Reclast Attorney: There are a number of special problems which face diabetics if they are going to have a transplanted kidney. First given the shortage of cadaver kidneys, many kidney units adopt a policy of not transplanting patients at higher risk. This is in part to protect you, the patient, from the extra risk of problems after the operation, but is directed in part to making the best use of what kidneys are available. Many diabetics unfortunately fall into the ‘high risk’ category because of heart or blood vessel disease—for example if they have already had a myocardial infarct. Thus, your heart and blood vessels will be examined with especial care and tests done to detect any problems, before a transplant will be considered. The iliac blood vessels to the leg, on to which the transplant is attached may need attention first if they are diseased, or may even prove an impossible barrier to doing a transplant.
In addition diabetics with severe neuropathy may have bladder problems. There is difficulty in emptying the bladder, there is sensation of the bladder being full, and urine left behind acts as a focus for infection. Occasionally it may be necessary for some diabetics to catheterize their bladders regularly to avoid this. Obviously this presents a problem in connecting the new transplanted kidney to the bladder, but you can still have a transplant successfully under these circumstances.
Double pancreas-kidney transplants are slowly increasing in number, as results improve, but this is still to some extent an experimental treatment. The advantage is of course that you no longer have to take insulin, since the new pancreas takes over. Usually the pancreas is connected to the bladder so that the digestive juices produced by the main part of the gland can pass without harm into the urine, whilst the islets which produce insulin can release this into the blood stream.
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There are two ways in which this should change in the near future. The first advance would be to be capable of inducing a tolerance in the recipient to the foreign antigens of the donor kidney. Despite the fact that this has been possible for some years by various routes in experimental animals, we have failed miserably so far in achieving this in human transplantation, although interestingly some living donor kidney recipients seem to become completely tolerant of their relative’s graft, and can stop all immunosuppression. Sadly, this never seems to happen spontaneously with cadaver grafts, even when present for many years, and stopping immunosuppressive drugs altogether always leads to rejection in a matter of weeks or months. The memory of the immune system is very, very good, unfortunately for transplantation, which is not surprising when one considers that exposure to an infection such as measles confers almost lifelong immunity against the disease.
I think it likely that within five to ten years we will be able to ‘re-educate’ the host’s immune system so that it no longer identifies the differences between the donor kidney and ‘self’. This would allow the grafted organ to remain in place indefinitely without any immunosuppressive drugs, whilst the reactions of the body against other foreign antigens, such as those on harmful viruses and germs, would remain intact. Clearly this would be an enormous advantage if it could be achieved.
The second major problem in transplantation is shortage of donor organs. I am not optimistic that any changes in people’s attitudes or the laws of the country will make a major impact on the number of cadaver kidneys available for transplantation, although a modest increase of up to 45/million/year kidneys should be possible in all the developed countries not yet operating at this level—which is all but Austria and Norway. However we need almost twice this number to be able to transplant everyone who could benefit from this approach. In the short term, using more living donors (as the USA and Norway already do) could help those countries not exploiting this source, but this rasies all the social and family problems.
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Doctors monitor kidney function in their patients by measuring substances in the blood and urine using several laboratory tests: blood urea nitrogen (BUN), or just urea, creatinine, creatinine clearance, and glomerular filtration rate (GFR). To perform these tests, your health care provider will draw small amounts of blood and will ask you for a urine sample.
Urea and creatinine in the blood are measures of the main products of protein metabolism. How concentrated these substances are in the blood indicates how effectively your kidneys remove waste products. Normal concentrations of these substances are 15 to 25 mg/dl for BUN and 0.5 to 1.3 mg/dl for creatinine (mg/ dl [milligrams per deciliter] refers to the amount of a substance in a bit more than 3 ounces of blood). Values higher than that range for either measurement mean that kidney function is declining.
A blood urea nitrogen (BUN) test measures the quantity of nitrogen in your blood that comes from the waste product urea. A BUN is performed to see how well your kidneys are functioning. If your kidneys can’t remove urea from the blood, your BUN level will rise.
Measuring creatinine clearance can determine how much creatinine your kidneys remove from your body as well as how well your kidneys are functioning. Creatinine clearance is a more precise measure of kidney function than relying on blood measurements alone. To perform a creatin le clearance test, your doctor will ask you to collect your urine ov r a twenty-four-hour period in a large container. A laboratory will t len analyze your urine for creatinine. In addition to a urinalysis, a s nail amount of your blood will be analyzed for creatinine. Your calc llated creatinine clearance is expressed as the volume of blood your cidneys completely clear of creatinine per minute. A normal creatinii e clearance ranges from 90 to 130 ml/minute. As kidney function d< clines, creatinine clearance also drops.
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