Organ Transplant

Bone marrow is the soft, sponge-like material found inside bones. It contains immature cells called stem cells that produce blood cells including, white blood cells, which fight infection; red blood cells, which carry oxygen to and remove waste products from organs and tissues; and platelets, which enable the blood to clot. 

The most primitive of the stem cells is called the pluripotent stem cell, which is different than other blood cells with regards to the following properties:

• Renewal - It is able to reproduce another cell identical to itself.

• Differentiation - It is able to generate one or more subsets of more mature cells.

It is the stem cells that are needed in bone marrow transplant.

A bone marrow transplant is a medical procedure to replace damaged or destroyed bone marrow affected by the disease, infection, or chemotherapy. This involves transplanting blood stem cells, which travel to the bone marrow where new blood cells are produced and increase the growth of new bone marrow.

There are two types of transplant. An autologous transplant in which the donor is himself/herself using their own cells which are collected from the bloodstream and stored for the transplant. In allogeneic transplant cells from a family member, unrelated donor or umbilical cord blood unit are used.

Bone marrow transplant is most commonly used in the treatment of leukaemia and lymphoma. They are also used in the treatment of childhood brain tumours and neuroblastoma ( uncommon cancer that occurs most often in children). 

The following diseases are the ones that most commonly benefit from bone marrow transplant:

• Leukaemia

• Severe aplastic anaemia

• Lymphomas

• Multiple myeloma

• Immune deficiency disorders

• Some solid-tumor cancers

However, patients experience diseases differently, and bone marrow transplant may not be appropriate for everyone who suffers from these diseases.

Depending on the kind of donor, Bone Marrow Transplant is classified in different types. Autologous bone marrow transplant - The donor is the patient himself or herself. Stem cells are taken from the patient either by bone marrow harvest or apheresis (a process of collecting peripheral blood stem cells), frozen, and then given back to the patient after intensive treatment. Often the term rescue is used instead of transplant.

• Autologous bone marrow transplant: An autologous transplant in which the donor is himself/herself using their own cells which are collected from the bloodstream and stored for the transplant. Stem cells taken from the patient either by bone marrow harvest or from peripheral blood stem cells are given back to the patient after intensive treatment.  

• Allogeneic bone marrow transplant: In allogeneic transplant cells from a family member, unrelated donor or umbilical cord blood unit are used.

• Umbilical cord blood transplant: Stem cells taken from an umbilical cord immediately after delivery of an infant tested, typed, counted, and frozen until they are needed for a transplant. These stem cells are quicker in functioning and more effective than stem cells taken from the bone marrow of another child or adult.

Matching of donors and recipients involves Human leukocyte antigen (HLA) typing. Few major antigens on the surface of these special white blood cells determine whether a donor and recipient match. The higher the number of matching HLA antigens, the better the chance that the patient's body will accept the donor's bone marrow.

Over the next one to two weeks, you will have a thorough evaluation to confirm your diagnosis and evaluate your health. Your evaluation will include -A variety of medical tests and imaging procedures, to see other organ functioning like kidney and liver, tissue typing for allogeneic patients, heart tests, imaging studies such as x-rays, CT scans, and PET scans, and a bone marrow biopsy.  Additional tests may be required depending on the overall health of the patient.

A bone marrow transplant procedure is similar in the time required to doing a regular blood transfusion.

Before the bone marrow transplant, the patient will receive chemotherapy, with or without radiation as a preparatory regimen a few days prior to the infusion of stem cells.  On transplant day, the autologous or allogeneic replacement cells are infused into the patient’s bloodstream.  It then takes between 10-20 days for a process called engraftment to take place.  This is when the newly infused cells begin to grow and make new white blood cells, red blood cells, and platelets. During this time, the patient may notice fevers and infections improving as more cells are produced to fight off infections.

Bone marrow transplant is a major medical procedure and can have complications that can be minor or major. Complications can include:

• Anaemia

• Bleeding in the lungs, intestines, brain, and other areas of the body

• Cataracts

• Clotting in the small veins of the liver

• Damage to the kidneys, liver, lungs, and heart

• Delayed growth in children who receive a bone marrow transplant

• Early menopause

• Graft failure, which means that the new cells do not settle into the body and start producing stem cells

• Graft-versus-host disease, a condition in which the donor cells attack your own body

• Infections, which can be very serious

• Inflammation and soreness in the mouth, throat, esophagus, and stomach, called mucositis

• Pain

• Stomach problems, including diarrhoea, nausea, and vomiting

The initial recovery period typically lasts around 3 months after an allogeneic transplant and approximately 1 month after an autologous transplant. 

