Question 1

How do you manage difficult multiple renal arteries during transplant?

Dr. Shafiq Ahmed · Accepted Answer

Every surgeon has a learning curve, and switching to robotic transplant is not easy in itself. But once you are well versed in single-vessel handling, vascular surgery principles, regional hypothermia and warm ischaemia time, handling multiple vessels is not much more of a problem. The size of the vessels matters, whether the surgery is open or robotic: joining vessels of 1 mm or less is difficult. If they are in the upper pole of the kidney, they can be sacrificed; if they are in the lower pole, they supply the ureter and cannot be skipped. If you have the slightest doubt about handling multiple vessels during a robotic transplant, join them together on the bench while the kidney is in ice, and then anastomose a single bigger lumen during the transplant. Having grown in experience over five to seven years of robotic kidney transplants, I have done three vessels multiple times and am now planning to go for four; as experience grows, it does not make much difference.

Question 2

What are the risks, challenges and lifestyle changes a living donor may face after donating a kidney?

Dr. Shafiq Ahmed · Accepted Answer

A living donor must be absolutely fit to donate; a healthy person can donate to a loved one without problems. Under Indian law, only a related donor can donate: near relatives such as a spouse, parent, child or sibling, and other relatives such as cousins once the relationship is proved, so the donor has to come from the family. Fear of donation usually comes from lack of knowledge. Unlike liver donors, kidney donors need to look after their kidney health in future: if there is diabetes or hypertension in the family, they should check for these regularly. They need to maintain an optimal weight, follow a strict diet and avoid taking too many painkillers or antibiotics, all of which are harmful to the kidney. Everyone, donor or not, should have an annual check-up; blood pressure, urine protein, kidney function tests and an ultrasound are four simple tests that show whether the kidneys are healthy. End-stage renal disease places a heavy financial and emotional burden on the whole family: a year of dialysis costs about the same as a kidney transplant, while a transplant returns the patient to normal life.

Question 3

What strategies reduce vascular thrombosis during renal graft implantation?

Dr. Shafiq Ahmed · Accepted Answer

The most important factor is how the vessels are handled. The intima, the innermost and most delicate layer of the artery or vein, should never be touched: injuring it leads to platelet deposition, clot formation and subsequent problems. There is no routine protocol of antithrombotic medication for all patients. If two vessels were joined on the bench and the patient's own vessels are atherosclerotic, the patient may be put on an antiplatelet drug for about one month to prevent early clot formation; long-term anticoagulation is not used. In paediatric transplants, children are kept well hydrated while in hospital, because they are more prone to renal vein thrombosis than adults. There are no clear-cut guidelines recommending antiplatelet therapy followed by anticoagulation in kidney transplant.

Question 4

How do we manage kidney rejection from unmatched donors?

Dr. Shafiq Ahmed · Accepted Answer

Rejection in an unmatched transplant is treated in exactly the same way as in a compatible transplant. When rejection is suspected, the first thing to look at is the creatinine trend and the urine output of the kidney. Biopsy is the gold standard test to confirm rejection. Non-invasive donor DNA tests are also emerging and are available in India, though not yet widely used across the globe. Once biopsy confirms rejection, first-line treatment is always pulse therapy, meaning high-dose steroids. If the response is good, the patient is maintained; if not, second-line treatment follows, which includes rituximab or plasmapheresis to remove the antibodies, chosen according to the condition and managed by the nephrologist.

Question 5

Is the rejection risk higher in unmatched donors, and what are the real odds?

Dr. Shafiq Ahmed · Accepted Answer

The risk is somewhat higher with more mismatches, but transplant has become very safe. Rejection was very high in the 1990s; it is now rare, because the understanding of immunology has advanced to the point where patients who will not have a successful transplant can be identified beforehand and excluded. Virtual crossmatch, single-antigen bead testing and PRA testing, which are highly specific, can even determine whether a kidney will suit a recipient and what the chances are. Patients are counselled that the chance of an acute rejection episode in the first year, despite all the testing, is around 1 to 2%, and in most cases the medicines are strong enough to save the kidney. In ABO-incompatible transplant, the rejection chance is 5 to 10%, and those kidneys are sometimes more difficult to save, but even with a 10% rejection chance, 8 out of 10 patients still survive with a functioning kidney after anti-rejection therapy. Rejection is not the big issue in kidney transplant that people think it is, whether the transplant is ABO-compatible or incompatible.

