Kidney Transplantation

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One option for the person with ESRD is a new kidney. Transplants are most successful when the kidney comes from a living relative. Another option is a cadaver kidney (a kidney from an unrelated person who has just died).

One year after getting a kidney from a living relative, about 97% of people with diabetes are still alive. After 5 years, the number is approximately 83%. For people who get cadaver kidneys, about 93% are still alive after one year, and 75% are alive after 5 years.

These numbers may sound scary, but people who have kidney failure will die without treatment. For those who choose dialysis, only about one-third are still alive 5 years later. So although kidney transplantation is a serious operation, it offers people with ESRD their best chance for survival.

The body has a complex system for telling its own parts from foreign parts. To fool the body into accepting the donor organ, doctors try to match the donor and recipient for a blood protein called human leukocyte antigen (HLA) type. A good match is most important when using a kidney from a living donor. The evidence for the value of HLA matching with cadaver kidneys is less clear. Some doctors believe that, at least in African Americans, cadaver kidneys all "take" equally well.

Unfortunately, there are too few kidneys for all the people who need them. Not enough people sign up to be organ donors. The shortage persists even though each person gets only one kidney at a time. Although the body normally has two kidneys, it can get by with just one as long as that kidney is healthy and working well.

Federal law says that kidneys should be given out in a fair and efficient way. In the current system, a national list contains the names and HLA types of people who need cadaver kidneys. When a kidney donor's kidneys become available, doctors check the list to see whose HLA types best match that of the donor. If there are several people who match equally well, the two people waiting longest get the kidneys. Some people must wait years before a kidney becomes available. Those waiting use dialysis in the meantime.

Despite the best HLA matching, the body may still not recognize the new kidney as part of itself. For this reason, people with kidney transplants must take certain drugs the rest of their lives. These drugs are called immunosuppressants, because they suppress the immune system to keep it from fighting the new organ. These drugs include azathioprine and cyclosporine A. Despite these drugs, some kidney transplants fail. When the body attacks the new organ as foreign, it is called rejection.

Immunosuppressant drugs pose dangers. Although suppressing the immune system keeps it from noticing the foreign organ, it also keeps the immune system from noticing infections. As a result, the person can get sick more easily. These drugs also have many side effects.

A new kidney does not cure diabetes, and the disease may damage the new kidney just as it did the original ones. But it took many years for the person's own kidneys to fail. If the new kidney does develop diabetic nephropathy, it too will take many years to fail.

Benefits and Risks

Kidney transplants are safest in people who do not have heart or blood vessel disease. Before you get a transplant, your doctor will check your circulatory system to see if it is healthy enough to risk the operation.

As with any operation, the healthier you are, the better you can withstand the physical stress of surgery. Possible side effects of surgery include bleeding and infection.

Immunosuppressive drugs are hard on the body, but people who get transplants must take these drugs the rest of their lives. Azathioprine and cyclosporine, two commonly used drugs, make it easier for you to get infections and have other side effects. You will need to avoid people who have infections, such as a cold or the flu. Also, you should not be immunized without first checking with your doctor. These drugs can also damage the kidneys. For example, using either of these medicines for many years could increase your risk for some cancers.

Because of these risks, kidney transplants are done only in people whose kidneys are failing.