Diabetes is now the leading cause of kidney failure and a leading indication for kidney transplantation. Alan Reed, MD,  director of the Division of Transplant Surgery in the UI Department of Surgery at University of Iowa Hospitals and Clinics and head a multidisciplinary center for abdominal organ transplantation and hepato-biliary surgery, talks about kidney transplantation:

What are the treatment options for kidney failure?

People with kidney failure have options. One option is to go on dialysis. Dialysis is a way to, in layman’s terms, clean the blood of the toxins that the kidney otherwise would, and there are various ways to do this.

The other alternative to dialysis is organ transplantation and for lots of reasons, that’s usually the preferred option for patients. It’s preferred because it improves the patient’s quality of life; it improves their ability to get around, to go to work, to raise a family – whatever the things they like to do. But most importantly, and there’s good medical data to support this, kidney transplantation is life extending. When you compare transplanted patients to those that are on dialysis, transplanted patients in general have a longer length of life.

Is there more than one type of kidney transplant option?

There are, and mostly it’s determined by the source of the kidney. The operation itself is relatively the same but you can get a kidney from the deceased donor list (that’s what we used to call cadaveric donors). That’s where you go on a list and wait anywhere from two to four years and somebody dies and their family donates a kidney. But the preferred option is a live donor kidney. That’s when somebody amongst your family or friends wants to donate a kidney to you. It can be done much more quickly and the results are much longer lasting. Patients usually do better with a live donor kidney.

Specifically for diabetics, sometimes we can add a pancreas into the mix, also from the deceased donor list, so that the patient gets transplanted both a kidney and a pancreas, which deals both with their renal failure and some aspects of their diabetes.

How many people are currently on the list for kidney transplantations in the state?” The region? Nationally?

There are some 360 patients just in Iowa alone who are waiting for a kidney transplant, and that’s only a very small fraction of the 73,000 people who are waiting nationally for a kidney transplant.

How safe is kidney transplantation?

Everything is comparative and you have to weigh the risks and benefits of the operation and the medicines you need to take afterwards with the risks of not doing the operation, which is staying on dialysis. In the big picture, kidney transplantation is fairly safe among the big lists of transplants. You always have to consider the difference between complications (or what we call morbidity) and mortality (or the chance of dying). The chance of dying from this operation is very, very small – less than one or two percent within the first year. And the risks of the operation are really the short-term risks, and those are easy to understand. Needing to take medicines for the rest of your life is an under appreciated risk. These medicines have potential complications, including development of certain types of cancers and infections. And the patients have to weigh the risks of doing this versus the risks of not doing this. Usually the risks fall in favor of transplantation overall.

Do kidney transplant patients take medications to prevent the new kidney from failing? How long?

Yes, and that’s a great question. If we were just to do a transplant on somebody, that kidney would fail because it’s the body’s immune system’s job to recognize things that are foreign and get rid of them. If we don’t manipulate the immune system some way, we have no chance of having these kidneys have lasting value. So we put these patients on medications that are designed to lower the body’s immune system, in fact they’re called immunosuppressive medications, in order for the kidney to function. Now unfortunately these medicines have side-effects, and we can’t turn the body’s immune system off just to the kidney. These patients need to take these medicines for the life of their kidney transplant and have to be very vigilant about keeping on top of their doses and any complications that can occur so that we can address those issues quickly.

Will the transplanted kidney cure the recipient’s diabetes?

No, it doesn’t cure their diabetes. It will get them off dialysis, it will make them feel better, it will extend their life. If we want to treat diabetes, we need to transplant a pancreas with the kidney. Transplanting a pancreas, which is usually done off the deceased donor list (or the kind where somebody dies and donates their organs) can address some features of the diabetes. For instance, diabetes can cause problems with the nerves in the legs. It can cause problems with blood vessels that go to the lower extremities, also. It can cause heart disease, problems with vision, and there’s some good data to suggest that transplanting a pancreas might either halt the progression of these or actually reverse them in some instances. And while this does not truly cure diabetes, these patients no longer require insulin and if these end organ complications can improve, I think the patients experience an overall improvement in their wellbeing. But the truth of the matter is the kidney turns out to be the important organ in terms of extending their lives.

Will the transplanted kidney or pancreas last the life of the new host’s body?

Unfortunately, not; it would be wonderful if we could achieve that. When we talk about how long organs last, we talk about half-lives. A nice way to think about that is if you took 100 people and transplanted them all with the same kidney and the same way. At what point would half of them still be working? If you look at a deceased donor kidney, the half-life is about 10 years. However, compare that to a live donor kidney, one that you get from someone in your family or your friends, the half-life there can be in excess of 20 years. For pancreas transplantation, the half-life is truly unknown. So you can see we can impact people for quite a long period of time. And sometimes their choice in what type of kidney they want to have transplanted, or they can have transplanted, can affect that.

Alan Reed, MD

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