Question 6

Once a patient returns home after transplant, how long do they need to stay on a special protocol?

Dr. Shafiq Ahmed · Accepted Answer

The initial 6 months are very crucial. During this time they need to check their drug levels, maintain extreme hygiene, and creatinine can go up and down. Drug toxicity, infection and rejection risks are all high in this window, so they need to stay in touch with their referring physician and keep us in the loop as well. Beyond 6 months they don't need to visit as frequently, but immunosuppression is lifelong. The two medications that remain long-term are tacrolimus and mycophenolate mofetil.

Question 7

Patients often cannot proceed because they have no donor from the immediate family. How is the relationship proved, and can a donor related by marriage donate?

Dr. Shafiq Ahmed · Accepted Answer

If a donor is available but the blood group does not match, the transplant is still possible. For example, if a wife is blood group A and wishes to donate to her husband, who is group B, the anti-blood-group antibody titres are checked. If it is below 1:256, the transplant can proceed: the protocol is one dose of rituximab followed by 5 sessions of plasmapheresis to bring the titre below 1:32, ideally 1:16 or 1:8. If the titre is very high, the couple can look, for example at their dialysis centre, for another pair with the reciprocal mismatch and swap donors; I have done many swap pairs, including 3 to 4 international swaps where the referring nephrologist arranged the pairing. If there is no donor at all, Indian law permits a transplant only through a swap or from a first-degree blood relative: parents, grandparents, grandchildren, brothers and sisters. The spouse is also included and is the only unrelated person accepted. The relationship is proved by DNA testing done in the hospital as part of the full screening process.

Question 8

In many cultures cousins are like brothers. Does Indian law allow a cousin to donate to a cousin?

Dr. Shafiq Ahmed · Accepted Answer

Yes. Donation is not limited to first-degree relatives; second- and even third-degree relatives can donate, but the relationship must be proved by DNA, which means constructing a full family DNA tree to show they are indeed cousins. That is the challenging part. The law restricts donation to prevent financial transactions and protect the donor. I have done many transplants from cousins, uncles and maternal aunts, and from a mother-in-law to a daughter-in-law and a father-in-law to a son-in-law; once the relationship is proved by DNA and the government is satisfied it is a genuine donation and not a financial transaction, they can donate.

Question 9

Does Indian law also treat the spouse's family, such as a brother-in-law, as family for donation?

Dr. Shafiq Ahmed · Accepted Answer

No. A brother-in-law is not a blood relation and cannot donate under the standard criteria. The law has a separate category, donation out of love, under which even a friend could potentially donate, but the formalities are heavy: the case has to be filed in a court of law, and the transplant can proceed only once the authorities are satisfied that the donation is genuine and involves no payment. I have not seen any authorisation committee, at hospital or national organ transplant level, give clearance for donation out of love, so the pathway exists in law but is very rarely used.

Question 10

Would that route be practically impossible for international patients, given the time constraints of a sick patient?

Dr. Shafiq Ahmed · Accepted Answer

Yes, it is not practical. International patients should come with a donor who clearly falls into the accepted categories: brothers, sisters, wives, husbands, parents or children. Those transplants proceed without difficulty. If the donor is a cousin, the full family documentation must be brought, all the DNA testing done and the full family tree constructed, which is genuinely difficult for international patients.

Question 11

What's the actual cost difference between open and robotic kidney transplant?

Dr. Shafiq Ahmed · Accepted Answer

The cost drawback mentioned in the talk refers to establishing a robotic programme: buying a robot is a heavy financial burden on a hospital. For the transplant itself, robotic surgery is effectively cheaper once you understand what it offers: less bleeding, fewer complications, a shorter hospital stay and very high graft success. The difference between open and robotic kidney transplant is only around USD 3,000. In an open transplant, a single serious infection may cost the patient's life, and even if they survive, the treatment alone may cost more than USD 10,000. Any 3 extra days of hospitalisation would exceed the difference. The serious infection risk is approximately 1% with robotic transplant against approximately 10% with open transplant, and a fungal infection after an open transplant is a very serious situation. At my centre, the robotic kidney transplant package for international patients is around USD 15,500, and the open transplant around USD 12,500.

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