treatment regimen. This can be particularly hard for teenage transplant patients and is frequently one of the most difficult challenge after transplant. Non adherence with medications and a  sometimes demanding visit and lab schedule after transplant can threaten the health and well-being of the transplant and the patient. The transplant team will likely take any concerns in this area very seriously and work with you to offer ways to increase the likelihood of success after transplant

Pediatric kidney transplantation part 13

Medical consult (as needed)

Your child will also see doctors in the hospital such as:

• An anesthesiologist (the doctor who gives your child sleep medication before an operation)
• A cardiologist (heart doctor)
• A hepatologist (liver doctor)
• A pulmonologist (lung doctor)
• A neurologist (nervous system doctor)
• A gastroenterologist (stomach doctor)

Pediatric kidney transplantation part 12

Interdisciplinary team assessments

These involve meeting and tests with different health care professionals, such as :

• Urologist
• Pediatric urologist
• Pediatric transplant surgeon
• Transplant nurse coordinator
• Transplant pharmacist
• Financial representative
• Physiotherapist
• Occupational therapist
• Dietitian
• Social worker
• Child family life specialist
• Pysicologist or neuropsycologist
• Pediatric dentist
• Psycologist/psychiatrist

Again, whether your child will meet all these professionals depends on their personal situation and where they are being assessed.

Pediatric kidney transplantation part 11

MEDICAL TESTS

Tests on other parts of the body

These can include:

• Chest radiograph
• 12-lead electrocardiogram
• Peritoneal fluid (cell count and differential, culture if patient is  on peritoneal dialysis)
• Ultrasound of the native kidneys with doppler (to assess blood flow to the inferior vena cava and to rule out thrombosis)
• Voiding cystourethrogram (to evaluate for urethral patency, vesicoureteral reflux and residual urine volume)
• Pap smear if  a female adolescent is or has been sexually active

Pediatric kidney transplantation part 10

MEDICAL TESTS

Other tests

These include:

• Complete blood count with platelets
• Chemistry profile including electrolytes, blood urea nitrogen, creatinine, calcium, phosporus, intact parathyroid hormone concentration
• Complete liver function tests, including serum liver enzymes, bilirubin, albumin, cholesterol and triglyseride concentration
• Coagulation profile including an internationel normalized ratio and partial parathrombin time (to screen for coagulation abnormalities), homocystein level, factor V leiden and parathrombin 2 tests
• Viral serology tests, including those for hepatitis A,B, and C; cytomegalovirus, Eipstein-Bar virus, varicella zooster, measles, mumps and rubella, herpes simplex, anti treponema EIA and human immunodeficiency virus
• Tuberculosis testing

Pediatric kidney transplantation part 9

MEDICAL TESTS

Blood tests

These include tests to identify your child's:

• Blood group (ABO typing)
• Levels of anti-human leukocyte antigen (HLA) antibodies and how strong they are. HLA antibodies are antibodies that your child has in their body that may attack someone else's kidney. This testing helps the transplant team determine if your child has a higher risk of rejection. It also helps predict if your child might have to wait longer for a donor kidney because having these antibodies may make it harder to find a suitable matching donor

Pediatric kidney transplantation part 8

How is my child asessed for kidney transplantation?

Your child will have a number of medical tests, and you will be asked questions about your child's medical history by different members of the transplant team. You can also ask questions of the team.
The evaluation have several purposes including establishing or confirming a diagnosis through review of medical records and biopsy material and assessing the complications of chronic kidney disease. Most patients have their assessment as an outpatient of the hospital over one or two weeks. This means they have appointments in the hospital but do not stay overnight.

The results of the tests will give an idea of your child's overall health. The tests your child will have may depend on:

• Their age
• What is wrong with their kidneys
• How long they have been sick
• How sick they are
• Whether they have been seen at the transplant center before

Pediatric kidney transplantation part 7

HOW DOES A CHILD GET REFERRED FOR A KIDNEY TRANSPLANT?

