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End stage renal disease is known as the last stage of kidney failure. In this stage, kidneys have lost most of their function to act as filters which excrete waste products from the body. They also fail to maintain the chemicals balance in the body. (11) As a result, there will be build-up of toxins and hence poison the entire body if left untreated. (1) The most common causes for end stage renal disease are diabetes and high blood pressure. A patient with this ESRD may undergo some symptoms such as weight loss, fatigue and nausea. In Malaysia, there are around 2200 new cases of patients diagnosed with this disease and the number is increasing each year. This indirectly links to the increasing mortality rate in our country. Therefore, it is important to have an effective way in overcoming this problem. In this report, the main treatment to be deliberate is kidney transplant.
Figure 1: new kidney failure cases in Malaysia from year 1998-2007 (6)
A Possible Treatment
Kidney transplant is a process of transferring a healthy kidney from the donor to a patient with ESRD. The organ needed for kidney transplant can be obtain form living related donor, living unrelated donor or deceased donor (cadaveric donor). (3)However, the kidney obtained from close relatives normally can match and perform better in the patient's body and the rate of organ rejection is lower. As compared to deceased donor, kidney donated by living donors can last longer. (4) Since healthy people can live with only one kidney, the donation will not harm nor shorten the life of the donor. Over 90% of living organ donors experienced no compilation at all. (8) Donors usually recover in a short period after operation and able to perform daily activities in a few weeks time.
Surgical procedure for kidney transplant:
The surgery is carry out by a transplant surgeon. Donor's surgery usually starts a few hours before the recipient's surgery. Both donor and recipient will be placed under general anesthesia during the operation.
The kidney is extracted from the abdomen of the donor and cooled while preparing for the implantation. (9) Health-care provider will carry out tests to match the donor's and recipient's tissue and blood before operation.
Recipient's surgery is carried out to place the new kidney in the abdomen of the patient. The kidney is attached to the artery and vein for normal blood circulation to perform.
The kidney should also be attached to the ureter which carries urine to the bladder for waste removing purpose. (11)
When the process is complete, blood flow to the kidney is reestablished and kidney become pink in colour. Urine may begin to flow from the ureter immediately.
Kidney transplant usually takes up to 3 hours.
Video of kidney transplant can be obtain from http://www.orlive.com/sentara-profile/videos/living-donor-kidney-transplant-surgery?view=displayPageNLM (10)
Donor Renal Vein
Donor Renal Artery
Figure 2: Location of transplanted kidney.(29)
Advantages of Kidney Transplant
Kidney transplant has many benefits. It can be consider as best form of treatment for kidney failure patients. Kidney transplant surgery is extremely successful with 90% of survival rates for cadaver transplants and 95% for live donor transplants. After the transplants, patients can live a better quality of life style without having any dialysis. People who get through transplant can even get back to work. Besides that, there will be less hospitals visits for the patients after first few months the operation is carry out. (11) Thus, patient will gain more freedom on time and mobility. There are also less restriction when comes to their diets and fluid intake. Normal kidney function is restored and many pathophysiologic changes associated with renal failure is reversed. (14)
Disadvantages of Kidney Transplant
There will always be risk where the kidney be rejected by the recipient. Thus regular life-long medication is necessary to prevent this situation from happening. The patient will be given several anti-rejection medications in order to suppress the immune response. (12) As a result, the immune system cannot perform well when the patient's body is attacked by pathogen and sometimes lead to infections. The intake of medication may also cause some side effects such as heartburn and nausea. It may increase the risk of certain types of cancers too. Moreover, it is very hard to get living donor who are willing to donate their kidney, especially when the recipient is non-relatives. In Malaysia, the transplant is not allowed to carry out if the donor and the recipient are not related in order to prevent organ trafficking syndicate. Most of the hospitals will advise their patient to carry out kidney transplants in other countries such as Singapore or Indonesia.(13)
The cost for kidney transplant is extremely high and sometimes reach a few hundred thousand ringgits.(15) This may be a huge burden for the lower income family. However, there are many charity organizations in Malaysia such as National Kidney Foundation of Malaysia (NKF) who provide funding for kidney failure patients to carry out their treatments. With increasing charities in the country, more fundraising activities has to be organize in order to cooperate with the expenditure.
While on the other hand, shortage of organ supply has lead to the development of organ trading. World Health Organization (WHO)'s report showed that kidneys are sold in some countries such as China, India, Pakistan. (16-17) The poor are force to sell their organ to earn some income but unfortunately the middle person who carry out these trading will be the one earning most. Some economist even suggested to create a legal market for organ trading so that both donor and recipients can obtain benefits thorough it.(18)
There are also ethical issues when comes to organ transplant. The requirement for healthy kidney is high but the cadaveric sources remains low for several reasons. Most of the time, cadaver organ transplant is carried out when the donor is in a situation of brain death. Most of the doctors agree that brain death is the final criterion of death. However, there is argument about the definition of death as the heart of the donor is still beating. For example, death is identified as the termination of heart's function by the Orthodox Jewish. Besides, cadaveric transplant is also restricted based on religious beliefs and cultural traditions. Although most of the religious encourage organ donation after death, some belief in after life and confine that the death person should not lose any parts of their body. For Japanese, the dead body must remain whole for burial in order to prevent misfortune.