The patient should maintain a normal healthy diet post-transplant.  This should consist of plenty of fresh fruit and vegetables, enough protein and not much fat. It is also best to avoid unpasteurized or raw milk and milk products including cheese and yogurt. In the initial days after transplant when appetite may still be poor, it is not necessary to follow a strict diet as the patient should eat whatever is appetizing until the appetite returns to normal.

Exercising after the bone marrow will depend on the blood cell values including the platelet count post-transplant.  Regular exercise can be done once the platelet count is about 50000, but if it is between 10000-50000 only low key limited exercise should be done.  If platelet count is below 5000, exercise should be avoided as it may cause internal bleeding.

In regards to activity including hugging, kissing and touching, this may be resumed after discharge from the hospital, although sick people should be avoided until cell counts are improving. In regards to sexual intercourse, it is recommended that the patient waits until the platelet count is above 50000.  It is also advised that a condom during intercourse be used for the first six months after the transplant to reduce the risk of viral transmissions. Sometimes there are hormone changes after a transplant, women's periods often stop after a transplant and long-term hormone replacement may be recommended. It is completely normal to have a lack of sexual desire after bone marrow transplant, but this will gradually improve as blood counts and hormone levels start improving and more strength is developed.

The liver's main job is to filter the blood coming from the digestive tract, before passing it to the rest of the body. The liver also detoxifies chemicals and metabolises drugs. As it does so, the liver secretes bile that ends up back in the intestines. Bile helps to break down fats, preparing them for further digestion and absorption. The liver also makes proteins important for blood clotting and other functions.

A liver transplant is considered when the liver no longer functions as required and the patient develops liver failure.  Liver failure can happen suddenly or more chronically leading to end-stage liver disease.

The reasons for liver transplant again vary with the patient’s age and severity of the disease.

There are many causes, but the most common reasons include heavy alcohol abuse leading to liver cirrhosis, viruses that cause Hepatitis B and C, hereditary defects such as Wilson's Disease, Budd-Chiari Syndrome, Primary Hemochromatosis, Autoimmune Hepatitis, reactions to drugs and chemicals, and liver cancer.

There are three types of transplant organs:

• Cadaveric

• Living related

• Living unrelated

Cadaveric

A cadaveric transplant is a kidney removed from someone who has died. Cadaveric kidneys are only removed after a series of tests have established that the donor is brain dead. This means that the part of the brain called the brainstem, which controls breathing, has permanently stopped working. A brain-dead patient is only being kept alive by a life-support machine.

Living Related

In living related transplants, a living relative donates a certain lobe of liver for transplant. A living related transplant is more likely to work than a cadaveric transplant because it is more likely to be a better match than from an unrelated donor.

If a liver patient has a relative who is at least 18 years old, healthy, and willing to donate a lobe, they should speak to the transplant coordinator at their unit. A number of tests will then need to be arranged for both the patient and the donor.

Living Unrelated

Sometimes an unrelated person will donate a lobe of a liver for transplant. It is usually someone close to the patient, such as a husband, wife, partner or close friend. As with a living-related transplant, both the donor and recipient will be given a number of tests and will receive in-depth counselling. This happens in another case as well when the members of two different families fails to donate their organ to their own family member due to the reason of unmatched blood groups then there is an option called swap transplant in which they can exchange their organs with each other.

The evaluation process involves first determining the severity of the liver disease by clinical evaluation, comprehensive laboratory testing, and imaging tests such as an ultrasound of the liver and radiographic studies.  In addition, systemic studies including heart tests will be done to determine the health of your cardiovascular system and a psychological evaluation to assess and treat any underlying issues, such as depression or anxiety.

Another testing to evaluate the kidneys and lungs may also be needed.  These studies will make sure there is no absolute or relative contraindication for liver transplantation.  Once these tests have cleared and the donor is available and cleared, the liver transplant can take place.

Dietary changes must be made after liver transplantation.  The diet should be low in salt, cholesterol, fat and sugar.  It is also very important to avoid drinking any alcohol to prevent damage of the new liver. 

