If chronic kidney diseases cannot be treated or they occur in the advanced stage (See: Our article titled “Chronic kidney failure is increasing rapidly”), it progresses to the point we call end-stage renal failure. During this period, kidney functions become insufficient to live, and it will be necessary to replace the kidney with something that will perform these functions. Fortunately, it is possible to replace the kidney with something. In order to fulfill these kidney functions, we often put the method we call dialysis in many patients. Undoubtedly, this method can remove some of the uremic toxins, while the secretion of hormones related to blood production and bone metabolism by the kidneys cannot be performed. In this case, it is tried to provide these deficiencies with some additional drugs. In addition, in the dialysis method performed with the machine we call hemodialysis, the person has to spend his life dependent on the center where the machine is located. Having to spend 4 hours at least 3 times a week in these centers seriously impairs the patient’s quality of life.
Although the quality of life is relatively better, since the dialysis method, which we call peritoneal dialysis, is applied at home by the patient, this method is also insufficient to fulfill kidney functions. However, since both types of dialysis treatment can be applied to any patient for chronic renal failure patients, it should be accepted that they are unquestionably life-saving treatments for all patients. Dialysis treatment, which started in the 1960s but has been widely applied all over the world since the 1980s, continues with the problems we have mentioned above, and unfortunately, it could not provide the quality of life of the patients sufficiently and unfortunately did not bring the life span of the patients to an acceptable level. That’s why kidney transplantation (renal transplantation), which means replacing the kidney with another kidney, has always proven itself as a superior treatment method for end-stage renal disease (ESRD) patients.
Why is Kidney Transplantation the best treatment for ESRD?
Kidney transplantation is definitely a real replacement therapy, first of all because it constantly offers the patient all the possibilities that the kidney can provide. In fact, the 10-year life expectancy of patients is 5 times better than that of dialysis patients. The quality of life is indisputably close to the quality of life of normal people. Although patients have to use immunosuppressive drugs, the cost of treatment is at least two or three times less than dialysis treatment. Being able to work and contributing to the economy are issues that cannot be calculated but definitely have more returns.
Who are the kidney donors in kidney transplantation?
The main problem in kidney transplantation is organ supply. The organ source is living relative or unrelated donors and dead donors. The blood group compatibility of the donors with the recipient is the first condition. Here, we should state that this rule should be understood as, just like blood donors, groups A and B can receive from their own groups and group 0, group AB can receive from all groups, and group 0 only from group 0. The Rh factor is not important here, negative to positive or vice versa is possible. Group O recipients can receive organs from group A with some special precautions, but these methods are both very risky and very expensive. For this reason, in our country, this knowledge, even experience and opportunities are not applied rightly. Rather than taking these risks, it is much more rational to increase the donation of dead kidneys. The tissue compatibility antigens (HLA antigens) found in the cells of the organ donors, meanwhile, in the white blood cells must be compatible with the recipient in sufficient quantity. In this way, an acceptable level of harmony can be primarily between parents and siblings. To a lesser extent, it can be seen in second or even third degree relatives such as uncle-aunt-aunt. In deceased donors, adaptation to the tissue type of an organ taken from a dead organ can always be achieved as -1, 2,3 incompatible. The greater this mismatch, the greater the risk of organ rejection.
Again, in mandatory cases, this risk increase is tried to be eliminated by making the post-operative immunosuppressive treatment design stronger. Of course, stronger immunosuppressive therapy means more drug-related side effects and risks. Since the advantage of renal transplantation always outweighs dialysis, these risks should be taken into account for very sick patients, especially young patients. Liver unrelated donor kidney transplantation is on the agenda due to the possibility of changing the treatment design in this way in order to partially compensate for organ absence. The main problem here is ethical issues. Our laws prohibit organ donation for profit and penalize organ trade. For this, the most typical live non-relative donor transplants are peer-to-peer. This definition can be extended to relatives such as father-in-law, mother-in-law. Since it is clear that there is no commercial situation in this type of donation, Ethics Committees can allow such donor candidates.
How is a dead (cadaver) organ provided?
