Introduction to live related & unrelated kidney transplantation

What is live related & unrelated kidney donation?

Live related kidney donation is the term used to describe the donation of a kidney from a living person who is related by blood to the person receiving the kidney, e.g. a father might donate a kidney to their son or daughter, an uncle or aunt to their nephew or niece.

‘Live unrelated donation’ describes the donation of a kidney from a living person who is not related by blood to the person receiving the kidney, e.g. donation by a husband to a wife or by a good friend.

Why is there a need for live related donation?

Most donated kidneys are obtained from people, previously fit and well, who have died suddenly, for example as the result of an accident. These are known as ‘cadaver donors’. Unfortunately, the number of people waiting for a kidney transplant is far more than the supply of kidneys from people who die suddenly. There are several reasons for this:

  • since the introduction of seat belt laws there have been far fewer deaths related to road traffic accidents
  • only about 7% of the population have registered a wish to donate their organs on the NHS Organ Donor Register
  • relatives sometimes do not know their loved ones wishes and are unable to donate their organs
  • not everyone is suitable for donation because of other medical conditions
  • transplantation is now available to more people as technology has allowed more people with kidney failure to be treated

In South Wales, the average period for waiting for a kidney transplant is about 1½ years. Many people have to wait much longer. If you come from an ethnic group, your waiting time could be longer because fewer organs are donated by ethnic groups.

Live related and unrelated donation offers an opportunity to transplant more people. Kidneys from live donors tend to be a better tissue type match and are only out of the body for a very short time. They are, therefore, on average, more successful than those from cadaveric donors.

Almost everybody is born with two kidneys. In a healthy individual, one kidney alone can perform the role of filtering the blood for waste products and excess water without any difficulty.

So why are there not more live related and unrelated kidney donations?

It is true to say that live related and unrelated kidney donation is not increasing at a rate anywhere close enough to match the demand for organs. This seems to be because people are not aware of or have not received enough information about live donation, some people find it difficult to ask family members to consider donation and others may have difficulty in receiving if offered and some family or friends may be worried that if they show an interest they may be forced to donate.

It takes courage to offer yourself as a kidney donor. It is important for people considering this step to be assured that if you are seeking more information on donation you will be viewed only as taking an interest. Finding out about donation is not a commitment to donation and, furthermore, anybody who has committed themselves to donation has the absolute right to withdraw from donation at any time. The reason for deciding to withdraw will be kept entirely confidential.

Protection under the law

Live donors are protected under law. The Human Organ Transplants Act 1989 makes it clear that live related donation must be between blood relatives and that they are donating under their own free will without payment or pressure from anybody.

Unrelated live donations can only go ahead with the approval of a governing body called the Unrelated Live Transplant Regulatory Authority (ULTRA). They ensure that the hospital adheres to the correct procedure and that the donor is donating without payment or pressure from anybody.

All live donors must be 18 years or above.

What are the advantages of live donation?

Overall, people receiving live donated kidneys can expect to have better kidney functionand fewer rejection episodes. This is because:

  • in live related donation, the kidney is often better matched
  • the transplant can be performed when the donor and recipient are in the best of health, both physically and emotionally
  • the kidney is removed and transplanted immediately (in cadaveric transplants a kidney may be stored in ice for up to 24 to 36 hours).
  • the kidney usually starts to work immediately. Sometimes cadaveric kidneys do not work straight away and dialysis may be necessary for the time that it takes for them to start working
  • surgery is planned and a date for transplant is often within 3 months of referral
  • technical problems e.g. bleeding or infection are rarer people sometimes have the opportunity to have their transplant before they need dialysis
  • What are the disadvantages of live donation?

    Success of live transplants is not guaranteed. At the University Hospital of Wales, we have a 100% success of living related/unrelated kidney transplants working after 1 year in the 27 years that live donation has been happening, whereas our record for cadaveric kidneys at 1 year is 94%. Nationally the figures are 97% for live donated kidneys and 85% for cadaveric kidneys.

    The potential donor will have to attend several outpatient appointments to determine their level of health and suitability to donate a kidney.

    The operation is bigger for the donor than the recipient (both take approximately 3 hours) and will involve some discomfort. Obviously, every effort is made to minimise any discomfort experienced by the donor and the recipient.

    What tests are needed to find out if you are fit to be a live kidney donor?

    If you are thinking about donating a kidney to a relative or a friend and express an interest, you will be given information by a transplant co-ordinator. It will then be left up to you to contact the transplant co-ordinators if you require more information and/or wish to proceed further. A transplant co-ordinator will come to your home and discuss what tests need to be undertaken, what the pros and cons of donating are and who will be responsible for your care.

    There are 3 blood tests that need to be done to establish your suitability to donate a kidney

    1. Blood group compatibility.

    A donor with blood group O can give their kidney to any person with any other blood group. A recipient with blood group AB can receive a donated organ from a person with any other blood group. Otherwise a recipient with blood group O can only match with O, A with A or O, and B with B or O.

    If the blood group is compatible, other tests can be run

    2. Tissue typing

    All tissues of the body carry special markers which are inherited from parents. The body recognises its own markers or tissue type, but will attack any different tissue type. Transplantation gives the best results when the tissue types of the donor and the recipient are as close as possible. A blood test will show how close the tissue type match is.

