For most people whose kidneys have failed, a kidney transplant is the best treatment. While dialysis – haemodialysis or peritoneal – allows a person with kidney failure to live with fairly satisfactory health, it has certain limitations, as well as long-term complications.

Dialysis does a good job at removing waste products and excess fluids from the blood, but it is not a perfect replacement for a functioning kidney. Those undergoing this procedure are still vulnerable to chronic complications such as anaemia, renal bone disease, heart disease, and stroke, among others.

They will also face rather strict limitations in terms of lifestyle, especially work and travel, as dialysis needs to be frequently carried out with specialised medical equipment.

Those undergoing haemodialysis need to go to a centre three times a week for about four hours each time.

Those on peritoneal dialysis need to perform the procedure four times a day, for 30 to 40 minutes each time in the case of continuous ambulatory dialysis, or once a day – usually during bedtime – for eight to 10 hours with automated dialysis.

In terms of survival, only about half of dialysis patients are still alive five years after starting treatment. In comparison, around 80-90% of patients who receive a donated kidney are still alive five years after their procedure.

Their quality of life is also better as they need not be tied down by the dialysis timetable, although they will need to be on immunosuppressant (anti-rejection) medications for life.

Also significantly reduced are the risks of chronic health complications, while younger patients could see a reversal of the infertility caused by kidney failure, and be able to have children naturally.

A patient whose kidney is failing should consider a pre-emptive transplant – that is, before they even begin dialysis. The longer he or she is on dialysis, the more complications they could develop, leading to lower benefits from the transplant.

Nevertheless, a transplant still has far better results even if performed after the patient has already begun dialysis.

Types of kidney donors

For a kidney transplant, there are two types of donors: living and deceased. In Malaysia, living donors must offer their kidney voluntarily and must also be related to the recipient. Living donors comprise, by far, the majority of kidney donors in the country.

Deceased donors, meanwhile, are usually registered organ donors who, as a result of vehicular accidents, would have sustained severe enough head injuries to be considered brain dead but still possess functioning kidneys.

While no surgical procedure is without risks, the advantage of a living-kidney transplant is that it is an elective procedure. This means there is plenty of time for the healthcare team, patient and donor to plan and prepare for the operation.

The risks are not as serious as a heart bypass, but not as simple as an appendectomy. The average hospital stay for the recipient after the procedure is seven to 10 days, while the donor usually gets to go home sooner, generally after three days.

Nowadays, the standard of care for donor surgery is minimally invasive laparoscopic surgery.

In living-kidney donations, the recipient is more likely to require a lower dosage of immunosuppressant medications as they would share a certain amount of genetic material with their donor, thus decreasing the chances of the organ being rejected by the body.

The kidney also tends to function well for longer, as donors would first be evaluated to ensure they are healthy enough to undergo the procedure.

When a kidney from a deceased donor becomes available, there is a “golden” period of 24 hours to complete the transplant. This includes time to identify the recipient and for them to come forward, as well as for both the recipient and healthcare team to complete all necessary preparations for the operation.

The donated kidney might also not be in an ideal condition as deceased donors would likely have been in an accident. The lack of shared genes also means the recipient will probably require a higher dosage of immunosuppressant medications.

Nevertheless, the recipient of a deceased-donor kidney transplant would have better long-term survival compared with those on long-term dialysis.

Myths and misconceptions

• ‘Being on immunosuppressant therapy will make me fall sick all the time’

Your doctor is responsible for adjusting the dosage of medications to ensure the best balance between preventing your immune system from rejecting the donated kidney and being strong enough to fight off infections.

Advancements in testing have allowed doctors to closely monitor the amount of the drugs needed and to personalise the treatment.

• ‘After transplant, I will someday be able to stop taking immunosuppressant therapy’

The dosage of the medication might be reduced, but you can never stop taking your anti-rejection medications. Your immune system might still be able to recognise and reject your kidney as a “foreign” object even decades after the transplant.

• ‘Both the donor’s and recipient’s blood groups have to be the same’

Blood group- or ABO-incompatible kidney transplants have been performed in Malaysia since 2011. The recipient only has to undergo extra procedures – namely plasma exchange or immunoadsorption – prior to the transplant to ensure any antigens they might have against the donor’s blood group are removed.

• ‘Certain religions prohibit the donation of organs after death’

All religions allow the donation of organs, as evidenced by the multiple engagement sessions doctors have had with various religious leaders in Malaysia.

• ‘I can go back to my normal lifestyle after my transplant’

While your diet will certainly not be as restricted as when on dialysis, you still need to eat – and live – healthily to ensure your donated kidney works well. A nutritionist or dietician will be able to provide the best recommendations.

• ‘As a donor, my part is over after the transplant’

It is important for the donor to continue seeing the doctor at least once a year for a medical checkup, even if they feel perfectly healthy.

This is to detect and tackle any medical issues – such as high blood pressure, diabetes, or protein in the urine – early on, given that they only have one functioning kidney.

Assoc Prof Dr Lim Soo Kun is the consultant nephrologist and head of the Renal Division in the Department of Medicine, University of Malaya.