Kidney Transplant Programme

No. Patients who are undergoing dialysis rely on dialysis machines to help filter wastes from the body. For haemodialysis, dialysis is only performed for about 12 hours per week, or peritoneal dialysis at around 10 hours per day. As a result, it may only be able to remove up to 70% of waste products from the body. Hence patients are required to continue strict fluid and dietary restrictions to prevent excessive waste accumulation.
However, a successfully transplanted kidney functions in a person’s body for 24 hours a day, hence the effectiveness in removing wastes can be similar to a person who does not have any kidney failure. After a successful transplant, patient will:

No longer require dialysis

Have a chance at a longer life-span

Experience an improved quality of life such as travelling, sports, return to education and/or employment

Increase their chances of having successful pregnancies; and be able to avoid the complications associated with long-term dialysis such as heart disease and nerve damage.

You can undergo a kidney transplant when you:

• Suffer from end-stage kidney failure, and already, or will soon require dialysis in order to maintain life and remain healthy
• Have been assessed by your doctor to be medically and psychologically fit to undergo transplantation.

Have a kidney available from a deceased or living donor for transplantation.

You can undergo a pre-emptive living kidney transplant when your kidneys are close to failure, before dialysis must be initiated. If a pre-emptive transplant is not possible for you, you can start dialysis while waiting for kidney transplantation.

Kidney transplantation is a major surgery conducted under general anaesthesia. During the surgery, a cut will be made in the lower part of the abdomen to place the donor kidney(s) into the patient’s body. The blood vessels from the donor kidney(s) are then connected to the patient’s blood vessels that supply blood to the legs. The ureter from the donor kidney(s) is/are connected to the bladder.

The patient’s own kidneys will not be removed unless there is a specific reason requiring such removal, such as an infection, or if it is necessary to make room for the new kidney(s) to be placed into the body. Besides the surgical operation, other tubes may be inserted for various purposes such as a central venous pressure (CVP) catheter into the vein of the neck to allow monitoring of fluid balance and the administration of fluids or medication, a urinary catheter into the bladder to monitor urine production, and a tube to drain fluid and blood from the operation site.

Finally, a small plastic tube (called a stent) is usually inserted into the connection between the ureter and bladder. This is removed 2 to 4 weeks after the transplant by an outpatient procedure called a cystoscopy under local anaesthesia.

Kidney transplant surgery has no higher risk than other major surgery. However, as with all surgical procedures, complications can occur. The risk of death is less than 1%. Other possible risks of surgery include reactions to anesthetic drug, blood clots, rejection of new kidney, bleeding and infection. It is our priority in ensuring patient’s safety and reducing these risks.

After completion of the transplant surgery, the patient generally stays in the hospital for one week. Some patients may require dialysis for a period of time if the newly transplanted kidney does not work immediately. Prior to your discharge, you will be counselled and educated on various aspects of caring for you and your newly transplanted kidney. Upon discharge, it is extremely important that you take the medication as prescribed, undergo the tests that are ordered for you and attend your appointments with your doctor or transplant coordinator.

Patients who do not have a living donor can be registered on the National Transplant Registry System (NTRS) if he/she fulfils the eligibility criteria to receive a DDKT.

Your kidney doctor will recommend registration on NTRS if you are medially eligible and willing. You are also encouraged to initiate and check with your doctor on your suitability for registration. A referral will be sent to the transplant team; after which you will be contacted by transplant coordinators to proceed with further screening tests to confirm your eligibility for registration.

These tests may include:

• Metabolic screening
• Cardiovascular screening
• Infectious disease screening
• Cancer screening

The criteria to be placed on the waiting list are stricter than the criteria to receive a living kidney donor transplant. This is because patients need to remain healthy and ready at any time to undergo kidney transplant surgery after a longer wait time. Patients who are NOT suitable to be placed on the waiting list include those with:

• Poor heart function
• History of stroke
• Active untreated infection
• History of untreated or treated cancers (except small kidney cancers that have been removed)
• Ongoing psychiatric illness or drug addiction
• Severely obese patients (body mass index 35 kg/m2 or more) who are unable to lose weight to decrease their BMI to < 35
• Any other organ disease which is likely to worsen while waiting for a kidney transplant or increase the risk of a poor outcome after kidney transplantation

One may develop complications while on dialysis that may render them unfit to receive a kidney transplant. Some complications like infections can be treated but require a temporary suspension on the waiting list. During this period, one will not be called for DDKT even if there is a suitable donor available. If one remains medically eligible, they will no longer be suspended once the complications are treated adequately. A suspension does not increase the waiting time as wait time starts from your date of first dialysis. However, some complications may result in a permanent ineligibility remain on the wait-list to receive a DDKT. Hence, one would need to remain on dialysis if a living kidney transplant is not available.