Other changes that need to be include are drinking low-fat/fat-free dairy products to maintain appropriate calcium levels, as well as eating lean meats, poultry and fish. 

Regarding physical activities, including sports and sexual activity may be resumed when the patient is physically able to, but general exercise should be started as soon as possible, even if this just involves walking.

Three types of liver transplant

There are three different types of liver transplant that may be offered to a person:

• Orthotopic transplant or transplant of a liver from a recently deceased donor: An orthotopic transplant is the most common type of liver transplant. The whole liver is taken from a recently deceased donor. This is usually from a donor who has pledged his or her organs for donation prior to death and has not transmissible illness or cancers that may be transmitted to the recipient.

• A living donor transplant: The donor has the operation first in which the surgeon removes either the left or right side (lobe) of their liver.

Right lobe transplants are usually recommended for adults while left lobes are used in children. This is because the right lobe is bigger and better suited for adults, while the left lobe is smaller and better suited for children.

Following transplantation, the transplanted lobe will quickly regenerate itself. Even for the donor the removed portion of the liver grows back. In the recipient the new lobe usually grows to 85% of the original liver size within a week.

• A split type of liver transplant: It involves transplantation of a liver from a recently deceased individual to two recipients. This is possible if the next suitable recipients are an adult and a child.

Patients with internal bleeding, coma, kidney failure, or other complications would make them unsuitable for surgery.  Other risks before surgery include intestinal bleeding, severe abdominal fluid, confusion, as well as severe infections which would need to be controlled and treated prior to consideration for a liver transplant.

NO, this is an illegal and punishable act in India. Buying and selling organs is strictly prohibited and punishable by prison sentences and fines of up to Rs 25 lakh.

The liver transplant procedure generally takes between four and eight hours. The patient will come to the hospital, often the night before, then go down to the operating room, often for about two hours of anaesthesia before the surgery even begins.

The patient will be under general anaesthesia throughout the surgery. Once asleep, the transplant surgeon will make an incision shaped like a boomerang on the upper part of the abdomen. The surgical team will then remove the patient's old liver, leaving portions of his major blood vessels in place. The new liver will then be inserted and attached to these blood vessels and to the patient's bile ducts. To help with bile drainage, a tube will also be inserted into the bile duct during surgery.

The tube remains in place for about 3 months after surgery. Bile production early after the surgery is a good sign and is one of the indicators surgeons look for to determine if the liver transplant is being "accepted" by the patient's body.

In other types of Liver Transplant, damaged liver is removed but in Auxiliary Liver Transplant, the recipient’s own liver is not completely removed. Its purpose is to retain the native liver in case of spontaneous recovery or if there is a potential for future gene therapy in cases of hereditary or metabolic liver diseases (except primary oxalosis, Wilson’s disease or tyrosinaemia in which there is a risk of cancer in the residual liver).

Yes, in general that is true, although every patient who has been involved with liver transplantation has often heard of that special case of someone who was able to stop the medication. Importantly, almost all patients who have to take these medicines long term can also undergo dose reduction as the body adjusts to the transplanted liver and the amount of medicine needed to control or prevent rejection is reduced.

Most patients need to spend a few days in the hospital in the intensive care unit and another few days on the ward; about a minimum of 6 days in the hospital. The range of days spent in the hospitalisation is from five days to maybe even six weeks.

Recovery after liver transplantation depends in part on how the overall health of the patient was prior to surgery and if any complications occurred in the post-operative period.  It can take up to 6 months to fully heal after the surgery depending on how much activity will be tolerated by the patient.  In a few months it is encouraged that the patient starts resuming their normal activities as tolerated.

Before liver transplantation, risks to the patient are mainly those who develop acute liver failure and it’s complications of bleeding, coma, kidney failure or progressive complications of chronic liver failure that might render the patient an unacceptable risk for surgery. This can also include intestinal bleeding, severe abdominal fluid accumulation, confusion as well as coma and severe infections. 

With surgery, the risks are those that are common to all forms of major surgery, or involve technical difficulties in removing the diseased liver, involve implanting the donor liver, and/or involve consequences of being without liver function briefly. Immediately after the operation, risks include bleeding, poor function of the grafted liver, bile leaks, and infections. We monitor the patient carefully for several weeks after surgery for signs that the patient is rejecting the new liver as well. Rejection long-term becomes less and less common.