Indication for and contraindications to transplantation

The cause of chronic kidney disease in childhood are varied. Children will qualify for transplants when their kidney functions falls below 20 ml/min/1.73m2. Generally, any child who requires dialysis is a candidate for kidney transplantation. Example of medical reasons that might prevent a child from being a good candidate for kidney transplantation include severe heart or lung disease, active or recent cancer (malignancy), or certain active infections and certain ethical consideration.

Pediatric kidney transplantation part 6

HOW DOES A CHILD GET REFERRED FOR A KIDNEY TRANSPLANT?

Evaluation of  a child for kidney transplantation

Kidney transplant is the preferred treatment for kidney failure for most children. A kidney transplant gives a child the best opportunity to lead a normal and healthy life. However, a transplant is not a cure and comes with many new responsibilities.
Most children with kidney failure are referred by their doctor to a center with a pediatric kidney transplant program. Most children are eligible for kidney transplants. Some children are not candidates because of medical and ethical reason.

Pediatric kidney transplantation part 5

For most children kidney transplantation is considered the optimal treatment for kidney failure. Some children require a period on dialysis before proceeding with a kidney transplant. Other children, whose kidney function is slowly getting worse, will have enough time  to plan for a transplant without needing to undergo dialysis.  This is called a preemptive kidney transplant.

Pediatric kidney transplantation part 4

Most children with kidney function of less than  15 ml/min/1.73m2 will need help to sustain  life and replace the failed kidney.  It is at this point that a child may need to proceed to either dialysis or transplantation. Usually your pediatric kidney doctor will begin discussions with you about your child's options early in order to prepare in plenty of time for either dialysis or transplantation.

There are two kinds of dialysis:

• Hemodialysis

Most commonly this is done with the help of a hemodialysis machine in a dialysis center, three or four times a week. With a special training this type of dialysis can sometimes be done by the family in child's home

• Peritoneal dialysis

This is done at home by the family, mostly at night  with the help of a peritoneal dialysis machine. This form of dialysis  can also be done manually several times per day

Pediatric kidney transplantation part 3

Sign of chronic kidney disease and kidney failure in children

Level of kidney function is determined by the glomerular filtration rate or GFR. The GFR  is expressed as  ml/min/1.73m2. Normal kidney function is considered 90-120 ml/min/1.73m2. We estimate kidney function in children using the equation that include child's height as well as their serum creatinine. Chronic kidney disease in children is when the kidney filtration falls below 90 ml/mim/1.73m2 for 3 or more months. Chronic kidney disease state 5 or end stage kidney disease in children is when this number falls below 15 ml/min/1.73m2

Signs and symptoms of chronic kidney disease in children can vary an can be quite subtle. The first signs of decreased kidney function may be abnormal bone health and poor growth. These effects can occur with a decrease in kidney function to 60-70% of normal. Frequently children  with decreased kidney function feel normal until their kidney function is very low at wich time some children may have fatigue, decreased appetite, nausea, the feeling of fullness when they are eating , lack of adequate weight gain, and at time decreased school performance.

Pediatric kidney transplantation part 2

What your kidneys do?

Think of your kidneys like a pasta strainer or filter. Your kidneys keep some things in your body that you need, and get rid of other things that you don't. The kidneys also do many other jobs that you need to live.

Your kidneys:

• Make urine
• Removes wastes and extra fluid from your blood
• Control your body's chemical balance
• Help control your blood pressure
• Help keep your bones healthy
• Help you make red blood cells

Pediatric kidney transplantation part 1

KIDNEY

The basic:

• Most people have two kidneys
• The kidneys are located on either side of the spine, just below the rib cage
• Each kidney is about the size of your fist
• The kidneys are shaped like "kidney beans"
• Your kidneys are connected to your bladder by tubes called ureters

Kidney transplantation part 46

What if I am struggling to cope?