Yes. LDKT is considered the best treatment option for patients with kidney disease because it offers better transplant outcomes. Kidney from living donors usually last longer than deceased donor’s kidney(s).
The waiting time for patients to proceed with LDKT versus DDKT is also significantly different. The average time to complete a LDKT is 6 months while on average, patients may have to wait for 9 years or more until a DDKT is available.

You will need to take long term medications (anti-rejection drugs) to suppress the immune system and be monitored routinely by the medical team after transplant. For best outcomes for you and the kidney, you will be advised to live a healthy lifestyle. The transplant team will provide step-by-step guidance as you embark on your new life with a kidney transplant.
At our hospital, the patient survival rates following a living and deceased kidney transplant at 1 year are 99.1% and 96.7%, as compared to 90.6% for patients on dialysis. Likelihood of transplanted kidneys functioning at 1 year exceed 98% and 89% for living and deceased donor kidney transplants respectively.

Before you return home, the ward clerk would have arranged for your follow-up appointment to see your kidney specialist. In the first year after transplant, you will need to attend frequent clinic visits so that your kidney specialist can review your tests results, adjust your medications and monitor for signs and symptoms of rejection and infection.

A typical schedule of outpatient clinic reviews:

• For the first 3 months – 1-2 times a week
• 4th to 5th month – Every 2 - 3 weeks
• 6th to 9th month – Every 4 weeks
• 10th to 12th month – Every 2 months
• After the 1st year – Every 3 months

However, patients with complications may require more frequent reviews.

The Importance of Clinic Reviews

Clinic reviews can be long and tiring. Depending on the complexity of their condition, some patients may require a longer time in the clinic. Therefore, appointment times may not take place according to schedule or sequence. We seek your understanding and patience in this matter. Clinic reviews are very important for the long-term success of your kidney transplant. Make sure you attend every visit.

Blood and urine tests

Your blood and urine tests should be done at least 1 – 3 days before the clinic visit for timely processing of tests. This is done at the Transplant Center (Singapore General Hospital Block 7, level 1) or Specialist Outpatient Clinic Laboratory (Singapore General Hospital Block 3, level 1).

Bring along the laboratory request forms given to you in the ward and hand these to the laboratory technician.

Avoid doing your tests on the day of your clinic appointment as the results may not be ready for the kidney specialist to review.

Remember to bring your medications when you get your blood tests done. Some tests, such as those testing for immunosuppressive drug levels (e.g. Prograf), will require bloods to be drawn before the morning dose of medication. Take your medications once these tests are drawn and do not omit your medications.

Bringing the Right Items

Your kidney specialist will need to see these at the clinic review:

Your medicines

A list of the medicines you are supposed to take

Monitoring book issued by transplant coordinators (i.e. records of your weight, blood pressure, heart rate, intake, output and blood sugar level if you are diabetic)

Virus screening file issued by transplant coordinator

A mask to wear while you are in hospital

A snack and drink in case you are hungry and thirsty

Being Punctual

Please come at least one hour before your appointment as you will need to register and be counseled by the transplant coordinator before seeing the doctor.

Meeting the Professionals

After registering with the clinic receptionist, a transplant coordinator will review your home records and counsel you on post-transplant care.

The transplant pharmacist may see you especially if you have just received a transplant or are receiving complex treatment or are participating in a research study. He/She will check your laboratory results and medications so that recommendations on the doses of your medications can be made to your kidney specialist.

When you see your kidney specialist, please clarify your concerns and the management plan. In particular, you should understand what adjustments are being made to your drug therapy.

After Your Visit

After the review by the kidney specialist, you should obtain your next clinic appointment, laboratory forms and prescription slip from the clinic assistant. Please check that you have these items before leaving the clinic. Talk to the transplant pharmacist if you need to carrageen medication delivery service.

Blood Testing without a Visit

Sometimes, you may be asked to do tests without the need to see the doctor. You may find out the results of those tests by asking the transplant coordinator who will advise you on follow-up actions after discussion with your doctor.

In order for your kidney transplant to be successful, you will need to take a combination of medications. There are two important groups of medications:

Immunosuppressive drugs which prevent rejection of the transplanted kidney, and
Prophylaxis (antibiotics and anti-viral drugs) to prevent infections.

