In cases where an essential organ fails and it is not possible to restore its function, a transplant often provides the only chance of survival. Perhaps also a chance at a new outlook on life. Since the first successful kidney transplant was carried out by Joseph E. Murray in the US in 1954, transplant medicine has made such significant progress that many patients are able to improve their quality of life as well as their chance of survival. The success rates we see today are unquestionably a consequence of the development of modern immunosuppressants that prevent the body from rejecting the transplanted organ.
Today we are able to successfully transplant the kidneys, liver, heart, lungs, pancreas and small intestine. In Germany, more than 10,000 people are currently on the waiting list for a donor organ, of whom around 8,000 are awaiting a kidney (Source: German Organ Transplantation Organisation). The reasons for the shortage of donor organs and often long waiting times are many and varied, although the most important is that Germany requires a written agreement to organ donation. Other countries, such as Austria, make a general assumption that everyone agrees to donate their organs and people have to opt out in writing if they prefer not to do so.
ORGANS AND DISEASES
What the kidneys do
The kidneys are a pair of organs that have a bean-like shape. They have several critical functions in the human body. For example, they produce urine and so cleanse the blood of harmful and waste substances. They also regulate the body’s salt and water levels, as well as blood pressure. The kidneys also have a vital role to play in the production of haematopoietic (blood-forming) hormones and vitamin D.
Kidney disease
Kidney injury can have a wide range of causes: infection, poison, abuse of medications, tumours, congenital polycystic kidneys, inflammatory kidney disease, high blood pressure and diabetes mellitus can cause a decline in kidney function (renal insufficiency) that may eventually lead the kidneys to shut down completely (renal failure). We differentiate between acute and chronic renal failure.
Possible symptoms of kidney failure include:
Patients in whom it is not possible to restore kidney function using appropriate measures frequently have to rely on dialysis (artificial haemodialysis). This process replaces the kidney function. It cleanses the blood of harmful metabolites and eliminates excess water from the body. However, there are some functions that it cannot replace, which means that the patient's abilities and quality of life are severely restricted. Dialysis is a lifelong treatment where the only alternative is a kidney transplant.
What the liver does
The liver is the largest gland in the body and the main organ responsible for our metabolism. It works to break down and eliminate substances, produces essential proteins, utilises food components and regulates metabolic pathways.
Liver disease
The liver is highly resilient and is able to keep working even when it is partly damaged. It also has a good ability to repair damage and balance out a loss of tissue, as long as it is not too extensive. Once the liver is damaged it forms scar tissue, which gradually replaces the normal liver tissue as the disease progresses. This obstructs the blood flow and the liver is no longer able to function as required. This is called cirrhosis of the liver. It is most often caused by drinking too much alcohol or by chronic hepatitis C. There are also a number of autoimmune diseases, metabolic disorders and other genetic diseases, such as cystic fibrosis, that can damage the liver.
Possible symptoms of progressive liver disease include:
Early stage liver disease is easily treated. However, any significant decline in function that leads to a life-threatening situation generally requires a transplant.
ORGAN DONATION
Waiting for a new organ
The basic prerequisite for a successful transplant is that a suitable donor organ is available. However, they are in very short supply. In Germany alone, more than 10,000 people are currently on the waiting list for a transplant, of whom around 8,000 are awaiting a kidney (Source: German Organ Transplantation Organisation). These figures contrast with the 3,488 organ transplants from deceased donors carried out in 2014 (Source: Eurotransplant). Many patients have to wait years for a donor organ. The average waiting time for dialysis patients is 5 to 6 years (Source: German Organ Transplantation Organisation).
For most other organs, the ratio of transplants carried out each year to people still on the waiting list is more positive. And yet transplants of these organs are often more urgent because the respective treatment method cannot guarantee that patients will survive for as long as is possible through dialysis.
Most donor organs come from people who have died (post-mortem). Living organ donation may be an option in some cases, for example, in certain circumstances it is possible for immediate relatives or people with close personal relationships to donate a kidney or part of a liver German Transplant Act passed in 1997 by the Bundestag and Bundesrat governs the donation, removal and transfer of organs and tissues.
Organ donation after death
The donation of organs after death, also called post-mortem donation, is the most important type of donation. Donor organs are recovered from a deceased individual where their cardiovascular system can be artificially maintained even though the brain has stopped functioning (brain death). Following the appropriate lab tests and medical investigations, organs that are deemed to be healthy and functional are recovered once approval has been given to do so. Eurotransplant, which acts as a mediator between donors and recipients, is then notified. The organs that have been recovered and preserved are transported to the relevant transplant centre where they are transplanted
Living donors
Living organ donations involve the transfer of an organ or part of an organ from a living person to a recipient. The kidney is the most likely candidate for a living donation, as long as the donor is healthy and has good kidney function since their remaining kidney will offset the loss.
Given the organ’s incredible ability to regenerate, it is also possible to transplant parts of a healthy liver. In a few weeks following the operation, the organ will grow back to its original size in both the donor and the recipient.
One important advantage of living donation is that the optimum time for each individual transplant can be determined according to the recipient’s stage of the disease. This means that the patient can receive a transplant at a time when their disease is stable enough that the operation carries a lower risk. There are fewer complications after surgery and the transplant recipient recovers faster.
If a disease has progressed so far that an organ transplant becomes necessary, the doctor treating the patient will usually refer them to a transplant centre. Here, investigations are carried out to discover whether the patient could be a potential recipient for an organ, among other things. If the answer is yes then the data is transmitted to an organisation that allocates organs. Eurotransplant. The basic principles of organ allocation are governed by the German Transplant Act>.