It is normal to feel anger, despair, fear and other negative emotions during the journey of kidney disease diagnosis and treatment. These feelings usually improve with time. If the impact of kidney disesase treatments and the changes to your lifestyle are overwhelming you, then it is important that you talk to someone.

The nurses, social worker or doctor at your kidney unit are the best place to start. Social workers are employed kidney units to provide professional councelling to patients and their family members.

They are very familiar with the issues you are experiencing. There is no need to feel embarrassed or ashamed or to suffer in silence.

Kidney transplantation part 45

How do I make the choice?

The choice between a kidney transplant, dialysis and supportive care depends on factors such as your age, health and lifestyle.

Education is the first step to choosing what type of treatment you will have. Take advantage of the nurses and social workers who offer group and individual education sessions. Use booklets, good quality websites, videos and consider talking to other people in the same position. Your health care team can offer advice on any possible reasons why a particular treatment may not be possible due to current or previous health issue.

Kidney transplantation part 44

Combined kidney and pancreas transplantation

If you have developed kidney failure due to the complications of diabetes it may be possible for you to be considered for a combined kidney and pancreas transplant.

If you are medically and emotionally suitable for a kidney transplant you may also suitable for a combined kidney and pancreas transplant if you:

Have type I diabetes and are dependent on insulin
Are ideally aged less than 50 years
Have no history of heart disease
A number of extra tests will be performed to check what impact diabetes has had on your blood vessels, eyes, nerves and kidneys. These tests are needed to make sure that the benefits of the transplant surgery are greater than any risks.

Outcomes of combined kidney and pancreas transplants vary from person to person. If you would like to consider a combined kidney and pancreas transplant your health care team can discuss this with you.

Kidney transplantation part 43

What are the risks to living kidney donors?

Emotional risks

Most living kidney donors say they feel very satisfied with the donation experience. Even if the transplant is not successful, many donors say they feel positive about their decision.

There is a small chance for living kidney donors to experience mixed feelings after the donation.

These feelings may be more likely if the transplant surgery has not gone as well as expected.

It is also common for living kidney donors to experience depression and anxiety after surgery. This is normal, and happens after many different type of surgery. Your donor's health care team can suggest ways of helping to manage this

Kidney transplantation part 42

What are the risks to living kidney donors?

Physical risks

Living kidney donors are unlikely to develop kidney problems in the future. The removal of one kidney triggers the other kidney to increase in size and function. The remaining kidney can provide up to 75 per cent of normal kidney function rather than the expected 50 per cent. Any decline in overall kidney function is usually mild. This has no impact on the life span of your living kidney donor.

However, living kidney donors may be at risk of kidney disease if their remaining kidney is injured or a disease develops unexpectedly. there is also a small risk of increased blood pressure and protein in their urine as they get older.

An annual check-up including a general health review, blood pressure measurement, and blood and urine tests are recommended for all living kidney donors.

Kidney trasplantation part 41

What are the risks to living kidney donors?

Physical risks

Being a living kidney donor means having major surgery. This always carries a risk of serious complications including death.

Complications that may occur during surgery include:

• punctured lung (pneumothorax)
• Lung infections (pnemonia)
• Nerve damage
• Blood clots (thromboembolism)
• Bowel perforation
• Bleeding

The transplant surgeon will talk to your living kidney donor about these risks in detail.

Kidney transplantation part 40

WHAT HAPPENS DURING A LIVING KIDNEY DONOR TRANSPLANT?

After surgery

After the transplant surgery your living kidney donor will feel some pain around their wound. They will be given medication to help with this.
The length of time that your living donor will need to stay in hospital may be around four to ten days.
They will then need up to six weeks of recovery time at home. It is recommended that your living kidney donor does not drive a car until six weeks after the surgery. They should also avoid any heavy lifting for six weeks.
Living donors who have laparoscopic (keyhole) surgery often recover quicker than livening donors who have an open nephrectomy, Everyone's experience is different so it is important to talk about recovery with the health care team, family and friends.

