Kidney Transplantation

Deceased (Cadaveric) kidney transplantation

What is deceased kidney transplantation?

Deceased (cadaver) transplantation involves transplanting a healthy kidney from a patient who is “brain dead” into a patient with CKD. The deceased kidney comes from a person who has been declared “brain dead” with the desire to donate organs having been expressed either by the family or by the patient previously, at the event of his/her death.

Why are deceased kidney transplants necessary?

Due to the shortage of living donors, many CKD patients, though keen to have a transplant, have to remain on maintenance dialysis. The only hope for such patients is a kidney from deceased or cadaver donors. The most noble human service is being able to save the lives of others after death by donating organs. A deceased kidney transplant also helps eliminate illegal organ trade and is the most ethical form of kidney donation.

What is “Brain Death”?

“Brain death” is the complete and irreversible cessation (stopping) of all brain functions that leads to death. The diagnosis of “brain death” is made by doctors in hospitalized unconscious patients on ventilator support.

Criteria for diagnosis of brain death are:

1. The patient must be in a state of coma and the cause of the coma (e.g. head trauma, brain hemorrhage etc) is firmly established by history, clinical examination, laboratory testing, and neuroimaging. Certain medications (e.g. sedatives, anticonvulsants, muscle relaxants, anti-depressants, hypnotics and narcotics), metabolic and endocrine causes can lead to an unconscious state that can mimic brain death. Such causes have to be excluded before confirming the diagnosis of brain death. The doctor should correct low blood pressure, low body temperature and low body oxygen before considering brain death.
2. Persistent deep coma in spite of proper treatment under care of experts for an adequate period to “exclude the possibility of recovery”.
3. No spontaneous breathing, patient is on ventilator support.
4. Respiration, blood pressure and blood circulation is maintained with ventilator and other life support devices.

What is the difference between brain death and unconsciousness?

An unconscious patient may or may not need the support of a ventilator and is likely to recover after proper treatment. In a patient with “Brain Death,” the brain damage is severe and irreversible and is not expected to recover despite any medical or surgical treatment. In a patient with “Brain Death”, as soon as the ventilator is switched off, respiration stops and the heart stops beating. It is important to remember that the patient is already legally dead and removing the ventilator is not the cause of death. Patients with “Brain Death” cannot remain on ventilator support indefinitely, as their heart will stop relatively soon.

Is it possible to donate a kidney after dying?

No. Death occurs after the heart and respiration stop irreversibly and permanently. Like corneal donation, after death, kidney donation is not possible. When the heart stops, the blood supply to the kidney also stops, leading to severe and irreversible damage to the kidney, preventing its use for kidney transplantation.

What are the common causes for “Brain Death?”

Common causes of brain death are head injuries (i.e. falls or vehicular accidents), intracranial brain hemorrhage, brain infarct and brain tumor.

When and how is “Brain Death” diagnosed? Who diagnoses “Brain Death?”

When a deeply comatose patient kept on ventilator and other life supporting devices for an adequate period does not show any improvement on clinical and neurological examination, the possibility of “Brain Death” is considered. Diagnosis of brain death is made by a team of doctors who are not involved in kidney transplantation This team includes the attending physician, neurologist or neurosurgeon, who, after independent examinations of the patient, declare “brain death.” By detailed clinical examination, various laboratory tests, special EEG test for brain and other investigations, all possibilities of recovery from brain damage are explored. When no chance of any recovery is confirmed, “brain death” is declared.

What are the contraindications for kidney donation from a patient with “Brain Death?”

Under the following conditions a kidney cannot be accepted from a donor with brain death:

1. A patient with active infections.
2. A patient suffering from HIV or hepatitis B or C.
3. A patient with long standing hypertension, diabetes mellitus, kidney disease or presence of kidney failure.
4. Cancer patient (except brain tumor).

Which other organs can be donated by cadaver donors?

Cadaver donors can donate both kidneys and save lives of two patients. Besides kidney, other organs which can be donated are eye, heart, liver, skin, pancreas etc.

Who comprise the team for deceased kidney transplantation?

For deceased (cadaveric) kidney transplantation proper team work is necessary. The team ncludes:

• Relatives of the deceased kidney donor for legal consent.
• Attending physician of the donor.
• Cadaver transplant coordinator, who explains and helps the relatives of the patient for kidney donation.
• Neurologist who diagnoses the brain death.
• Nephrologist, urologist, transplant surgeon and team.

How is deceased kidney transplantation performed?

These are essential aspects of deceased kidney transplantation.

• A proper diagnosis of brain death is mandatory.
• The donor kidneys should be confirmed to be reasonably healthy and the donor should have no systemic disease that would contraindicate donation.
• Consent to donation should be given by a relative or person who is legally allowed to do so.
• Donor is kept on ventilator and other life-supporting devices to maintain respiration, heart beat and blood pressure until both kidneys are removed from the body.

• After removal, the kidney is processed properly with a special cold fluid and is preserved in ice. One deceased donor can donate both kidneys, so two recipients can be given the gift of life.
• Appropriate recipients are selected from a waiting list of patients following a protocol based on blood group, HLA matching and tissue cross matching compatibility.
• Better outcomes are expected the earlier the harvested kidneys are transplanted. They should ideally be transplanted within 24 hours of harvest. Beyond a certain length of time, they may not be viable for transplantation anymore.
• The surgical procedure on the recipient is the same for both living or deceased kidney donation.
• During the period of time between harvest and transplantation, the donor kidney sustains some damage due to lack of oxygen, lack of blood supply and cold exposure from storage in ice. Because of such injury, the kidney may not function immediately after transplantation and on occasion, short term dialysis support may be necessary while waiting for the donor kidney to recover and regain function.

Is there any payment made given to the donor’s family?

None. Giving another person a new lease on life is an invaluable gift. Being a donation, the donor or the donor’s family should not expect to receive any payment in exchange for the donated kidney, neither does the recipient need to pay anyone. The joy and satisfaction for this humanitarian gesture should be enough compensation for the donor or the family