Kidney transplant

from Wikipedia, the free encyclopedia

A kidney transplant (NTx, NTPL) is the operative transfer of a kidney to another organism. In the past, however, a kidney transplant was understood to mean the “relocation of a kidney to another part of the body” in the same patient, then as now without an operative nerve anastomosis .

In addition to dialysis (hemodialysis and peritoneal dialysis), it is a treatment option in renal replacement therapy and is carried out in the event of terminal kidney failure (ultimate kidney failure) or loss of both kidneys.

A kidney transplant is usually a desirable goal for patients with renal insufficiency - as far as it is individually possible and desired - as it contributes significantly more to the restoration of physical performance, quality of life and social integration of those affected compared to dialysis . Organs are transplanted from brain-dead organ donors and from living donors. In the ideal case, living donation takes place preemptively, i.e. before dialysis.

The chances of success of a kidney transplant have increased significantly in recent years. The operation is now a common procedure; z. B. 25,000 kidneys are transplanted annually in the USA and over 2000 in Germany. The average functional time of a transplanted kidney is around nine years, but there are also kidneys that still function well after 20 or more years. The survival times of transplanted patients are now much longer than those of dialysis patients. Kidney transplant people must - unless the donor organ has the same genetic material (donation to identical twin) - take medication that prevents rejection ( immunosuppression ) for life .

Finally, a kidney transplant is currently the cheapest solution from an economic point of view: a successful kidney transplant, including follow-up care, costs about as much as two years of dialysis in the first year.

Post-mortem organ allocation

In the Benelux countries , Germany , Croatia , Austria and Slovenia , the kidneys are awarded according to the criteria of the Eurotransplant organization. The criteria for organ allocation include the waiting time (from the start of dialysis ) and the correspondence of the tissue compatibility characteristics ( HLA characteristics ) of the donor and recipient. In addition, the country of origin of the donor and recipient and the distance between the location of the organ removal and the transplant center are taken into account. The waiting time for a post-mortem donor kidney in Germany is around 6 to 10 years.

Living donation

→ For more information on living donation in general, see the article on organ donation

Legal

An alternative to listing at Eurotransplant for a post-mortem donor kidney is living kidney donation ( living organ donation ), which is tied to a few requirements: First of all, the blood groups of the donor and recipient should generally be compatible and the crossmatch should be negative, i.e. That is, there are no antibodies against cells of the donor on the recipient's side. However, kidney transplants are now also performed despite blood group incompatibility and despite a positive crossmatch. In addition, various preliminary examinations make demands on the health of the donor. The donor must also be a close relative (he donates a so-called relative kidney ) or at least have a special relationship with the recipient. To ensure this and to exclude any financial interests , the donor in Germany must speak to an ethics committee before the operation . Even so-called altruistic cross donations (cross-over transplantation), ring exchanges ( ring donation ) in exchange rings or donations to an organ pool ( pool donation ) are currently not arranged by Eurotransplant ; the German transplant law forbids such an “organ exchange” as well as organ trade . The long-term results of living donation are better than post-mortem donation. The loss of a kidney at the donor entitles the donor to a degree of disability of at least 25 percent and a reduction in earning capacity of at least 20 percent; Depending on the previous damage to the remaining kidney, up to 100 percent are justified.

Risks

Because living kidney donation is not without risk for the donor either. It harms the donor and endangers his health. A postoperative fatigue syndrome , significant performance restrictions and kidney failure in the organ donor are described. In addition, lymph fistulas, wound healing disorders, hematomas and fascia dehiscences are described in kidney donors . The psychological burden for the donor and his family must also be considered. This must be explained thoroughly before the explantation (Transplantation Act, Patient Rights Act ). The donor's two kidneys have different glomerular filtration rates (GFR). It must therefore be clarified whether the better or the worse kidney will be donated ( choice of side of donor nephrectomy ). It is usual to remove the kidney with the poorer performance .

Renal failure

After the organ removal, the total GFR of the donor is reduced by the GFR of the donated kidney, usually to around half. In the medium the residual kidney of the donor increases its filtration rate (by a renal hypertrophy , a blood flow improvement , a drinking amount increase and a rise in blood pressure ) to a maximum of 70 percent of the initial value (the sum of both kidneys GFR). It is therefore assumed that the GFR will be reduced by around 30%. Severe renal failure is therefore a contraindication for living donation. On the other hand, the donated kidney may even have a better GFR in the recipient than in the donor, namely if the recipient's cardiac output or the daily fluid intake is greater than that of the donor. The total GFR at the recipient is the sum (and not the mean ) of the glomerular filtration rates of his now three individual kidneys (see figure). Live kidney donors have a better quality of life than the reference population . Transplant recipients also have a greater overall quality of life than dialysis patients. However, like any operation, the transplant is not without risk for the recipient.