Kidney transplantation part 39

WHAT HAPPENS DURING A LIVING KIDNEY DONOR TRANSPLANT?

During surgery

Open nephrectomy

The surgeon makes a cut about 15-25 cm long on the side or front of the living donor's abdoment. The cut is along the bottom of their rib to a point  just above their belly button. The cut will be on their left or right side depending on which kidney is being donated. The vessels connecting the kidney to its blood supply are clamped and cut. Their ureter (which is connected to their bladder) is disconnected.

Kidney transplantation part 38

WHAT HAPPENS DURING A LIVING KIDNEY DONOR TRANSPLANT?

During surgery

Laparoscopic nephrectomy

This is also called keyhole surgery. The surgeon inserts special instruments into the living donor's abdoment through three small cuts (also called incisions). A thin tube with a video camera on the tip (called a laparoscope) is inserted into the donors abdoment. This allows the surgeon to see inside the living donor's body.
The kidney is collected in one of two ways:

• Endo catch - a drawstring bag is used to catch the kidney and draw it out of their body through a small cut about 10-12 cm long
• Handport - the surgeon's hand is used to remove the kidney

Kidney transplantation part 37

WHAT HAPPENS DURING A LIVING KIDNEY DONOR TRANSPLANT?

During surgery

There are two ways of removing the kidney from a living donor, laparoscopic nephrectomy or open nephrectomy. The transplant team will discuss these procedures in detail with your living kidney donor. Most live donation procedures now occur  through laparoscopy.
The procedure for transplanting the living donor's kidney into your body is the same as the procedure for  a deceased donor kidney.

Kidney transplantation part 36

WHAT HAPPENS DURING A LIVING KIDNEY DONOR TRANSPLANT?

Before surgery

In the week before surgery, you and your living kidney donor will be re-tested to make sure you are both healthy and emotionally ready for the surgery. Another serum cross match test is done. The day before surgery, you and your donor go to hospital. You (the kidney recipient) may have a dialysis session or other special treatments.

Kidney transplantation part 35

PSYCHOLOGICAL ASSESSMENT

A psychological assessment is performed to make sure the living kidney donor is certain about donating and making a voluntary and informed choice.

Living kidney donors must be fully aware of the risks to their own health. The transplant team helps the donor to weigh up the risks and benefits and understand the medical procedure. This is called informed consent.

A psychological assessment also helps to make sure that the donor:

• Is comfortable with the idea of donation
• Is not being forced or paid for the donation
• Has a good understanding of the physical and emotional outcomes of kidney donation

Kidney transplantation part 34

MEDICAL ASSESSMENT

If someone is considering being a living kidney donor they will need a thorough medical check by a doctor. These tests will check that donating a kidney will be safe for the donor both in the short term and the long term. The transplantation team will also decide whether the donor is fit for surgery and has a suitable kidney to donate.

A number of tests are needed to make sure that the living donor is suitable to donate their kidney to you. These may include:

• Tissue typing
• Blood group
• Testing the recipient for anti-HLA antibodies
• Blood tests and scans to check their kidneys are functioning well and to make sure there are no signs of kidney damage
• Tests to find any viruses that may lead to an infection
• Tests for heart disease, diabetes, lung problems and cancer

During these tests donors may find out that they have a health problem that they didn't know about. If this happens they will receive support and referral to a specialist.

Kidney transplantation part 33

THE LIVE KIDNEY DONATION PROCESS

To be a living kidney donor, the potential donor must have normal kidney function, overall good health, and be emotionally suitable for living donation.

The evaluation process includes blood tests and other investigations, as well as a physiological assessment.

