Transplantation: A success story
Recent advances in organ preservation and new immunosuppressive drugs have resulted in high short-term success rates for kidney transplantation. The vast majority of kidneys from cadaver donors and living donors still function one year post-implant. These high success rates have created two unique problems:
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An organ shortage
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High expectation of long-term success
The organ shortage
In order to increase the number of kidneys available for transplant, transplant centers have begun using kidneys from several previously overlooked sources.
1) Marginal cadaver kidneys:
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From babies under age 3
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From older donors (age 60 and older)
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From those with mild hypertension or diabetes
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From those with atherosclerosis
2) Living kidney donors:
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From spouses or friends
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From donors with unilateral renal vascular disease (disease that affects only one side of the renal vascular system)
Doctors repair the kidney with vascular disease when it is ex-vivo (out of the body). The types of lesions repaired have included:
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Aneurysms (swelling of an artery caused by weakness or damage in the artery wall)
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Arteriovenous malformations (abnormal communications between blood vessels)
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Renal artery occlusions (closed renal arteries)
Long-term success
Chronic rejection or chronic allograft nephropathy (scarring of the kidney) is the leading cause of graft loss in surviving patients beyond 2 years.
There has not been an increase in the long-term survival of kidney transplants beyond 10 years.
Doctors have noted that a large percentage of patients who have a serum creatinine over 2 milligrams percent (a measure of kidney function) by 6 months will develop chronic rejection by 5 years. High risk factors include:
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Having an acute rejection episode
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Having a donor kidney over age 50
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A racially mismatched kidney
Therefore, events happen early that predict the long-term success of kidney transplants. Unfortunately, one reason that kidneys develop chronic allograft nephropathy is that the class of drugs used to prevent rejection actually damages the kidney. These drugs, called calcineurin inhibitors (for example, cyclosporine [Neoral, Sandimmune] and tacrolimus [Prograf]), can lead to kidneys scarring themselves. One immunosuppressive regimen that avoids the use of calcineurin inhibitor drugs is based on the drug sirolimus [Rapamune], a potent agent that is not nephrotoxic to the transplanted kidney. At 2 years, the kidney function of patients given sirolimus is significantly improved compared with the kidney function of patients given calcineurin inhibitor drugs.
Ischemic nephropathy
Ischemic nephropathy is a unique form of kidney disease that threatens renal function and may lead to dialysis. This disease involves atherosclerosis of both main arteries or that of a solitary functioning kidney. The entire renal mass is damaged. There may be associated high blood pressure, and it almost always leads to kidney dysfunction when a certain type of blood pressure medication is given (the converting enzyme inhibitors, which include captopril [Capoten], enalapril maleate [Vaseretic, Vasotec], and others. In certain circumstances, kidneys can be saved by reconstructing the renal artery lesion.
To perform the reconstruction:
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The kidney should be over 9 centimeters in length
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The kidney should demonstrate some function on imaging tests (IVP, nuclear scan)
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The kidney should have collateral blood supply
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A renal biopsy (viable glomerulus) should be performed
The best results are seen when creatinine is under 4 milligrams percent
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 7/8/2003
