A major problem has been the world shortage of suitable organs to transplant. Some countries have banned “live” transplants, for commercial rackets were developing. Donors were being paid for their organs, and recipients also were being charged huge fees for organs, and this is contrary to the spirit of the whole procedure.
People are being encouraged to donate their organs, and in some states driving licenses bear an authority for doctors to remove the owner’s organs in the event of a fatal accident. In time this will greatly increase supplies. There has been talk of taking the organs from deformed babies (e.g. those born without a brain, and similar cases). All avenues are being explored to improve the potential donor field with modern technology.
Ideally, the donor should be less than 70 years of age, and have good working kidneys that are disease-free. The kidney must be removed from the donor within one hour of death, irrigated with special fluids and refrigerated. It must be used within 10 hours. Often, tissue typing is started well before the donor has died, and the recipient alerted that the time has come for surgery.
Usually the recipient is on dialysis for some time before the operation. The idea is to get the patient’s health in as good a state as possible. If there is severe disease present, kidney removal may take place at the time of operation. Chronic infection, vesicoureteral reflux (the urine tracking back from the bladder into the ureters during voiding), cystic kidneys, stones or severely elevated blood pressure may be indications for kidney removal before the transplant is carried out.
The new kidney is usually implanted in the iliac fossa (in the general area about where the appendix is located) because it is possible to get access to a good blood supply here. The ureter is implanted into the bladder via an artificial tunnel. Most patients bear up surprisingly well under the surgery, seeing it is such a major undertaking. Often there is impaired renal function for a few weeks, for some of the kidney cells may show necrosis (destruction), but these usually resolve. The patient is kept on dialysis during this time.
Tissue rejection has been a major problem in the past, but with closer attention to tissue matching, this is becoming less frequent. This is the body’s inbuilt tendency to reject foreign material. “Immunosuppression” must always he carried out. Drug therapy is given for this purpose, usually the corticosteroids and azathioprine. If rejection seems imminent, this therapy is greatly increased.
In some patients, symptoms occur from the treatment rather than from the operation itself. In a few cases ruptured peptic ulcers have occurred as a result of steroid treatment.
A major jump forward came in the early 1980s with the advent of cyclosporine, which now virtually prevents tissue rejection. It represents the biggest single advance in therapy, and now rejection is much less common than ever before. However, it is expensive, requires regular use (probably on a long-term basis), and there are often adverse side effects. However, it has revolutionized the total concept of tissue rejection. Today, by using a variety of anti-rejection drugs, smaller doses of each are possible, reducing side effects to a minimum. Other new technologies are also being developed to assist patient selection, tissue selection, and a favorable long-term result.
In the overall picture the results are surprisingly good. “In recent years the importance of tissue matching and limitations of immunosuppressive treatment have both been realized and disasters occur rather less frequently,” Mr Chisholm Ogg has stated in the British Medical Journal. However, at worst, “if a transplant fails, the patient can always be returned to dialysis and perhaps have another transplant later on.” Survival figures are improving each year. “Using live donors, the best American series show good transplant functioning in 80 – 90 per cent of cases at two years, while the same figure for kidneys from cadavers is about 60 per cent.
Most kidneys are lost in the first three months, and there is no obvious reason why these long survivors should not continue to function for many years.” History will gradually unravel the picture more clearly. Good and bad features will be shown to occur. For example, the risk of cancer in the transplanted kidney is greatly in excess of the normal. Conversely, infection from hepatitis B has largely been overcome in many units where dialysis and surgery are carried out, and this is a positive benefit.