Kidney transplantation part 32

Anti-rejection medication side effect

Anti-rejection medications have a number of possible side effects. This side effects are usually able to managed by changing the dose of your medications.
Some of the most common side effects include:

• Increased risk of infections
• Puffiness of your face and stomach
• Unwanted hair growth or hair loss
• Increased appetite and weigh gain
• Mood swings
• Increased risk of high blood pressure, diabetes and cancer (particularly skin cancer)
• Pimples
• Muscle weakness and shakiness in  your hands
• Stomach problems such as indigestion and diarrhoea

If you become worried about any possible side effects, you should discuss them with your health care team.

If you need treatment from other health proffesionals (such as a dentist), let them know that you have had a kidney transplant.

Kidney transplantation part 31

TYPES OF REJECTION EPISODES

Hyperacute rejection

This can occur minutes or hours after the transplant. This type of rejection is very rare. It is untreatable and the kidney is removed immediately.


Acute rejection

Acute rejection appears as an inflammation in the kidney. This usually needs quick diagnosis and action. It usually occurs in the early weeks following a transplant. This why you will have frequent blood tests in the first weeks after your transplant. Mild acute rejection is very common in the first year after a kidney transplant.
Acute rejection sometimes causes pain and fever but usually has no symptoms. An increasing eGFR or creatinine is usually the first sign of acute rejection. A biopsy of the kidney transplant is often used to diagnosis rejection and to decide on the best treatment.


Chronic rejection

Chronic rejection refers to a gradual process, which leads to scarring and damage in the transplanted kidney. This usually occurs over several years and can be very difficult to treat. Often this is due to anti-HLA antibodies that are present. During this time the kidney is gradually losing its function and may eventually fail, leading to the need for dialysis and another kidney transplant.

Kidney transplantation part 30

Transplant rejection

You must take anti-rejection medications for as long as your transplanted kidney is working. These medications partially block the activity of your body's immune system. This prevents your body from attacking  your transplanted kidney.
There are many different medications which are used to prevent rejections. For each of your medications find out:

• When and how to take them
• What to do if you miss a doses
• Possible dietary restrictions
• Interactions with other medications
• What side effects you may experience
• How to store your medications

In the early period after your transplant, you may have some rejection episodes. These may only be picked up by your regular blood tests. These episodes can usually be managed with changes to your medications.

Some rejection episodes may require extra treatments such as plasma exchange (to remove antibodies in your blood) or special infusion.

Kidney transplantation part 29

Emotional well-being

Having a transplant should have a positive effect on your life. However it is still a major life event. You may have mood swings and feel stressed or depressed as you adjust to your transplant, and as your body responds to your anti-rejection medications. It is not unusual to have these feelings. The earlier you talk to someone the quicker you can get support.

You may also:

• Have to come to terms with having another person's organ inside you. Some people worry that they may develop the donor's personality but this is not possible.
• Having conflicting feelings about receiving a kidney from a deceased donor. You may feel relief and happiness at having a new kidney, but upset because the donor's family and friends are grieving.
• Be overwhelmed by feelings of being normal again
• Find that your relationships change as your family and friends adjust to you becoming more active
• Experience a roller-coaster of emotions about the possibility of rejection. You may feel anxious about attending medical appointments and then relief after being told that your transplant kidney is functioning well
• Be overwhelmed at the thought of taking many medications with their possible side effects
• Feel guilty about your transplant because there are other people still on dialysis

Many people who receive a deceased donor kidney may wonder who the kidney came from.

Kidney transplantation part 28

Sexuality and fertility after a transplant

Sexual activity will not harm your transplanted kidney. It will also not increase your risk of infection. It is recommended that you wait  about four weeks after your transplant before having sexual intercourse.

As your health improves after your kidney transplant your fertility may increase. This is true for both men and women.

If you are a woman and would like to have a baby it is usually suggested that you wait at least 1 year after your transplant before trying to get pregnant. This allows time for you to become stable on your anti rejection medication.
If you become pregnant some of your medications may need to be changed and you will be carefully monitored to make pregnancy safer for you and your baby.