    3. Crossmatch

    This is a blood test that takes place where the blood cells of both the donor and the recipient are mixed together to see if there is a reaction. This will show if the kidney will be accepted or rejected by its new body. If the crossmatch is negative, this means that the kidney will be accepted. If positive, that it will be rejected and donation would not proceed. This test is repeated again prior to surgery as a final check.

    After these tests have been run and you are found to be suitable, you will be referred to a medical consultant specialising in transplant who will carry out further tests to check your own medical health.

    These tests will include:

    1. Blood tests

    • Check liver and kidney function is normal,
    • To check for anaemia
    • To check for viral infections such as hepatitis B & C, HIV and cytomegalovirus

    These blood tests are routine for all potential donors be they living or cadaver.

    2. Physical examination by the transplant consultant physician

    3. Chest x-ray, electrocardiogram (ECG) and exercise test to rule out any heart or chest problems

    4. Ultrasound of kidneys and bladder to ensure that both kidneys and the bladder are healthy

    5. Urine tests to rule out any urine infection, and a 24 hour urine collection as part of tests to ensure that the kidneys are working properly.

    6. Arteriogram, a procedure that allows x-ray pictures of the kidneys’ blood supply to be taken which will require a day in hospital.

    7. Meetings of donor and recipient with the transplant co-ordinator to discuss worries and concerns that either may have about the donation or the operation. These will happen as necessary.

    8. Outpatients appointments with both the transplant surgeon and the transplant physician prior to the operation to discuss results and raise any concerns or questions.

    What happens during the operation?

    The operation, which takes about 3 hours, will take place on a set date that is convenient to the donor and the recipient. One theatre is used, for the donor and recipient. The kidney is removed (a nephrectomy) under general anaesthetic through an incision made in the side of the body. As soon as the donor operation is over, the recipient’s operation is started. The new kidney is placed inside the lower abdomen or groin.

    What are the risks during the operation?

    All operations carry a small risk. There is a theoretical risk of death in any operation, either during the surgery or afterwards. A survey in North America covering 20,000 live donor nephrectomies, where 5 deaths were recorded as a result of the operation, showed a risk to the donor of 1 in 4,000.

    Other complications can also occur, such as infection or deep vein thrombosis (a blood clot in a leg vein). These occur at a rate of about 5-10 in 100 donors. These complications can cause discomfort, prolong the hospital stay but generally leave no lasting effects and are rarely fatal.

    What are the long term risks?

    Living donation has been carried out for 40 years and there have been many studies, across the world, that have looked at the long term effects on the donor.

    All the studies have shown that there is no significant deterioration of the remaining kidney. It has been noted that there is a little more protein excreted by the kidney in the urine, but this does not appear to affect the kidney.

    Will it hurt?

    There is discomfort from the surgical wound and the paraphernalia of drips and tubes that is put in place for the operation but which are removed as necessary. This is minimised with the use of pain killers.

    How long does it take to recover?

    Donors are encouraged to get up and about as soon as possible. Discharge from hospital should be within 5 to 10 days of the operation with between 4 to 12 weeks before returning to work, depending on the work.

    Once the wound has healed, you should feel no different to how you were before the operation and be able to resume a full and active life as before with no changes. For women, donor nephrectomy does not stop you from becoming pregnant after the operation if you so wish.

    How will I feel after the operation?

    Physically, you should feel no different after a donor nephrectomy. Emotionally, studies have shown that the majority of patients have not regretted donation and would do the same again if the clocks were turned back.

    However, should the kidney not work or fail after a period of time the transplant co-ordinator would be available to help the donor and recipients with their feelings at that time. It is an issue that is explored before donation takes place because it is not possible to guarantee that a kidney will work every time.

    How long does a live donor transplant last?

    At 1 year post-operation

    Nationally, 97% of live donated kidneys and 85% for cadaver donor kidneys are working after one year. At UHW, we have a 100% success of live donated kidneys working after 1 year in the 27 years that live donation has been happening, whereas our record for cadaveric kidneys at 1 year is 94%.

    At 10 to 15 years post-operation

    Nationally, about 50% of live donor kidneys are still working after 15 to 20 years whereas 50% of cadaveric kidneys are working after 10 years. At UHW x% of live donor kidneys are working at 15 to 20 years.

    Conclusion – the key points

    • Only the person thinking about being a donor can make the decision to donate
    • They must weigh up the pros and cons of live donation based on as much information as they can get
    • Nobody should be pressurised or paid to donate a kidney
    • Live donation offers an opportunity for transplanting a kidney that will work better and longer than a cadaveric kidney. It is truly a ‘gift of life’ for the recipient.
    • For more information or an informal discussion please contact the Transplant Co-ordinators:

      Sarah Matthews/Louise Coller (029) 2074 8429

      Karen Morgan (029) 2074 8422

      Fiona Casey (029) 2074 8423

      There is also an answer phone on (029) 2074 8423

      .

      By post:

      Transplant Co-ordinators, Nephrology & Transplant, University Hospital of Wales, Heath Park, Cardiff CF14 4XW


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