Complications

The perioperative mortality risk associated with living kidney donation is 0.03 percent. Previously, the mortality risk after nephrectomy was estimated at 0.1 to 0.2 percent. 1 to 5 per thousand of all living kidney donors require dialysis themselves in the first 15 years after organ removal. Your individual further life expectancy is reduced by six to twelve months. The postoperative complication rate for robot-assisted living kidney donation at the Leipzig University Hospital was 9.25% in 2018 (i.e. in 4 of 27 patients, but that would be 14.8%). In Germany, the statutory accident insurance is responsible for such complications .

statistics

The mean operating time in Leipzig was 151 minutes. The median hospital stay was 7.3 days. Only 37 hospitals in Germany carry out living kidney donations. In 2018, 39% of all kidney transplants were carried out as living donations. For 2018, 1653 corpse donations and 638 living donations were reported; mathematically, 638 of a total of 2291 kidney transplants are only about 36%.

Surgical procedure

Representation of a heterotopic kidney transplant

In contrast to heart transplantation or lung transplantation and liver transplantation, kidney transplantation is usually carried out heterotopically, that is, the donor organ is not transplanted in the place of its own kidney, but outside the peritoneum in the pelvic area. The blood vessels of the donor kidney are usually sewn to the pelvic vessels, while the transplant ureter is connected directly to the bladder. Your own kidneys can therefore usually remain in the body; only in the case of special indications do you have to remove one or both of your own kidneys before or after the transplant. In most cases, the transplant will still function during the operation, but in some cases some dialysis will be necessary postoperatively. Surgical complications include infections, bleeding, the development of a lymphocele , narrowing of the transplant ureter and the development of incisional hernias after the operation.

Immunosuppression after kidney transplantation

To prevent a rejection reaction , medication must be taken after the transplantation that dampens the recipient's immune system so that the donor organ is not attacked by the recipient's immune system . These drugs are known as immunosuppressants . Usually, in the kidney, a combination of a so-called is calcineurin - inhibitor (eg. Cyclosporine or tacrolimus ), a proliferation inhibitor ( mycophenolate mofetil or azathioprine ) and (at least in the initial phase) a glucocorticoid (e.g., prednisolone ) is used.

During the first phase after the transplantation, the drugs are administered in high doses, later the dose can usually be reduced. Typical side effects of immunosuppression are an increased susceptibility to infections, an increased risk of malignant diseases of the skin and blood and an increased rate of metabolic diseases (such as diabetes mellitus and lipid metabolism disorders). Finally, tacrolimus and cyclosporine also have a nephrotoxic effect , which means that they have a damaging effect on kidney function and should therefore not be overdosed. The two calcineurin inhibitors are the main cause of the development of chronic graft nephropathy , which is the most common cause of the loss of the donor kidney. Switching to another immunosuppressant that does not work by inhibiting calcineurin can sustainably increase the statistical probability of maintaining kidney function. Taking sirolimus (rapamycin), which suppresses the proliferation of T lymphocytes by blocking the signal induced by interleukin-2, is an option. Sirolimus is not toxic to the kidneys in monotherapy . A number of studies have shown that the duration of function of transplanted kidneys is significantly higher in patients treated with sirolimus than in patients treated with the "classic" immunosuppressants. The risk of cancer after a kidney transplant with “classic” immunosuppression, which is otherwise increased by a factor of three to five, is significantly reduced by sirolimus.

