While kidney transplantation has been around for several decades, the notable milestone is still a challenge today. As the surgery is an intricate one, only surgeons who are well-versed can perform it. However, once a success, the patient receiving the kidney can live a normal life again.
An intricate process that has benefitted many
The medical field has come a long way since ancient times. Through civilisation and the innovation of modern technology, numerous scientific breakthroughs have paved the way for many successful milestones.
One such notable milestone happened in the late 19th century when the first successful skin transplant was performed by the renowned Swiss surgeon Jacques-Louis Reverdin. His work paved the way for the first successful skin graft, which was performed in Denmark in 1870.
Further progress in the medical field was done in the middle of the 20th century when the first solid organ transplantation happened. A major milestone occurred in 1954 when the first successful kidney transplant (from one identical twin to another) was performed by Dr Joseph E. Murray in Boston, Massachusetts.
Such a breakthrough has paved the way for doctors, leading towards advancement in the field which has benefitted many. From the initial stage of organ transplantation, much research and fieldwork have been done in the past decades to ensure the future of medicine.
Despite the advancements, the procedure is still a challenge due to its intricacy. Hence, only surgeons who are well-versed in the technique can conduct the operation. Speaking to consultant nephrologist, Dr Yew Shiong Shiong and consultant urologist, Dr Koh Eng Thye on the topic, the New Sarawak Tribune managed to get an in-depth look into this complex operation.
Consultant Urologist, Dr Koh Eng Thye. 
Consultant Nephrologist, Dr Yew Shiong Shiong.
Why the need for kidney transplantation?
The human body relies on each internal organ to function. However, there comes a time when we experience organ failure, thus needing immediate medical attention. Often, we hear of patients diagnosed with end-stage kidney failure, where the kidneys can no longer function on their own. But without a kidney transplant, other medical treatment options are made available.
According to consultant nephrologist, Dr Yew, these patients will have to undergo long-term dialysis, either haemodialysis or peritoneal dialysis. “Haemodialysis is the process of removing toxins and excess water from the blood by circulating a patient’s blood through a haemodialysis machine. This haemodialysis process usually needs to be performed three times weekly, each time over four hours.”
Meanwhile, Dr Yew explained that peritoneal dialysis worked the same as haemodialysis, but used a different method. “By filling up a special peritoneal dialysis fluid into the patient’s peritoneal space (cavity inside the abdomen), leaving it for six hours before draining. Simultaneously, re-infusing a new bag of peritoneal dialysis fluid. This procedure usually needs to be done four times a day and each exchange may take around 30 minutes.”
Though the treatment options are made available, Dr Yew emphasised that these methods were not completely compatible with life as there might be pitfalls along the way. “At times, certain toxins are not cleared completely by the above methods. Furthermore, many other functions of a normal kidney are not addressed, causing the patient to struggle with anaemia, bone weaknesses and a lot of dietary restrictions.”
But with successful kidney transplantation, the patient would have a fully functional and biological kidney implanted into their body, he said. “The newly planted kidneys will be able to perform all the original duties of a kidney. This gives them freedom in terms of diet and grants them better health and physical ability.“
“Nevertheless, all kidney transplant patients need to continue long-term follow-up and take medications to prevent rejection of the organs because the transplanted kidneys do have a different genetic origin and the recipient of the organs may reject the organs if the immune system mistakes the ‘new’ organs as unwanted visitors to the body,” he added.
A second chance in life
With kidney transplantation, it is as though the patient receives a second chance in life. Though not all end-stage kidney failure patients could receive it. Dr Yew said that if a patient was too frail to undergo such a procedure, or if he/she refused, then he/she would be excluded from the national kidney transplantation waiting list.
In Malaysia, there are two ways a person can donate his/her kidneys. The first method is to pledge as an organ donor with the Malaysian National Organ Donor Registry. When the pledger passes on, his or her organs, including the kidneys, can be harvested and transplanted according to the national organ transplant waiting list.
The other method is to donate as a living kidney donor. “This means the donor will first have to undergo stringent medical examinations and ensure that the person is healthy and fit to undergo nephrectomy (surgery to remove one of the kidneys), with reassurance that the donor will remain healthy with the remaining kidney for the rest of his/her life,” said Dr Yew.
A complicated surgery
The nature of kidney transplantation is to retrieve one kidney from a perfectly healthy person, and the specialist must ascertain the success of such a kidney when transplanted into another person. Sharing insight into the complicated surgery, consultant urologist, Dr Koh Eng Thye, emphasised that the two operations required meticulous planning and it was of paramount importance to safeguard the safety of both patients.
“It involves prolonged training and exposure in the field of kidney transplantation. A successful kidney transplant programme in any institution should entail a track record of good outcomes.” He also said that in Malaysia, surgeons who could conduct the surgery were rare.
Nonetheless, with the experience he has accumulated since the late 90s, Dr Koh has done numerous kidney transplant surgeries.
I spent 15 months in Australia, working in a highly sought after kidney transplantation centre. After returning to Malaysia, I have been doing kidney transplantation for both adults and children in Kuala Lumpur Hospital and also various accredited private hospitals.”
According to him, each kidney transplantation surgery requires two teams — the donor retrieval team and the kidney recipient team. At present, there are two methods of conducting the operation — sequentially and concurrently. “However, in Malaysia, we are only allowed to practise concurrent method. This system requires two transplant surgeons and involves two operating theatres simultaneously, “ disclosed Dr Koh.
Before the operation, there will be a detailed discussion meeting of the transplant cases in a few weeks. With intense scrutiny on the operation, Dr Koh said the multidisciplinary team meeting (MDT) involved staff and specialised doctors for the case.
“All possible problems and complications that may be encountered will be discussed. Radiologists who are involved in the case are required to present any possible anatomical abnormality that may be encountered during the surgery.
“Hence, on the day of the surgery, all possible problems and complications will have been noted and the necessary measures are being done so that the retrieved kidney works immediately upon the surgery,” he added.
The donor surgery usually takes approximately three to four hours. Sharing the details, Dr Koh said it was usually done with keyhole surgery for a faster recovery rate. After being discharged, the donor can resume a normal life without fluid intake restriction.
But the post-operative care for the recipient requires complex management. “After the surgery, the recipient will be placed under ICU care. Intensive fluid management is needed to handle the possible fluid and electrolyte imbalance. “
Dr Koh added that the intensive monitoring done on the recipient was mandatory to avoid organ rejection. “Normally, the kidney function will improve significantly. But the fluid and electrolyte imbalance needs to be corrected aggressively.
“Some patients can produce up to 20 litres of urine per day for the few days after the surgery. If the kidney function, for some reason, fails to improve, immediate steps will be taken to ensure there is no organ rejection despite adequate immunosuppression,” he said.
Post-transplantation
Kidney transplantation offers an improvement as opposed to before. After a successful kidney transplant, the new kidney will be able to filter the blood. To prevent the body from rejecting the donor’s kidney, doctors will provide medications to suppress the immune system.
Aside from regular check-ups, the recipients will have to discuss with the dietician their nutrition and diet to maintain a healthy lifestyle. Exercising and physical activity should also be part of the recipients’ life to continue improving physically and mentally.