There are varying degrees of failure of the liver; even with imperfect function, patients can remain quite well. Occasionally, when circumstances and time permit, a patient's transplanted liver that is failing can be replaced by a second or even a third transplant.

With new advances in medicine, you may want to discuss with your doctor the possibility of a new liver support device that can postpone the need for transplantation or possibly improve the likelihood of a successful transplant. These devices are still in research but are often discussed with patients when they are admitted to the hospital.

The kidneys are two bean-shaped organs that extract waste from blood, balance body fluids, form urine, and aid in other important functions of the body.

The normally functioning kidney controls the concentration of body fluids. It accomplishes this by excreting excessive amounts of water in the urine if body fluids are too dilute or by excreting excessive solutes when body fluids are too concentrated. Despite large intakes of salt and water, almost no change in blood volume or concentration occurs.

Another important function is an acid-base balance. The body maintains a constant pH via several buffering mechanisms. The kidney plays a major role in this by the net excretion of hydrogen ions when the blood is too acidic and the net excretion of bicarbonate ions when the blood is too alkaline.

The kidneys also have a hormonal role. They are in part responsible for the conversion of Vitamin D to its active metabolite, which is important in the absorption of calcium from the intestine.

Kidney failure is the last (most severe) stage of chronic kidney disease. This is why kidney failure is also called end-stage renal disease, or ESRD for short

A sudden loss of blood flow to your kidneys can prompt kidney failure. The Most common cause of kidney failure is the result of uncontrolled diabetes and high blood pressure. Diseases like glomerulonephritis and polycystic kidney disease can also lead to end stage kidney disease.  

Some other diseases and conditions that cause loss of blood flow to the kidneys include:

• heart attack
• heart disease
• scarring of the liver or liver failure
• dehydration
• a severe burn
• an allergic reaction
• a severe infection, such as sepsis

Blood pressure and anti-inflammatory medications can also limit blood flow.

When 90% of a person’s kidneys are not functioning adequately to remove the waste products and toxins from the body resulting in kidney failure. A kidney transplant may be performed regardless of the age of the recipient (patient who requires the kidney) provided they have a general health status that can withstand the major operation. According to experts of Kidney Transplant, for people who meet the requirements for kidney transplantation, it’s the best option for treatment for kidney failure compared to a lifetime on dialysis.

There are three types of transplant organs:

• Cadaveric

• Living related

• Living unrelated

Cadaveric Organ Transplants

A cadaveric transplant is a kidney removed from someone who has died. Cadaveric kidneys are only removed after a series of tests have established that the donor is brain dead. This means that the part of the brain called the brainstem, which controls breathing, has permanently stopped working. A brain-dead patient is only being kept alive by a life-support machine.

Living related Organ Transplant

In living related transplants, a living relative donates a kidney for transplant. A living related transplant is more likely to work than a cadaveric transplant because it is more likely to be a better match than from an unrelated donor.

If a kidney patient has a relative who is at least 18 years old, healthy, and willing to donate a kidney, they should speak to the transplant coordinator at their unit. A number of tests will then need to be arranged for both the patient and the donor.

Living unrelated Organ Transplant

Sometimes an unrelated person will donate a kidney for transplant. It is usually someone close to the patient, such as a husband, wife, partner or close friend. As with a living-related transplant, both the donor and recipient will be given a number of tests and will receive in-depth counselling. This happens in another case as well when the members of two different families fail to donate their organ to their own family member due to the reason of unmatched blood groups then there is an option called swap transplant in which they can exchange their organs with each other.

During a kidney transplant evaluation, a transplant coordinator will arrange a series of tests to assess your treatment options. You'll be evaluated for potential medical problems such as heart disease, infections, bladder dysfunction, ulcer disease and obesity. A social worker will discuss transportation, housing, financial and family support needs in regard to a transplant and a financial counsellor will address the benefits of your insurance policy.

Each transplant centre has its own guidelines for deciding if you are a good candidate for a kidney transplant.  However, at every centre, you can expect to have:

• A Medical and Surgical History:  The transplant team will review your medical history carefully.  You will be asked about any illnesses, surgeries, and treatments you’ve had in the past.  You will also be asked about your family’s history.  If any problems are found, they will be looked at further.