Kidney transplantation part 27

Stay at  a healthy weight:

• Your anti-rejection medications may increase your appetite
• Talk to your doctor or renal dietatian about how to stay at a healthy weight

Avoid food poisoning:

• Wash your hands well
• Keep cooking utensils, chopping boards, and knives separate for raw and cooked meats
• Cook foods thoroughly - no pink left in cooked meats such as mince, sausages and chicken
• Avoid eating foods that have a higher risk of food poisoning - soft cheeses (such as brie and camembert), pate, salami and raw seafood

Kidney transplantation part 26

MORE TIPS ON STAYING HEALTHY

Avoid infections:

• Limit contact with people with colds or viruses (especially small children)
• Wash your hands well
• Treat scratches
• Keep your vaccinations up to date

Reduce your risk of skin cancer:

• Follow the slip, slop, slap, seek, slide advice (slip on a shirt, slop on sunscreen, slap on a heat, seek shade and slide on sunglassess)
• Have regular checks for other cancers such as breast cancer (women)  and prostate cancer (men)

Be a non-smoker:

• Having a transplant increases your risk of having health problems caused by smoking
• This include lung cancer, stroke and heart attack
• Your chances of a long-term, successful transplant may be reduced if you smoke

Let your health care team know if you get sick:

• If your illness is treated quickly your risk of damaging your transplant is reduced.

Kidney transplantation part 25

Living with your new kidney

You should be able to return to normal activities and work within three to six months of your transplant. You will need to allow time for your wound to heal and for your stomatch muscles to get strong again. Regular exercise is an important part of staying healthy. It is recommended that you start with gentle exercise first.

It is recommended that you do not drive a car until six weeks after your transplant. You should also avoid any heavy lifting for six weeks.

You will need to manage your medications carefully. It is important that you take your medications exactly as prescribed by your doctor.

It is important your kidney has enough fluid to work properly. You need  to make sure you drink enough water or fluids to stop you feeling thirsty, and to keep your urine a pale yellow colour.

Kidney transplantation part 24

Going home with a successful transplant

Caring for yourself after your kidney transplant is very important. The first few months following your transplant are often when things will be  the most unstable and you may be at risk of developing problems. It is important that you report any changes in your health to your health care team as soon as possible.

You will have regularly check-ups to monitor the function of your new kidney. These will be daily at first, then weekly, then monthly.

At these visits your wound will be assessed to make sure it is healing well, and you will be checked for any signs of rejection of the transplanted kidney. Slow wound healing can be caused by some medications, diabetes and obesity.  If you are at increased risk you will be monitored closely.

You will need to think about where you will stay after you are discharged from hospital. If you live long distance from the transplant unit you will need to find short-term accomodation close to the hospital. Travel and accomodation assisstance schemes are available to help with this.

Kidney transplantation part 23

WHAT HAPPENS DURING A KIDNEY TRANSPLANT?

After surgery

A physiotherapist may assist you with an exercise plan. You will probably be able to sit out of bed on the first day after your surgery. You should be able to go for a walk within a couple of days.

Reducing the risk of an infection is very important. For this reason, you may be looked after in a separate room or ward of the hospital, your visitor numbers may be limited,  and you may not be allowed to receive flowers from visitors.

The length of time that you will need to stay in hospital after the transplant surgery will depend on how well your body responds to the new kidney and wether you have any complications. Most people are in hospital between six and ten days. You may feel better immediately after your surgery or you may take lo

Kidney transplantation part 22

WHAT HAPPENS DURING A KIDNEY TRANSPLANT?

After surgery

After the transplant surgery it is normal to feel some pain around your wound. You will be given medications to help with this.

Your transplanted kidney may start to make urine immediately, or you may need dialysis for a few days. If you need dialysis it does not mean that your transplanted kidney will not work. It just may need a bit of time to recover from the transplant procedure.

A catheter will be placed in your bladder for around five days to drain your urine into a bag. This helps your health care team to check that your kidney is working well. Often there are tubes from your wound draining away extra fluid. These are usually removed after a few days.