Historical development of organ transplantation, especially kidney transplantation

  • 1902 - the world's first experimental autologous (from the original seat to the neck) kidney transplants by the Austrian Emerich Ullmann (1861–1937) on a dog in Vienna (at the same time Alexis Carrel (1873–1944) carries out similar experimental operations on dogs).
  • In 1936 the first transplant of a human cadaveric kidney was carried out by the Ukrainian surgeon Juri J. Woronoi . However, the patient only survived a few days and the donor organ never functioned due to ischemia .
  • In 1947 David M. Hume failed in Boston with the first kidney transplant on a young woman because of the subsequent rejection reactions.
  • 1953 - The world's first successful kidney transplant from a living donor is carried out by surgeon Jean Hamburger in Paris. However, the 16-year-old patient who received his mother's kidney only survived briefly.
  • 1954 - The first long-term successful transplant takes place between the twin brothers (Richard and Ronald Herrick; survival period eight years) in Boston at the Peter Bent Brigham Hospital. The surgeon, Joseph Murray , received the Nobel Prize in Medicine in 1990 . The interdisciplinary team was led by nephrologist John P. Merrill .
  • In 1962 he succeeded in transplanting through immunosuppression (see Brian Medawar ) even in genetically not identical people.
  • In 1963, the first kidney transplant in Germany was carried out by Reinhard Nagel and Wilhelm Brosig , in the Berlin University Hospital in Charlottenburg (today DRK Kliniken | Berlin Westend of the DRK Sisterhood Berlin )
  • 1967 - Christiaan Barnard performs the first heart transplant on December 3, 1967 in Capetown, South Africa, because the US authorities did not approve the transplant. The Americans Norman Shumway and Richard Lower contributed important findings for the operation . Jon van Rood and his colleagues in Leiden in the Netherlands showed that the correspondence of tissue characteristics (HLA, Human Leucocyte Antigen) between the patient and the transplanted organ is important for the long-term survival of the organ and the patient. They founded the first international organization for patient-oriented organ allocation - Eurotransplant.
  • 1968 - First heart-lung transplant by Denton Cooley in Houston, USA.
  • 1979 - First pancreas transplant in Germany at the Großhadern Clinic in Munich.
  • 1989 - the 100,000th kidney transplant was performed worldwide.
  • 1997 - On June 25, 1997, the Bundestag passed the Transplantation Act with a large majority. The extended consent solution applies. The Federal Council confirmed the bill on September 26, so that the law has been in effect since December 1, 1997.
  • In 2004 a team from the Freiburg University Medical Center led by Günter Kirste succeeded in performing a live kidney donation transplant for the first time in Germany, even though the blood groups of the donor and recipient were incompatible.
  • In 2019, US researchers implanted artificial kidneys in live pigs for a three-day trial run without complications.

Movies

See also

literature

Web links

Wiktionary: kidney transplant  - explanations of meanings, word origins, synonyms, translations

Studies:

  • Transplant results : In a collective study (Collaborative Transplant Study) the results from 400 transplant centers in 45 countries on the transplantation of kidneys, heart, lungs, liver and pancreas are summarized and constantly updated.

On the history of the kidney transplant:

Individual evidence

  1. ↑ Maxim Zetkin , Herbert Schaldach: Dictionary of Medicine . 1st edition. Verlag Volk und Gesundheit, Berlin 1956, p. 622.
  2. ↑ Numbers on kidney transplantation ( memento from September 25, 2008 in the Internet Archive ) on the homepage of the University Clinic Gießen and Marburg
  3. ↑ New procedure: kidney transplant despite blood group incompatibility and positive crossmatch. In: JournalMed of November 28, 2006.
  4. ↑ Rudolf Gross , Paul Schölmerich (Ed.): 1000 memoranda of internal medicine , 2nd edition, Schattauer Verlag , Stuttgart, New York 1978, ISBN 3-7945-0511-5 , p. 160.
  5. ↑ Sabine Wöhlke: Donated organs? Ethical and cultural challenges in familial living kidney donation. Campus, Frankfurt am Main / New York 2015, ISBN 978-3-593-50279-3 .
  6. ↑ Willibald Pschyrembel: Clinical Dictionary . 267th edition. Walter de Gruyter Verlag, Berlin / Boston 2017, ISBN 978-3-11-049497-6 , p. 1024.
  7. ↑ Beate Schumacher: Kidney donation: Every third donor develops renal insufficiency . In: Ärztezeitung , number 32-54D, March 20, 2019, p. 8.
  8. ↑ dpa message, Westfalen-Blatt , Herford Kreisblatt, 175. Born January 30, 2019 p. 2
  9. ↑ Maximilian Brunotte et al .: Robot-assisted living kidney donation . In: connexi-Magazin Nephrologie , The paideia Group, issue 2/2019, p. 32 f.
  10. ^ Ingeborg A. Hauser: Nierentransplantation , in: Helmut Geiger, Dietger Jonas, Tomas Lenz, Wolfgang Kramer (eds.): Kidney Diseases , Schattauer , Stuttgart, New York 2003, ISBN 3-7945-2177-3 , p. 280.
  11. ↑ Dietmar Hipp: Never recovered . In: Der Spiegel . No. 46 , 2018, p. 48-49 ( online ).
  12. ↑ Leif Steinecke: Federal Court of Justice on the disclosure obligations under the Transplantation Act . In: Diatra , Volume 29, Issue 1/2019, p. 78 f.
  13. ^ Ulrich Kunzendorf: Kidney Transplantation . In: Ulrich Kuhlmann et al. (Ed.): Nephrology . 6th edition. Georg Thieme Verlag, Stuttgart / New York 2015, ISBN 978-3-13-700206-2 , p. 764.
  14. ↑ Maxim Zetkin , Herbert Schaldach: Dictionary of Medicine . 1st edition. Verlag Volk und Gesundheit, Berlin 1956, p. 622.
  15. ↑ Other information: "approx. 80% of the output power". Source: Jörg Dötsch, Lutz T. Weber (ed.): Kidney diseases in childhood and adolescence . Springer-Verlag, Berlin 2017, ISBN 978-3-662-48788-4 , p. 250.
  16. ^ Rüdiger Zart: Aftercare after transplantation in everyday nephrology . In: connexi-Magazin Nephrologie , The paideia Group, issue 2/2019, p. 37.
  17. ↑ Hans Eduard Franz, Walter H. Hörl (Ed.): Blood purification process . 5th edition. Georg Thieme Verlag, Stuttgart / New York 1997, ISBN 3-13-497705-2 , p. 461 f.
  18. ↑ Jörg Dötsch, Lutz T. Weber (ed.): Kidney diseases in childhood and adolescence . Springer-Verlag, Berlin 2017, ISBN 978-3-662-48788-4 , p. 250. However, it should not be forgotten that the general mortality of young adults (p = 0.002 = 0.2% per year) for one The seven-week range is also 0.03%.
  19. ^ Ingeborg A. Hauser: Nierentransplantation , in: Helmut Geiger, Dietger Jonas, Tomas Lenz, Wolfgang Kramer (eds.): Kidney diseases , Schattauer , Stuttgart, New York 2003, ISBN 3-7945-2177-3 , p. 279. But on the following page it gives the perioperative mortality at around 0.05%.
  20. ↑ Hans Joachim Sarre : Kidney Diseases , 4th Edition, Georg Thieme Verlag, Stuttgart 1976, ISBN 3-13-392804-X , p. 640.
  21. ↑ Other information: "Absolute risk approx. 0.8%". Source: Jörg Dötsch, Lutz T. Weber (ed.): Kidney diseases in childhood and adolescence . Springer-Verlag, Berlin 2017, ISBN 978-3-662-48788-4 , p. 250.
  22. ↑ Maximilian Brunotte et al .: Robot-assisted living kidney donation . In: connexi-Magazin Nephrologie , The paideia Group, issue 2/2019, pp. 32–34.
  23. ↑ Wolfgang Albert Eisenhauer: Influence of therapy with ACE inhibitors on proteinuria in kidney transplant patients Dissertation, University of Münster, 2007
  24. ↑ A. Benigni et al. a .: Nature and mediators of renal lesions in kidney transplant patients given cyclosporine for more than one year. In: Kidney Int . 55, 1999, pp. 674-685. PMID 9987092
  25. ↑ WM Bennett u. a .: Chronic cyclosporine nephropathy: the Achilles' heel if immunosuppressive therapy. In: Kidney Int 50, 1996, pp. 1089-1100. PMID 8887265 (Review)