It is important to take these medications every day, according to your doctor’s instructions.

Immunosuppressive Drugs (Anti-rejection drugs)

The immune system comprises of cells and proteins (antibodies) that help us fight off infections from foreign microorganisms (bacteria/viruses/fungi).

However, the transplanted kidney is also recognized by the immune system as an object foreign to the body. If unchecked, the implanted kidney will be attacked and destroyed by the immune system in a process termed “rejection”.

Fortunately, the use of immunosuppressive drugs has allowed us to put the immune system into a partial sleep, thereby dampening the immune system’s response to allow a transplant to take place. These immunosuppressive drugs prevent the body from rejecting the kidney.

If you stop taking your immunosuppressive drugs, the immune system will wake up and attack your kidney transplant. Rejections may be severe enough for you to go back on dialysis due to kidney failure or die. It is therefore important to take your immunosuppressive drugs every day.

Special instructions on taking immunosuppressive drugs

• Immunosuppressive drugs must be taken every day at the right dose and at the right time.
• Do not miss any doses. If a dose is missed, take it as soon as you can remember.
• However, if the medication has been delayed for more than 8 hours, skip the missed dose and resume your regular dosing schedule. Do not take 2 doses to make up for the missed dose. You should inform the transplant coordinator as you may need to have blood levels of the immunosuppressive drug checked.
• Some patients are on Diltiazem to help increase the blood levels of immunosuppressive drugs. Do not miss your Diltiazem or blood levels of immunosuppressive drugs will fall and may cause rejection.
• Do not take any other medications (including traditional medications) or health supplements on your own. Consult your kidney specialist, pharmacist, dietitian or transplant coordinator for further advice.
• If you are seeing other doctors (e.g. general practitioner), inform them that you are a kidney transplant recipient and the medications you are taking to prevent administration of conflicting drugs.
• Inform your transplant coordinator if you are not able to consume your immunosuppressive drugs e.g. vomiting or medication supply running out.
• Keep medications out of reach of children and pets.
• For patients planning to get pregnant or have discovered that they are pregnant, inform the kidney specialist or transplant coordinator as soon as possible. Some immunosuppressive drugs have harmful effects on the developing fetus and may need to be stopped or replaced. Discuss pregnancy planning with your kidney specialist.
• It is important to have regular blood tests, including those to measure blood levels of immunosuppressive drugs before you see your kidney specialist. These tests will help the doctor decide the most appropriate dose of immunosuppressive drugs for you.

Prophylaxis Drugs

Because immunosuppressive drugs dampen the immune system’s response, transplant patient are vulnerable to infections. Your kidney specialist will put you on medications to try to prevent infections (prophylaxis).

These medications include:

Co-Trimoxazole (Bactrim)

Valganciclovir

Valacyclovir

Take your prophylaxis drugs as prescribed and do not omit them – this would help keep you safe from infections.

Depending on the test you are going for, take note of the remarks

• FK 506 ( Tacrolimus) Trough - 0 hour (test to be done before morning dose medication). Take medications after blood test.
• Cyclosporine A Trough - 0 hour (test to be done before morning dose medication). Take medications after blood test.
• Cyclosporine A Peak - 2 hours (test to be done 2 hours after taking morning dose medication )
• Mycophenolic Acid Trough - 0 hour (test to be done before morning dose medication). Take medications after blood test.
• Everolimus Trough - 0 hour (test to be done before morning dose medication). Take medications after blood test.
• Sirolimus Trough - 0 hour (test to be done before morning dose medication). Take medications after blood test.

Before your kidney transplant, you were restricted to certain types of foods and drinks because of your kidney disease. However, this changes after transplant.

Before discharge, a dietitian will advise you of a nutritional plan. This plan will be tailored to your eating habits, weight, laboratory tests, kidney function and medications.

To promote healing after transplant surgery, you should eat adequate protein-rich foods such as lean meat, poultry, fish, eggs, milk, beans and legumes, and its products. You should also include a variety of grains, fruits and vegetables for adequate calories, vitamins and minerals.

Fad diets, diet supplements and herbal products should be avoided.

Find out more about eating well after kidney transplant here >

Before Transplant

Renal failure and dialysis can affect the renal patient’s physical function.

Before transplantation, there is a window of opportunity to increase the success rate of their renal transplantation through prehabilitation.