You will have blood tests every day to check the function of your transplanted kidney, to measure medication levels and to detect any problems early so they can be treated quickly.

The blood test for creatinine and eGFR measure how well your kidney is working. These may already be familiar to you. In many cases your creatinine and eGFR will go back to what they were before you first got kidney disease.

The amount of fluid you take in is important.The nurses may be asking you regularly how much you have had to drink, If your kidney is working you may find yourself having to drink lots of fluid.

Kidney transplantation part 21

WHAT HAPPENS DURING A KIDNEY TRANSPLANT?

During surgery

Surgery for a kidney transplant takes about two to three hours. A cut is made in your lower abdomen, on the right or left side. The new kidney is placed in your pelvis. The renal artery and vein of the tranplant kidney are connected to an artery and vein in your pelvis (usually the illiac artery and vein that lead down towards the leg). The ureter of the transplanted kidney is connected to your bladder so urine can flow.

Many people are surprised to learn that their own failed kidneys are not removed. They are left in your body to continue to provide whatever amount of function they may still have. Sometimes it may be necessary to remove your failed kidneys if they are very large (if you have polycystic kidney disease) or in the case of chronic infection. If this is needed, your failed kidneys will be removed in a separate surgical procedure before your transplant surgery.

Kidney transplantation part 20

WHAT HAPPENS DURING A KIDNEY TRANSPLANT?

Before surgery

You will admitted to the hospital where the transplant surgery will take place. You will have a physical examination, and you may need to have a dialysis session. If you have any active infections or other significant medical problems the transplant surgery may need to be cancelled.

You will be given anti-rejection medications before and after the surgery to control your immune system and stop your body from rejecting the new kidney.

Kidney transplantation part 19

Cross match

In the cross match test, your blood cells are added to blood cells taken from the donor. A positive reaction means that there is a high likelihood of severe rejection of the donor kidney. In the case of a deceased donor, the transplant will not go ahead if there is a positive cross match.

Kidney transplantation part 18

HLA proteins and cytotoxic antibodies

You have a combination of A,B and DR HLA proteins inherited from your parents. When you are exposed to other HLA proteins your immune  systems attacks them. Your body  then develops antibodies against these HLA proteins. If you have already have antibodies against a donor cell HLA protein then your body may attack those donor cells and reject the donor kidney.

When you are tissue typed, a blood test is taken to determine your HLA proteins and cytotoxic antibodies. This is usually one of the first  steps in your transplant work-up. Your HLA proteins and cytotoxic antibodies can also change overtime, so these test will be repeated every one to two months.

You will share some HLA proteins with other people and the more you share the more likely your body is to accept their kidney. How similar your tissue typing is with someone else's refers your "HLA-match". This is usually given as a number out of six as there were six groups of protein identified many years ago that were found to be important.

For many people, HLA-matching is less important than it was a few decades ago. This is because the anti-rejection medications have improved. We also understand more about tissue typing than we used to, and this has led to longer survival of transplanted kidney.

Kidney transplantation part 17

DONOR AND RECIPIENT MATCHING

Tissue type matching

Your immune system is designed to keep you safe from foreign invaders such as viruses and bacteria. Everyone has special proteins on their cells called HLA proteins. Your combination is unique to you and is recognised by your immune system so it will not attack your own cells.

Your immune system will recognise a combination of foreign proteins not belonging to you and will attack them. It will then develop cytotoxic antibodies against these HLA proteins. This is how your immune system defends your body against infections. This is also the underlying cause of your body rejecting a transplant and the reason you need to take anti-rejection medications.

Cytotoxic antibodies are called donor specific antibodies if they are shown to be against your potential donor's HLA proteins. These can make it hard for you to be compatible with other donors. These antibodies may have developed because you have  previously been exposed to other people's HLA proteins through a blood transfusion, through pregnancy, or from a previous transplant. Sometimes there is no clear reason found for the presence of these HLA-antibodies.

