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4.2 Preparation for Renal Replacement Therapy (RRT) 4.2.4 Exploring Transplant Options A minority of patients with planned entry onto RRT can avoid dialysis by 'pre-emptive' transplantation. The timing of cadaveric transplantation cannot be planned so receiving a kidney before the need for dialysis is usually most practically achieved by live donation. For the majority, however, live donation is not an option and cadaver transplantation usually takes place after a variable time on maintenance dialysis. The demand for renal transplantation in the UK now exceeds 50 pmp. Unfortunately, transplant activity is severely limited by the number of kidneys available to around 30 pmp per year (ref.6). Patient enthusiasm for transplantation must be tempered by discussion of the risks associated with surgery, chronic immunosuppression and the rejection process. Pre dialysis education should provide an honest appraisal of the chances of receiving a transplant particularly in the elderly. Screening for potential renal transplant recipients is a time consuming multidisciplinary process involving medical and surgical assessment, histocompatibility testing and radiological investigation. The 1999 Royal College of Surgeons Working Party report on Organ Transplantation identified a number of problems, including a shortage of transplant surgeons, falling organ donor rates and the lack of a national strategy for effective delivery of the service (ref.69). Currently there are around 28 renal transplant units in the UK and it is generally accepted there is a need for rationalisation to around 20 larger units. The Department of Health recently published plans to modernise transplant services (ref.70) . The UK Transplant Support Services Authority (UKTSSA), established since 1991 was re-named UK Transplant (UKT) in July 2000. It has a new Board, Chief Executive and new responsibilities. UK Transplant plans to orchestrate a national strategy for transplant co-ordinators with the aim of maximising organ donor numbers. The Department of Health is currently developing a commissioning framework for renal transplantation services which is likely to lead to rationalisation of the number of transplant units and an agenda to ensure equitable access to transplant organs for all ESRF patients who are deemed suitable. The use of kidneys from living donors for transplantation finds its most important justification in the existing shortage of organs from cadaver donors. A second justification is that recipients have better graft survival and quality of life when organs from living donors are used. It has been suggested that transplant rates can be increased by using donors with non beating hearts. Potential donors are those who have a permanent circulatory arrest either occurring in the intensive care unit or shortly after their admission to an emergency service. The kidneys are cooled while still in the patient using special catheters. If cooling can be achieved within 45 minutes of the arrest the kidneys can be used for transplantation. Additional guidance on the use of non-heart beating donors would be helpful. Also, the issue of elective ventilation needs to be resolved. If transplant centres are to be reduced and the number of autonomous renal units (nephrology and dialysis) continues to rise (currently 70) it is important that the profile of transplantation does not diminish in non-transplanting centres. This is best achieved by transplant surgeons, physicians and co-ordinators carrying out regular clinics in the autonomous centres.  |