Surprisingly, there are cases where people are kidnapped and the organs are removed from their body without their permission. The organ is sold to developed country at a high price by the criminals. While in some other countries, prisoners are force to donate their organs. This situation has created argument about humanity of the nation. Moreover, ethical issues regarding who should have higher priority to receive the organs appear when the waiting list for kidney transplant is extremely long. The main problem is whether the allocation should be based on medical criteria which are biased towards utility or on equity benefiting the needy.(19-22)
Haemodialysis is one of the popular treatments for ESRD. During the treatment, bloods will run through a filtering device outside the body known as dialyzer several times. Fistula is the surgical linking of artery to a vein providing access to blood vessels so that the blood can be removed and replaced in a smooth way. This process is to clean up the waste products containing in the blood and balance up blood chemistry. Then, the clean blood is returned to the body. Treatments usually last 3 to 5 hours and are done three times per week to obtain adequate results. Dialysis treatment is very inconvenient as it takes a long period causing the patient to lose their job opportunity. There are certain restrictions for the dialysis patient based on their diet and fluid intake.
Haemodialysis is still an imperfect treatment for ESRD as it cannot fully replace the functions of the kidneys. There are many dialysis centers all around Malaysia. Although it cost more than RM30000 annually, many patients choose this treatment because it is very easy to excess. This treatment can lead to side effects such as low blood pressure and muscle cramps. When too much fluid is removed from the body during dialysis, the blood pressure drop and the patient may undergoes dizziness and nausea.(23-24)
Fig 3: process of haemodialysis (25)
Fig 4: Patients dialyzing in Malaysia on December 31, 1980 to 2003. (7)
Another way to remove waste product from the body of ESRD patient is through peritoneal dialysis. Peritoneal dialysis has several benefits and limitations. This treatment is less expensive compare to haemodialysis. It is better tolerated by the patient suffer from cardiovascular compromise as peritoneal dialysis delivers steady treatment without fluctuation of plasma volume and solute. 4 bags (mixtures of dextrose, salt and other minerals dissolved in water) of dialysis solution is needed per day. This treatment is more independence and gives the patients control over the schedule. Patients may have their opportunities to work, travel and participate in their favourite activities. It requires less restricted diet thus patients can enjoy a higher quality lifestyle. Treatments can be carry out by patients themselves. There are no needles needed for this treatment. As a result, the risk of getting acquiring blood-borne infections such as hepatitis C can be minimizes. However, the connection between the catheter and dialysate bag is broken few times a day. The aseptic technique cannot maintain the sterility and thus patients may be infected by tunnel infections and peritonitis. Being a continuous daily therapy may also be the drawback of peritoneal dialysis. (27,30)
Fig 4: Peritoneal dialysis(26)
The best-documented risks associated with donating a kidney are those of the operation itself. Some kidney donors have died in the process, with the risk said to be 0.03 percent (3 in 10,000). This is similar to the risk of death with any procedure performed under general anesthesia (Bay and Hebert, 1987) Over 90 percent of donors experience no complications at all.
This extract is taken from reference (8), http://www.kidney.org/transplantation/livingDonors/pdf/safe_to_donate.pdf. This source is trustable since it also agrees with many other sources such as (7)
which states that most long-term studies on living donors have not found any adverse impact on blood pressure, proteinuria, or survival. Moreover, the www.kidney.org is a website based on the National Foundation in New York and its information is updated to year 2010.This information has has also been extracted manually by the professional evaluation team and the extracts are retrieved from the site at a precise date to support the evaluation criteria. They have also provided the legal and copyright information in the website to shows that the content is highly reliable.
I also evaluated another source Lewis,S.M, Heitkemper,M.M & Dirksen,S.R. (2004) Medical Surgical Nursing. 6th end. USA : Mosby,Inc. which shows patient will have more freedom on time and mobility and also less restriction when comes to their diets and fluid intake after carry out kidney transplant. This source is reliable because it agrees with many other similar texts based on kidney transplant such as those in Nettina,S.M. (2006) Manual of Nursing Practice. 8th end. USA: Lippincott Williams & Wilkins. which also shows that kidney transplant can help to restored the function of kidney and provide the patients a better quality of life. These texts are published after year 2003 so the information is considered updated. They are also reliable because the information and materials have gone through many stages of confirmation to ensure the validity before being published.