If the doctor assesses a patient to be frail or to have problems with mobility, they may require an assessment by a physiotherapist. The physiotherapist will work closely with the patient to prescribe an individualized exercise programme to improve their function to help with their recovery after surgery.

Post-transplant

During the immediate post-surgical period, you may feel tired easily, loss of appetite, swelling around the ankles and legs, difficulty in breathing and shortness of breath which could lead to physical inactivity. In addition, side effects of medications such as steroids may include weight gain, osteoporosis (loss of bone mass/decrease bone strength) and sarcopenia (loss of muscle mass).

Physical activity is important to mitigate many of these risk factors - if left untreated, this can lead to strokes and heart attacks.

Find out more about Physiotherapy Before and After Kidney Transplant here>

Now that you have gathered more information about kidney transplantation and donation, we hope to guide you through some actions that can help you decide on your preferred treatment option. If you have kidney failure,

• Apart from the medical team, think about who you want to discuss your treatment options with
• Discuss your medical condition and treatment options available with your family and loved ones
• Speak to a kidney transplant coordinator to find out more

If you are a family member or a friend of someone who has kidney failure,

• Discuss the treatment option available
• Motivate your loved one to pursue kidney transplantation
• Share the information about kidney transplantation to with other family members, friends or social networks of your loved one. A potential donor may step forward by doing so.
• Speak to a kidney transplant coordinator to find out more about kidney transplantation and/or donation

Here are some of the resources to aid patients with their kidney transplant journey:

Live On: Support Organ Donation

Live On is a webpage maintained by the National Organ Transplant Unit that provides education and support on organ transplantation in Singapore.

Calculator

• Body Mass Index (BMI) for Adults

You can refer to our leaflets here:

• COVID-19 Advisory for Transplant Patients
• COVID-19 Patient Advisory Booklet (English)
• COVID-19 Patient Advisory Booklet (Chinese)

After your transplant, you will be given medications to suppress the immune system - these medicines are critical to prevent your body from rejecting (fighting) the transplanted kidney. However, body's immune system not only defends the body from infections, it also helps prevent cancer. Abnormal cells are constantly being produced in our bodies - they are identified by our immune system and destroyed. The suppression of the immune system compromises this clearance of abnormal cells and puts transplant recipients at higher risk for development of certain cancers.

Cancer is a common problem in Singapore with 1 in 4 people developing cancer in their lifetime even without a transplant. Colorectal, lung and breast cancer are the commonest cancers diagnosed*.

Transplant recipients are at particularly high risk of cancers of the skin, lymph nodes and cervix (neck of the womb) compared to people without a transplant. Whilst cancer is treatable if detected early, cancer is among the top 3 causes of death in transplant recipients and we should be vigilant.

Prevention

Some cancers can be prevented with vaccinations such as Human Papilloma virus (HPV) vaccinations for cervical cancer and hepatitis B vaccinations for liver cancer. Other cancers can be prevented with treatment of underlying causes - for example treatment and eradication of hepatitis C virus would prevent hepatitis C mediated liver cancer. The risk of cancer developing can be mitigated by reducing exposure to cancer-causing agents such as smoking, tobacco chewing or excessive sunlight exposure.

Diagnosis

It is essential to detect cancers in the early stages in order to implement timely treatment for better outcomes. During your follow-up visits, you will be actively screened for cancer with annual ultrasound of the abdomen, stool testing for blood, mammograms and pap smears as appropriate. The intensiveness and type of screening will also depend on each person’s medical condition as assessed by his/her doctor. All transplant recipients are encouraged to examine their skin for worrisome lesions at least once a month (e.g. unusual moles, spots, rashes, nonhealing ulcers) and to practice sun protection measures such as application of sunscreen (SFP 50), avoiding prolonged sun exposure and wearing protective clothing. Early detection of breast cancer is helped by self-examination of the breasts for any new lumps or skin changes.

Treatment

If cancer is diagnosed, you will receive appropriate anti-cancer treatment. In the course of treatment, the anti-rejection medications will be adjusted to allow the immune system to fight off the cancer. Some types of cancers e.g. blood cancers, may go away if the anti-rejection medications are stopped. However once these anti-rejection medications are stopped, there is a risk of rejection of the transplant although this is not always the case. Your nephrologist and oncologist will individualize the balance of anti-rejection medications and cancer treatment with you. *Singapore Cancer Registry 50th Anniversary Monograph 1968-2017

Infections are diseases caused when microorganisms such as viruses, bacteria, or fungi invade the human body.