The transplant centre can provide information about a patient’s current position on the waiting list, but it is not possible to give a specific date for a transplant. While they are waiting, the patient must be constantly available to the transplant centre and must be ready to undergo their operation at any time. During this time there are regular tests and investigations to ensure that the doctors always have as accurate a picture as possible of the patient’s current state of health. If the patient contracts an infection or other disease during the waiting period that requires a stay in hospital, the transplant centre must be notified.
As soon as they receive the call that a suitable organ is available, the patient must travel to the transplant centre as quickly as possible. This is because organs, once recovered, have only a limited lifespan and the less time without blood flow, the better their ability to function in future. Additional rules regarding the patient’s behaviour during the period immediately preceding the operation will be provided by the transplant centre.
TRANSPLANTS
What happens during the operation
Once an organ on the waiting list becomes available, things have to move incredibly fast. For a post-mortem donation, typically only a few hours pass between the notification that an organ is available. As a result, it is important for potential organ recipients to be easily reachable at all times. Additionally, patients should be prepared for a longer stay in hospital.
For kidney transplants there is more time available for the preparations than for other organs. 36 hours are allowed to pass between the organ being recovered and being transplanted. A liver must be transplanted within 8 to 9 hours.
The hospital then carries out a number of tests to make sure that the transplant will not negatively affect the patient's state of health. The patient takes a number of medications before the operation. These suppress the body’s natural immune response to reject foreign organs – they are called immunosuppressants.
Kidney transplants
In kidney transplants, the patient’s own non-functioning kidneys are often left inside the body. The donor organ is transplanted into the lower abdomen and then connected to the major blood vessels in the pelvis. To ensure that urine can flow out of the new kidney, the ureter is sewn into the bladder. This connection is often stabilised using a special catheter that can be removed a few weeks after the transplant.
Liver transplants
With the exception of very few metabolic diseases, the recipient’s original liver is always removed in its entirety during a liver transplant. However, the transplanted organ in this case can be either a complete liver or part of a liver. Partial organs grow back to their original size in the space of a few months. The donor organ is inserted in place of the recovered organ and is then connected to the relevant structures.
Immunosuppression
During the period immediately following the transplant, it is necessary to carry out frequent and regular checks to see how the body is coping with the new organ. Despite the donor and recipient having compatible blood groups and high matches in terms of tissue markers, the body still recognises the new organ as being “foreign”. Our natural immune response can result in the transplanted organ being rejected. To prevent this, the patient must take medications to suppress their body’s immune response. These medications, called immunosuppressants, are given before and during the operation, and the patient will need to take them for life according to very precise dosing instructions. If the patient does not take their medication regularly or stops taking it without their doctor’s approval, it can put the transplanted organ at risk and can lead to a short- or long-term decline in function, and potentially to complete failure with loss of the organ.
LIFE AFTER A TRANSPLANT
The new organ
The patient has had a successful transplant operation. But what happens next? What happens whilst the patient is in hospital, and later on when they are back at home?
Immediately following the transplant operation, both the patient and the function of the new organ are closely monitored in intensive care. Where necessary, the patient receives medication to help with post-operative pain. The potential risk of a blood clot, meaning either a narrowing or obstruction of the blood vessels (thrombosis or, if the clot moves into the lungs, a pulmonary embolism) is prevented using appropriate methods, such as compression stockings and drugs that thin the blood (e.g. heparin or aspirin). Early mobilisation with support from a physiotherapist can also reduce the risk of thrombosis.
The time spent on a regular ward allows the patient to recover and still have regular checks of their blood and urine, among other things. Patients typically remain in hospital for around 2 to 3 weeks, mainly because their immunosuppression needs to be closely monitored. Another important aspect during this time involves training the patient in how to self-monitor and how to document the function of their new organ. During their time as an in-patient, plans are usually put in place for subsequent residential treatment in a rehabilitation unit. The patient starts this treatment within 2 weeks after being discharged.
Following their time in hospital, patients are regularly monitored in the transplant outpatients clinic or by another doctor. For the first four months after a transplant, it may be necessary to carry out these checks 2 times a week. Such close monitoring is vital in order to identify potential organ rejection quickly and to initiate the necessary treatment. If the patient’s recovery is straightforward then the interval between these checks is extended until the patient is asked to visit their doctor once every 3 months. Many transplant recipients are able to go back to work with no restrictions a little time after the operation.
All that said, it is important for patients, as recipients of new organs, to feel responsible for their own health, and for the self-monitoring of certain parameters, such as urine output, volume of fluids drunk, weight, pulse, blood pressure and body temperature, as well as regularly taking prescribed medicines, to become an integral part of everyday life. The better informed and more knowledgeable the patient, the sooner they will be able to respond to changes and notify their doctor
Counteracting organ rejection
The most feared complication after a transplant is rejection of the donor organ. So how do we recognise when an organ is being rejected? The earlier that we can identify a rejection response, the lower the risk of losing the transplanted organ.
Signs of rejection can vary depending on the organ. Generally speaking: if one or more symptoms occur then the patient should immediately visit the doctor responsible for their treatment or the transplant aftercare centre. Failure to initiate appropriate treatment quickly can lead to organ loss in just a few days. If rejection responses are identified early on then they usually respond well to treatment with drugs.
The following can be signs of a rejection response to the kidney:
The following can be signs of a rejection response to the liver:
For advice on travelling after an organ transplant, visit the Service section.