These donors are often hospitalized donors. Since the organs must be removed, treated with a suitable solution and cooled within 30-35 minutes after the circulation stops, this is rarely possible in practice in deaths outside the hospital. Brain death is also a form of death, an irreversible condition like death. We, the patients whose brainstem reflexes of all brain functions have disappeared, and whose breathing has stopped, but who have to be connected to a breathing machine for the maintenance of the ongoing circulation, are included in the definition of brain death. In order to be able to say this, examinations and tests that prove brain death should give positive results when repeated every 12 hours. However, both legally and scientifically, the brain death report can be given unanimously by 4 physicians as a result of these examinations and examinations carried out with at least 12 hours of follow-up. In organ transplants with dead donors, organs are provided from such patients. Organ donations can be taken from patients who are known to have an organ donation card in their lifetime – and since it is a testament, organ donation is a duty for their families – without permission, organs can only be taken with the permission of their families. Usually, the kidneys, liver, heart and clear layer of the eye (cornea) are removed. The cause of death of the donors should not be an infectious disease or cancer, the functions of the requested organs should be normal in case of death. Removed kidneys should be used within 48 hours after cooling with a suitable solution. This period is different in each organ. In the religious sense, there are many clergymen, theologians and the opinion statement of the Presidency of Religious Affairs on the issue that there is no harm in organ donation and there is merit.
How does the system work in dead kidney transplantation?
Tissue type determinations are made from the blood of patients who cannot be transplanted with a living kidney, who do not have a donor, by applying to a hospital where kidney transplantation is performed. It is placed on the waiting list in the Ministry of Health (MoH) along with information about tissue type, blood type and disease. The organ provided in any hospital within each region is sent to whichever center is the most suitable recipient. That center invites the 5 most suitable patients on the list, provided that they apply within 4-5 hours. These patients are rechecked clinically and laboratory. In terms of organ compatibility, a comparison test (cross-fit test -XM) is also applied. If there is more than one candidate for an organ with the same tissue type and XM status, the patient is selected using the score system prepared according to the criteria (age, waiting time in dialysis, etc.) determined by the MoH, and the organ is attached to a patient by that center.
What are the requirements for a live donor? Can a person who donates kidneys to a relative be harmed?
Of course, dialysis patients often ask this question because the people who will make this donation are their relatives. Live kidney transplantation has been performed since 1955, so there is 50 years of experience. If the necessary examinations are made, the kidney donor can have no risk arising from the fact that he continues his life with a single kidney, except for the very minor operation risk. For this reason, kidney patients, diabetes patients and hypertension patients, who we cannot consent to continue their lives with a single kidney, cannot be donor candidates. The donor age must be over 18 years old, preferably less than 60 years old. For married people, the consent of their spouses to this operation is required. In addition, the recipient should not have a transferable disease (incurable infection such as viral hepatitis, cancer, etc.) during the examinations. One should be aware of the benefits and harms of this donation, and it should be accepted without factors such as family pressure. Of course, they should also have the legal capacity to accept (mental retardation, psychosis, etc. should not be in question).
What are the results of the treatment?
The biggest problem of kidney transplant patients is kidney rejection. We use immunosuppressant drugs to prevent this. Despite this, 5-year survival of kidneys is 90% in living donors and 70-80% in transplants with dead kidneys. There is a risk of side effects, infections caused by the drugs used by the patients, and a very low rate of malignant organs. Despite all this, it should not be forgotten that kidney transplantation is definitely more advantageous when compared to dialysis. Even if the patient loses his kidney, he can be transplanted again, or he may think that his quality of life does not deteriorate much by continuing his life with dialysis in his advanced age.
Can everyone get a kidney transplant?
The person to be transplanted should not have an active infectious disease or a malignant disease such as cancer. Infections meanwhile, if viral hepatitis B and C have not caused significant damage to the liver, they can be treated and prepared for organ transplantation. Diabetics can also get a kidney transplant. Insulin needs of these patients may increase due to medications, but this is not a problem. The quality of life demand of patients over 60-65 years old may not be like younger patients. Even at this age, there is no significant difference between the survival times of patients on dialysis and those with kidney transplants. For this reason, it may not be considered, but this is also a relative concept. If the patient has some difficulties in maintaining dialysis, for example, if there are vascular access problems, kidney transplantation may well be considered as an option. An elderly-to-elderly deceased kidney program or a peer-to-peer kidney transplant may be considered at almost his own age. Some kidney diseases may recur in the transplant kidney, but negligible kidney loss is therefore negligible, so no disease is an obstacle to organ transplantation. Examples can be very diverse. If every dialysis patient has such a request, he should definitely reach a center with a kidney transplant program and discuss his/her own.
