Risks and benefits of kidney transplant
Risks and benefits of kidney transplant
An inquest into the tragic deaths of two transplant recipients in Cardiff in 2013 shortly after receiving a kidney transplant from the same donor drew a significant amount of media attention last winter. The cause of the men’s deaths was found to be an extremely rare nematode that had been transmitted through the transplanted organ and was unidentified at the time of donation. The coroner concluded their deaths were the unintended consequence of necessary medical intervention.
We spoke to Professor James Neuberger, associate medical director of NHS Blood and Transplant, to find out whether patients should be concerned about undergoing a transplant, how long they should expect to wait for an organ, how successful transplants are and how the consent process works for patients in need of a transplant.
Should patients waiting for a kidney transplant or patients who may need a transplant in future be worried about what happened in Cardiff?
“What happened in Cardiff was a tragedy and we were incredibly sad for the families concerned. The families were naturally devastated by their loss. We must remember though that the nematode responsible for the men’s deaths had only been seen a few times anywhere in the world before and never before in transplantation.
“While no one can completely eliminate the risks associated with a kidney transplant, we all work hard to make sure transplants are as safe and successful as possible. While we know that all organs are associated with some risk, the level of risk is very small whereas the benefits of transplantation in terms of a better and longer life are considerable. Nonetheless, when harm comes to the recipient, this can be devastating to the patient and their family, so we do not take the risks lightly.”
How successful are kidney transplants?
“Kidney transplant success rates have been increasing since they first took place in the 1950s. In fact, now more than nine out of ten (93%) of kidney transplants still function well a year after transplant, and 96% of kidney transplant patients are alive a year after their transplant. 89% are alive five years afterwards.
“The alternative to kidney transplantation is some form of dialysis: Dialysis can be quite restrictive as patients have to spend so long on a machine, often several times each week. Having a kidney transplant can give them back more freedom to live their life again.”
Should patients be told about the risks of a transplant?
“The information the clinical team provides to a patient when they are assessing the patient’s suitability for a transplant is extremely important. All organs are in one sense ‘second hand’ as they come from someone who inevitably will have some risk. Some donors, especially those who are older, have more risky life styles or a complex medical history, may have a greater risk and the organ itself can carry risks. We are working to give as much information as we can to patients and their families so that, with the support of their clinical team, each person will make the decision that is right for them. Such information can be found on our website (www.odt.nhs.uk).
“We, together with British Transplantation Society,created Guidelines for consent for solid organ transplantation in adults. This guidance seeks to ensure that potential transplant recipients can make informed decisions about the type of organs they would accept as well as the consequences of rejecting an organ to wait for an organ they perceive to be better quality. It is a balance that surgeons and patients face every day.
“The guidelinesset out the information potential transplant recipients should be given when they are listed for a transplant and also when they are offered an organ. As time is pressured when an organ becomes available, the more detailed discussions between the clinician and patient take place at the time of listing and annually during the patient’s wait for an organ. When an organ becomes available for a patient, we recommend that the patient should be told about any additional risks relating to the donor or the organ itself so the patient can make an informed decision whether or not to go ahead with surgery. This may include, for example, specifics about known infection transmission risks or the cause of the donor’s death.”
Is it possible to predict how long you’ll be waiting for an organ after being listed?
“We appreciate that the wait for an organ can be an anxious time for patients and for their families. It’s helpful to have some idea of how quickly a matched kidney will become available. While on average adult patients can expect to wait approximately three to four years for a deceased donor kidney transplant and paediatric patients approximately one year, there is considerable variation according to patient characteristics.
“We have a probability calculator on our website. Patients can put in various information, such as their blood group, age at registration, previous graft history and the transplant centre where they are listed, and it will give an indication of how long you could wait for a kidney transplant. We also have introduced another calculator to help patients decide whether it would be better for them to join the incompatible kidney paired donation scheme. The latter scheme is when a person needing a kidney transplant has a living donor whose donated kidney is not compatible. We recommend that you use these calculators with your doctor or nurse.
“It’s important to remember that they are probability calculators rather than tools that give you exact timeframes, but we hope they are useful resources for patients and their clinical teams. You can find the calculators at: www.odt.nhs.uk/transplantation/guidance-policies/tools/”
Would a surgeon always accept an organ offered to him or her for one of their patients?
“When NHS Blood and Transplant offers a kidney to a transplant unit for a specific patient, the surgical team assesses whether or not to accept the organ by weighing up the risks with the particular patient in mind. They do this using knowledge of the potential recipient and the available information about the donor’s history and organ function. It is not unusual for a surgeon to decline a kidney for a patient and there are many reasons why they may do so. Reasons include that the organ may not be the right size for their patient, or that they may deem the function inadequate for their patient, for example if the kidney has come from an older donor and their patient is much younger. If a patient is highly sensitised (so that they are likely to reject the kidney) they may only get a kidney offer every five years so the surgeon may be more likely to accept the kidney than if the next offer for their patient is likely to be in six months’ time.
“Surgeons and their teams have to balance the risks of using a donated kidney with the risks of waiting for the next offer for their patient. When a surgeon rejects a kidney for their patient, it is offered to the surgical team for the next patient on the offering sequence.”
It is unusual for a kidney rejected by transplant units to be used?
“We want as many donated kidneys as possible to be used for transplant but only if the outcome will be good for the recipient. Over the last few years, we have introduced Kidney Fast Track Schemes to help optimise the use of kidneys. Kidneys are put through the Fast Track system if the time to transplantation is becoming too long so there is a risk that the organs will become unusable or if they have been declined for the first five patients to whom they have been offered (3 for donors after circulatory death). At that point, the organs can be offered to all other transplant centres that are part of the Kidney Fast Track System at the same time. Twelve of the 23 UK kidney transplant units are currently part of the scheme.
“Between 1 November 2012 and 30 April 2014, 291 kidney transplants were carried out after the organs were offered through the Fast Track Kidney Scheme (115 DCD kidneys and 176 DCD kidneys). Both the patient and graft outcomes are similar to those offered outside of the fast track scheme. These figures show that kidney transplants can be successfully carried out after being declined by other transplant units. A surgeon will always consider using an organ with a specific patient in mind, so the decision whether or not to use an organ is made on a case by case basis.”
If you could change one thing what would it be?
“This is an easy one for me to answer. I’d want every patient in need of a transplant to get the organ they need and to undergo a successful transplant. For this to happen, we need more families to agree to donate their loved one’s organs. Currently four out of ten UK families say no to donation. So what I want is for everyone in the UK to decide if, in the event of their death, they would like to become an organ donor and save and improve other people’s lives: if they do, to make sure their family and close friends know their wishes so they can help those wishes be fulfilled.
“Real life stories of successful transplants are incredibly powerful as are the stories of what it’s like waiting for a transplant and that’s why it’s great seeing people share their stories publicly to encourage the public to donate.”