Infections can occur when germs are passed onto a person from another person (e.g. cough droplets), animals or the environment (e.g. soil, water, the food we eat). Infections may also occur when germs that are usually in our own body get out of control or reactivate.

Common infections that can develop in kidney transplant recipients include infection of the lungs (pneumonia), urine (urinary tract infection), food poisoning (gastroenteritis) and soft tissues. Kidney transplant recipients may also acquire unusual infections that do not usually affect healthy people (opportunistic infections).

Because of the kidney disease and anti-rejection medications which suppress the immune system, kidney transplant recipients are more susceptible to infections and are at risk of developing more severe or complicated infections.

Infections can cause symptoms such as fever, breathlessness, diarrhea and serious complications such as organ injury (e.g., kidney, lung) and even death. Therefore, it is important for kidney transplant recipients to learn how to recognize infections and take steps to prevent them.

The signs and symptoms of infection depend on the type and severity of infection. In general, they may include:

• Fever (>37.5 degrees Celsius), chills, shivers
• Malaise, lethargy
• For respiratory tract infections
• Cough
• Sputum
• Shortness of breath
• Chest discomfort
• For gastrointestinal infections
• Diarrhea (sudden onset, >2 episodes of loose, watery stools)
• Nausea, vomiting
• Stomach pain or discomfort
• For skin, soft tissue infection
• Redness, pain or discharge over skin or wound
• Rashes
• For urinary tract infection:
• Cloudy, discolored or foul-smelling urine
• Pain, burning sensation or increased frequency with urination
• Pain or discomfort over the transplanted kidney
• Blood in urine

If you are unwell, please speak to our Transplant Coordinator for advice. Depending on the situation, you may be advised to seek medical attention from a general practitioner, to see us in clinic, be admitted into hospital or to present at the Emergency Department. Many infections are contagious and can be dangerous for your fellow transplant recipients. Therefore, you should avoid walking into the Transplant Center without prior arrangement.

Healthy lifestyle

• Take a healthy balanced diet as recommended by our dieticians
• Exercise regularly as recommended by our physiotherapists
• Drink adequate fluids as discussed with your doctor
• Get adequate rest and sleep

Safe practices & personal hygiene

• Avoid crowded places
• Wear a face mask when in public
• Avoid close contact with people who are sick
• Wash your hands frequently with water and soap or other cleansing solutions
• Wear gloves when coming in contact with soil / gardening
• Avoid high risk behavior such as casual sex, using drugs of abuse

Food safety (to prevent intestinal infections)

• Avoid raw or partially cooked food (e.g. salad, sushi, soft-boiled eggs)
• Avoid food that have been left overnight or out in the open
• Eat freshly peeled fruits (instead of cut fruits left in the fridge for some time)
• Avoid food that may have been prepared in an unhygienic fashion (e.g. unlicensed street-side store)

Preventing urinary tract infections

• Avoid holding your urine
• Drink adequate fluids
• Pass urine after sexual intercourse
• For women
• Wipe from front to back when cleaning your private area
• After menopause, if your private area feels persistently dry or itchy, you may have vaginal dryness which can increase your risk of urinary tract infections. Discuss with your doctor for the necessary treatment.

Medications

• Kidney transplant recipients usually receive medications that help them prevent infections especially within the first 3-6 months after transplant
• It is important that you take these medications as prescribed to help you prevent infections. If you have any issues with the medications, please discuss with your doctor.

Vaccinations

• Kidney transplant recipients are recommended to receive vaccinations ideally before and regularly after transplant.
• In general, vaccinations are only administered when you are stable about 6 months to 1 year after your transplant.
• Vaccines “train” your immune system to remember how to fight certain infections the next time it is exposed to the germ
• Common vaccinations include
• Influenza vaccine – administered annually
• Pneumococcal vaccine – in general 2 doses, spaced 8 weeks apart
• Other vaccinations that may be recommended by your doctor include vaccines for hepatitis viruses, tetanus/diphtheria/pertussis, meningococcus, Hemophilus depending on your condition
• However, some vaccinations (such as vaccines which are composed of live viruses) may not be suitable kidney transplant recipients
• Vaccinations will not be able to prevent all infections. Therefore, good personal hygiene and infection prevention measures remain important

These restrictions may cause inconveniences and impede your newfound freedom and independence after being dialysis-free. However, it is important to prevent infection in an immunocompromised state to maintain your health and avoid complications.