Kidney transplantation in patients with renal failure

Posted June 14, 2018

By Alfredo Mota, Physician
Emeritus Professor of the Faculty of Medicine, University of Coimbra, Portugal

The first transplant was performed on identical male twins (immunologically identical, thus without rejection). One twin donated his kidney to his brother, in a complex surgery performed by two surgical teams headed by the surgeon Joseph Murray who, for that great achievement, was awarded the Nobel Prize in Medicine in 1991. Transplantations thus began with a living donor and a kidney, since persons have two kidneys and can lead a normal life with only one. That is, a father can donate a kidney to be transplanted in his son and continue to live as usual. Some years later, further advances made it possible to transplant kidneys from cadavers, thereby increasing the number of kidney transplants and eventually leading to transplants of the heart, liver, pancreas and lung.

In Portugal, kidney transplantations on a regular basis from cadavers began in 1980 in Coimbra, at its University Hospitals. I participated as an assistant surgeon in that first team, after which I continued to work in kidney transplantation and became a head surgeon some years later. Since 1980 until now, the Urology and Kidney Transplantation Service at the Coimbra Hospital and University Centre has already performed over 3,000 kidney transplants.

Working in transplantation is very gratifying. We offer a patient who needs an organ (kidney, heart, liver, pancreas or lung) a second opportunity to live. The organ to be transplanted, from an anonymous deceased person, who in life did not oppose having his/her organs transplanted after his/her death, or from a living donor who is altruistically willing to donate a kidney or part of his/her liver, is acting under the noblest human feelings, as of love for and communion with a fellow sufferer. It is the “Gift of Transplantation”, as described by the distinguished American surgeon Anthony Monaco: “For the donor, it is an opportunity to give someone the gift of life; for the surgeon, the gift allows him/her to help someone; for the patient who receives the organ, it is a gift that saves him/her from the disease and from death”.

Unfortunately, not all patients waiting for an organ that will allow them to live or improve their quality of life become recipients, since organs are scarce and not sufficient for everyone in need. For example, about 500 kidney transplants are performed per year in Portugal, and about 2,200 patients are on the waiting list for a kidney! That is, only 1/4 of patients on the waiting list receive a transplant, seeing as the number of donors has not increased even though Portugal has a well organised transplantation system that enables us to use practically all organs suitable for transplant.

These circumstances led Sir Roy Calne, one of the world’s foremost experts in this field, to wisely point out the following about transplantation: “A kidney transplant is not a right, it’s a privilege”. This phrase fully portrays the responsibility to which patients are bound after having been given the enormous privilege of being transplanted. They were selected, by luck or by nature (for believers, by God), based on criteria in which scientific and clinical factors prevail.

Transplant patients must have the notion that the “Prize” they were bestowed is priceless. The new organ that gave them new life must be treated with care and with the same love and affection bestowed on one’s new-born child. That is, transplant patients must not, under any circumstance, act in a way that may harm their new organ, for three main reasons: because they were selected from among the many who are still on the waiting list; because it will seriously affect their health, running the risk of death; and, finally, because transplantation is an expensive therapy, fully financed by the National Health Service (in other words, by all Portuguese who pay taxes), and each kidney transplant costs, merely in the first year, more than 50,000 euros.

For all the above reasons, transplant patients must strictly abide by all the medical team’s indications: take the medication in the specified doses and time intervals, eat and drink moderately, not smoke, maintain good daily hygiene, sleep sufficiently, perform the recommended physical exercise, etc.

The main problem of transplantation is rejection of the organ by the organism. The body will not accept anything that is foreign, which is a means of defence against aggressions from external agents and the reason why we are able to ward off the millions of microbes that are constantly invading us, specially through the air we breathe. To prevent or decrease the severity of rejection, patients must take medicines daily for the rest of their lives, which are called immunosuppressants and supplied for free at hospitals; otherwise they may lose the transplanted organ and even die.

Despite all recommendations and the privileged conditions available to them, it is estimated that about 30% of kidney transplant patients lose their kidney by not taking their medication properly! Do you now understand why a kidney transplant is not a right but, rather, a privilege? It is precisely because those who cannot abide by what is expected of them – and consequently lose a kidney that so many other persons were anxiously waiting for and at risk of dying, and who thus squandered public funds spent on their transplant – do not deserve to have a transplant and, therefore, do not have the right to the transplant.