  26. ^ WM Bennett: Insights into chronic cyclosporine nephrotoxicity. In: Int J Clin Pharmacol Ther 34, 1996, pp. 515-519. PMID 8937936 (Review)
  27. ^ VW Lee and JR Chapman: Sirolimus: its role in nephrology. In: Nephrology (Carlton) 10, 2005, pp. 606-614. PMID 16354246 (Review)
  28. ↑ K. Budde, M. Giessing, L. Liefeldt, HH Neumayer, P. Glander: Modern immunosuppression following renal transplantation. Standard or tailor made? In: Urologe A 45.1, pp. 7-19, PMID 16328215
  29. ↑ JJ Augustine et al. a .: Use of sirolimus in solid organ transplantation. In: Drugs 67, 2007, pp. 369-391. PMID 17335296 (Review)
  30. ↑ W. Arns: Long-term protection for transplanted kidneys. (PDF; 1.1 MB) 2004, pp. 1–8.
  31. ↑ Conversion of rejection prophylaxis to sirolimus - chance of maintaining kidney transplant function for longer. In: Dialyse aktuell 12, 2008, pp. 526-528. doi: 10.1055 / s-0028-1104662
  32. ↑ C. Plank et al. a .: Reduction of calcineurin inhibitors in long-term immunosuppression after kidney transplantation in children and adolescents - less nephrotoxicity, better transplant function? ( Memento of the original from January 19, 2012 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 324 kB) In: Transplantationsmedizin 16, 2004, p. 81. @1@ 2Template: Webachiv / IABot / www.transplantation.de
  33. ↑ RK Wali and MR Weir: Chronic allograft dysfunction: can we use mammalian target of rapamycin inhibitors to replace calcineurin inhibitors to preserve graft function? In: Curr Opin Organ Transplant 13, 2008, pp. 614-621. PMID 19060552 (Review)
  34. ↑ C. Morath et al. a .: Sirolimus in renal transplantation. In: Nephrol Dial Transplant 22, 2007, pp. 61-65. PMID 17890266 (Review)
  35. ↑ G. Stallone et al. a .: There is a choice for immunosuppressive drug nephrotoxicity: Is it time to change? In: J Nephrol 22, 2009, pp. 326-332. PMID 19557709 (Review)
  36. ↑ J. Dantal, E. Pohanka: Malignancies in renal transplantation: an unmet medical need. In: Nephrology Dialysis Transplantation . 2007, Volume 22 Suppl 1: pp. I4-10. doi: 10.1093 / ndt / gfm085 . PMID 17456618 . (Review).
  37. ^ BK Law: Rapamycin: an anti-cancer immunosuppressant? In: Critical Reviews in Oncology Hematology . Volume 56, Number 1, October 2005, pp. 47-60, ISSN  1040-8428 . doi: 10.1016 / j.critrevonc.2004.09.009 . PMID 16039868 . (Review).
  38. ↑ R. Marcen: Immunosuppressive drugs in kidney transplantation: impact on patient survival, and incidence of cardiovascular disease, malignancy and infection. In: Drugs . Volume 69, Number 16, November 2009, pp. 2227-2243, ISSN  0012-6667 . doi: 10.2165 / 11319260-000000000-00000 . PMID 19852526 . (Review).
  39. ↑ J. Alberú: Clinical insights for cancer outcomes in renal transplant patients. In: Transplantation proceedings. Volume 42, Number 9 Suppl, November 2010, pp. S36-S40, ISSN  1873-2623 . doi: 10.1016 / j.transproceed.2010.07.006 . PMID 21095450 . (Review).
  40. ↑ Thomas Schlich: Kidney Transplantation. 2005, p. 1049.
  41. ↑ Other spelling: Emmerich Ullmann, Privatdozent from Vienna, on March 7th, 1902. Source: Rudolf Pichlmayr , B. Grotelüschen: Development and current status of kidney transplantation , in: Hans Erhard Bock , Karl-Heinz Hildebrand, Hans Joachim Sarre (Eds. ): Franz Volhard - Recollections , Schattauer Verlag, Stuttgart 1982, ISBN 3-7845-0898-X , p. 251. Its source: Emmerich Ullmann in the Wiener clinical Wochenschrift , 15th year, 1902, page 281.
  42. ↑ Other information: Lawler carried out the first human kidney transplant in 1950 [sic]. Source: Gill Davies (ed.): Zeittafel der Medizingeschichte , Könemann Verlagsgesellschaft, Cologne 2000, ISBN 3-8290-2831-8 , p. 35.
  43. ↑ Other information: John Putnam Merrill et alii carried out the first kidney transplant between two identical twins in the USA in 1956 [sic] . Source: Gill Davies (ed.): Zeittafel der Medizingeschichte , Könemann Verlagsgesellschaft, Cologne 2000, ISBN 3-8290-2831-8 , p. 36.
  44. ↑ History of Kidney Transplantation
  45. ↑ History of the kidney transplant ( Memento of the original dated February 16, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / transplantation-cbf.charite.de
  46. ↑ Rüdiger Meier: Researchers implanted artificial kidneys in pigs , in: Deutsches Ärzteblatt online from November 8, 2019 with the source: Conference report of the Kidney Week 2019 of the American Society of Nephrology .