Your immune system remembers this exposure and is ready to attack cells with similar HLA-proteins on them. The cross match test also checks for this.

Kidney transplantation part 16

DONOR AND RECIPIENT MATCHING

Blood group

If your transplanted kidney comes from a deceased donor, the ordinary blood groups (A,B, AB O) and red blood cells of the donor must be compatible with yours. This is similar to matching blood groups for a blood transfusion. We all have antibodies to blood groups different to ours.

If your transplanted kidney comes from a living donor it may be possible to have the transplant even if you and your donor are not from a compatible blood group. This is called an ABO incompatible transplant. Extra treatments will be needed to remove the antibodies before the transplant can go ahead.

Kidney transplantation part 15

How are kidneys matched and allocated?

Kidney donor and recipient matching can be divided into several areas. These areas  include blood group matching, tissue type matching, cross matching and survival matching. This involves the assessment of how long a certain kidney is likely to last. It also involves allocating kidneys partly based on how long different recipients are likely to survive.

For these reason, allocation and acceptance of a kidney offer needs to consider compatibility, your waiting time and the quality of the kidney being offered and its likely benefit to you.

A computer can manage  of these factors. Your doctors will also need to consider other issues and possibly discuss these with you if needed.

Each area of compatibility is impotant for donor and recipient matching for both living and deceased donors.

If you are receiving a kidney from a living donor  it may be possible to get around some of these matching issues. For example, it may be possible to prepare your immune system so that you are able to receive a kidney that would have been incompatible.

Kidney transplantation part 14

Deciding whether to accept the kidney

Once you have received the phone call that there may be a kidney available for you, there may be further issues to think about. Your doctors will need to assess the compatibility, the safety, as well as the quality (likely survival) of the kidney that is being offered for donation.

Some of these issues may involve possible risks to your health. For example, it is discovered that the donor had suffered from cancer or other infection.

In recent years there are more kidneys coming from elderly donors who may had illnessess such as high blood pressure, diabetes or a history of smoking. In some cases, donors may have had a history of taking illegal drugs.

All these factors need to be taken into account by your doctors or by yourself. The quality of the kidney being offered may also influence the decision to go ahead with the transplant.

You may have to decide whether it's best to accept an immediately available, but less-than-ideal deceased donor kidney or take the chance and wait for a healthier one in the future.

Kidney transplantation part 13

What happens when a deceased donor kidney becomes available?

When a kidney from a deceased donor becomes available for transplantation a number of laboratory tests are done. These tests include tissue typing and cross matching. The tests are done to work out who would be the best match for the kidneys.

Once the laboratory tests have been completed the organ donor coordinator will receive a list of potential recipients. They will then contact the transplant unit responsible for the first potential recipient on the list.

If you are selected to receive a kidney from a deceased donor the hospital will contact you.

Kidney transplantation part 12

Stay healthy while waiting for your kidney transplant by:

• Keeping to your regular dialysis schedule
• Following your recommended diet and fluid restrictions
• Taking your medications as prescribed
• Controlling your weight with  diet and physical activity
• Visiting your dentist regularly to watch for any infections
• Protecting your skin, which will help to prevent skin cancer after your transplant
• Being a non-smoker
• Keeping your vaccinations up to date
• Avoiding blood transfusions if possible

Kidney transplantation part 11

Staying healthy while waiting for a kidney transplant

To give  your transplant the best chance of success, it is important that you look after your self while you are on the transplant waiting list.

You will also need to provide routine tissue typing and antibody blood tests every one to two months.

This allows current samples to be used in the cross match tests. Small amounts of these samples are sent in case a donor matches with you. If you do not do these blood tests, the laboratory will not be able to assess your compatibility with a donor and you may miss an opportunity. You will also have regular reviews where you can discuss any concerns about your transplant preparation.