Chapter 7: Kidney Transplantation

A kidney transplant is the best replacement for the dialysis machine. A living donor is superior to diseased kidney donor. In some countries, deceased donations are either not available or are not legally allowed.

The donor pool is increased by using extended criteria for donors defined as donor age >60 years with 2 or more risk factors such as hypertension, renal impairment (creatinine >1.3 mg/dl) or death due to intracranial hemorrhage. With these less desirable organs, the outcomes are still better than in patients remaining on dialysis. How organs are allocated varies, with major differences in donation and transplantation rates between countries⁶.

Recently the use of genetically modified pigs has been used as kidney donors which has the future potential of unpredictable outcome of xenotransplantation²⁴.

The most common cause of kidney transplant loss is a patient dying with a functioning graft. The lifespan of a kidney transplant is unpredictable on an individual basis as it depends on both donor and recipient. The average lifespan of a kidney is >15 years when all transplants are considered, but it covers a wide range with some patients retaining function after 40 years while others fail within the 1st year.

The transplant team is best visualized with the patient in the center¹²³⁴⁵⁶. The team comprises transplant surgeons, transplant nephrologists, referring physicians, transplant coordinators, the hospital transplant unit, dietitians, psychologists, the operating room, histocompatibility laboratory, hospital administration, the organ procurement organization and other ancillary facilities. The outpatient clinic, home care services and social workers may also be required. The optimal outcome of a transplant is not only survival but also returning the patient to an active and a normal life. To do this and to achieve long-term success of a transplant, the multidisciplinary team must work together, with each team member clear on their specific role to ensure continuity of care.

As in complex systems¹⁷, the use of protocols allows monitoring of outcomes and the ability to audit and adapt. Because of the complexity of the transplant process, it is essential to have protocols, checklists, standardized procedures and clinical practice guidelines to ensure patient safety and maintain good outcomes in an efficient and cost-effective manner. Protocols and standard operating procedures reduce errors and facilitate early identification of complications or accidents; allowing the whole team to communicate, work effectively and synergistically and to progressively develop. The key features of success in such programs are trust and cooperation^1256723.

The well organized, efficient and safe transplant program can develop and grow as processes are measured and managed. The similarity to the airline industry is striking. Often, a series of errors or mishaps (miscommunications) lead to a single fatal decision or event, and, frequently, the responsibility rests on a single person. A successful transplant program is dependent on each member of the team performing their responsibilities without failing, as well as adhering to a system of checks and balances which keeps the entire team on track. Protocols must be continuously updated as medical knowledge and technology evolve. Successful development and implementation of protocols rest with a few key individuals. For example, what may be a routine process in one transplant center requires regular maintenance others.

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