• Physical Exam:  The transplant team will need to make sure you are healthy enough for transplant surgery, and that a transplant is the best choice for you.  They will examine all your major organs and body parts.

• Compatibility Tests:  The transplant centre will need to know your blood and tissue type in order to match you to a suitable kidney.  A sample of your blood will be taken, and the following tests will be done:

  • Blood Typing:  It is easiest to get a kidney from a donor whose blood type is compatible with yours.  There are four main blood types: A, B, AB, and O. Everyone fits into one of these types.  Although getting a transplant from an incompatible blood type is possible in some cases, it requires additional medical treatment before and after transplant to reduce the risk of organ rejection.  These are known as ABO incompatible kidney transplants.

  • Tissue Typing: This test compares the tissue within your body to the potential donor’s tissue.  A good match means it’s less likely that your body will reject the donor’s kidney.

  • Crossmatching: When a kidney is available, your blood and the blood of the donor's kidney are tested.  With a negative crossmatch, (no reaction) you are "compatible" with the donor. A positive crossmatch (reaction) the kidney will not work for you because it is "incompatible".

Under Indian law, only close relatives can donate their kidneys to patients in need. Buying and selling organs is strictly prohibited and punishable by prison sentences and fines of up to Rs. 25 Lakhs.

When you arrive at the transplant centre, you'll be quickly assessed. Some of the tests you had at your initial assessment may be repeated to ensure no new medical conditions have developed

The kidney transplant procedure involves three main stages:

• First, an incision (cut) is made in your lower abdomen (tummy), through which the donated kidney is put into place. Your own kidneys will usually be left where they are unless they're causing problems such as pain or infection.

• Second, nearby blood vessels are attached to the blood vessels of the donated kidney. This is to provide the donated kidney with the blood supply it needs to function properly.

• Finally, the ureter (the tube that carries urine from the kidney to the bladder) of the donated kidney is connected to your bladder.

When the kidney is properly in place, the incision in your abdomen will be closed with surgical staples, stitches or surgical glue.

Although the procedure may sound relatively straightforward, it's very demanding and complex surgery that usually takes around three hours to complete.

In most cases, the diseased kidneys are not removed because even failed kidneys release chemicals that help your body work.

There are three conditions that might require your diseased kidneys to be removed:

• Repeated infection that could spread to the transplanted kidney

• Uncontrollable hypertension caused by your original kidneys

• Backup of urine into your kidneys (a condition called reflux) 

Hospital recovery for a kidney transplant is usually 5 to 10 days if there are no complications. The length of stay depends on your medical condition and needs. You'll spend 24-48 hours in intensive care immediately after surgery.

The health risks associated with kidney transplant include those associated directly with the surgery itself, rejection of the donor organ and side effects of taking medications (anti-rejection) needed to prevent your body from rejecting the donated kidney.

Kidney transplant surgery carries a risk of significant complications, including:

• Blood clots

• Bleeding

• Leaking from or blockage of the tube (ureter) that links the kidney to the bladder

• Infection

• Failure of the donated kidney

• Rejection of the donated kidney

• An infection or cancer that can be transmitted with the donated kidney

• Death, heart attack and stroke

Most kidney transplant recipients can return to work and other normal activities within three to eight weeks after transplant. No lifting objects weighing more than 10 pounds or exercise other than walking until the wound has healed (usually about six weeks after surgery).

A healthy lifestyle is important for many reasons. Many conditions such as new onset diabetes after transplant (NODAT), high cholesterol, and high blood pressure can be avoided through living a healthy lifestyle. You may be able to return to activities that you gave up because of your illness. Many people return to playing sports, gardening, or hiking. Consult your transplant doctor first before resuming any activity.

You should:

• Return to your normal routines, such as work, school or housework.

• Increase physical activity with regular exercise. Check with your doctor before you start an exercise program.

• Napping and pacing your activities is recommended to prevent placing a strain on your recovery

• Eat a proper diet. A dietician can help you make the right heart healthy food choices for a healthy lifestyle.

• Lose weight, as needed, to reach and maintain a healthy weight. Consult with your dietician and transplant team for a healthy weight loss diet. Fad diets should be avoided. Once you get to your healthy weight you will feel better.

• You can have a normal sex life after transplant, but always remember to practice safe sex as any contracted diseases can be devastating for transplant patients.