Question 1

What is the role of shock wave therapy and PRP in erectile dysfunction?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Low-intensity shock wave therapy uses a device that is a mini version of a lithotripter. Around 2,000 shocks are delivered into the corpora, repeated either once a week for six sessions or twice a month for three months. The shocks stimulate growth factors and neoangiogenesis in the corporal muscle. Success is around 65 to 70%, but patients must be carefully selected: it works well in diabetic men with well-controlled diabetes and borderline erectile function. For PRP, 5 ml of the patient's blood is centrifuged and about 1 ml of the platelet-rich concentrate is injected into each corpus, once a week for three sessions. The effect of PRP is seen in around 60% of patients, carefully selected ones such as well-controlled diabetics with vasculogenic erectile dysfunction; it is not a good treatment for neurogenic erectile dysfunction, and the evidence is still from small studies. Both are thought to work through neoangiogenesis. Intracavernosal injections are also a good on-demand option: patients are taught to self-inject a prescribed dose.

Question 2

How is a donor deemed eligible, and what are the rules on related donors and blood group compatibility for Indian and international patients?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

The rule is that there must be a related donor in the family first: husband or wife, children donating to parents, parents to children, grandparents. Only if there is nobody in the close family can the extended family be considered. Every relationship is confirmed by DNA testing and the family tree, and the embassy verifies all relationships and documents; no transplant is done without this. Cousins are not automatically eligible: they are considered only when there is nobody in the near family, and two or three DNA tests may be needed to establish the relationship. A blood group mismatch can be tackled, though a compatible donor is preferred: an A recipient takes an A or O donor, a B recipient a B or O donor. If the groups are incompatible, the IgG and IgM titres are measured; up to about 1:64 they can be reduced by plasmapheresis to allow a successful transplant, and titres of 1:128 and above need an immunoadsorption column.

Question 3

How do you manage kidney transplants in patients with HIV, or whose immunity is already compromised?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

HIV-positive patients do fairly well after transplant. Their CD4 count is addressed first: communication starts while the patient is still at home, under the local doctor's observation and medical care, and the patient travels only once they are in a suitable category. The immediate transplant risk in HIV-positive patients is the same as in other patients, but later complications related to immunocompromise and infection are more frequent, so immunosuppression must be handled with more care. Routine ATG is often avoided in HIV; induction with Simulect keeps immunity from falling too low, so the patient can withstand the transplant and infection can be controlled afterwards.

Question 4

When screening family members for a suitable donor, which investigations are done, and how is a match determined?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Screening starts with basic tests: CBC, KFT, blood group, blood sugar, ultrasound of the whole abdomen, urine routine and urine culture. If these are normal, both kidneys are healthy and the sugar is controlled, level two investigations follow where available: DTPA, CT urography, CT renal angiography and cross-match. In some countries CT or DTPA is not possible; in that case the ultrasound report and basic investigations are reviewed, and if they are good the donor travels and the further investigations are done in India.

Question 5

Blood group-incompatible transplants are increasingly reported. Can you explain how they are done?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Blood group-incompatible transplants are increasingly reported. Can you explain how they are done?

Asked by Moderator

Blood group-incompatible transplants are done routinely, but they are the second choice; a blood group-compatible donor always comes first. Eligibility depends on the recipient's antibody titre against the donor's blood group, mainly IgG. Titres of 1:4 or 1:8 are as good as a compatible transplant. Titres of 1:16, 1:32 or up to 1:64 respond to one or two sessions of plasmapheresis. Above that, at 1:128 or 1:256, a column is needed: immunoadsorption on the column filters out the antibodies and reduces the titre. Once titres are below 1:8, the transplant proceeds. The protocol differs from a standard transplant: titres are checked and rituximab is given 15 days before, plasmapheresis is given two or three days before, and titres are checked daily; patients whose titres rebound quickly are managed with plasma filtration around the clock until they reach an acceptable range. Success is slightly lower than with a compatible transplant: hyperacute rejection occurs in about one in 50 patients.

Answered by Dr. Yajvender Pratap Singh Rana

Question 6

Can we risk a transplant even when the HLA match, for both donor and recipient, is low?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Yes, HLA incompatibility alone is not a major problem, even between spouses with no HLA match at all. What actually determines eligibility is the cross match: a negative CDC and flow cross match clears the way for transplant. If CDC is negative but flow is positive, donor-specific antibody testing by the single antigen bead method quantifies the real risk, an MFI reading up to roughly 1,500-2,000 is not a concern, while higher readings call for plasmapheresis first. The key requirement is simply that there should be no antibodies against that particular HLA antigen.

Question 7

How is a compatible deceased-donor (cadaveric) kidney obtained for transplant, and how long does the process take?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Whenever there is a brain-dead patient anywhere in Delhi NCR, the hospital informs NOTTO, the National Organ and Tissue Transplant Organisation, which guides it through the brain stem death declaration. The declaration is made in the hospital by a board of medical experts that includes the doctor treating the patient and a neurologist or neurosurgeon, or, where neither is available, an anaesthetist or intensivist. The next of kin then give consent for donation of the kidneys, liver, corneas or heart, depending on the organs' condition, and NOTTO is informed. NOTTO holds a waiting list across hospitals and allocates strictly by turn: a hospital with a brain-dead donor cannot simply use the kidney for its own patient. The process is an overnight, roughly 12-hour job. The second brain stem death declaration follows the first after an interval of six hours; the waiting recipients are then informed and prepared, with dialysis and cross-matching done simultaneously, and the cross-match report comes within 6 hours. If it is negative, organ harvesting begins at the donor hospital while the recipient is prepared at the transplanting hospital, so the transplant can be done as soon as the kidney arrives.

Question 8

What are the success rates of kidney transplantation?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

A kidney transplant is always better than remaining on dialysis. Around 97% of transplants are successful and working in the first year, and 93 to 95% of patients have a good life with a functioning graft in the second year. After 10 years the figure is around 75 to 80%, and after 15 years around 60% of grafts and patients survive.

Question 9

After donation both the donor and the recipient live with one kidney. Are there lifestyle risks, complications or general health challenges for the donor?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

The donor workup is so thorough that any problem in the kidneys or elsewhere in the body leads to the donor being refused. As a result, donors live as long as their peers, and many live happier lives, partly because of the pride of having helped a family member. Their lifetime risk of kidney failure is slightly higher than that of equally healthy people who have not donated, though still low, so donors should have their blood pressure, kidney function and urine protein checked every year. The workup also uncovers problems that are treated before donation and would otherwise have damaged the kidneys. In one donor, the workup found mild hydronephrosis from a small, long-neglected stone and a stricture in the upper ureter; that kidney was the one removed, the stone was cleared and the passage opened, and it was transplanted into the recipient, leaving the donor with the normal kidney. Donors are healthy before donation and, with that yearly check, stay healthy afterwards.

Question 10

What can be done for cases of transplant rejection where the antibody attacks the new kidney?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Rejection is a reality of transplantation and can occur at any time. With good immunosuppression I have not seen hyperacute rejection in blood group-compatible transplants for the last 10 to 12 years; in ABO-incompatible transplants it can still happen. Acute rejection is either cell-mediated (ACR) or antibody-mediated (AMR), and a kidney biopsy is needed to tell them apart. Early clues include a creatinine that was low starting to creep up. Treatment is a simple methylprednisolone pulse first, then ATG if that does not work, and for antibody-mediated rejection plasmapheresis after that. Most rejection today is reversible, and once it is reversed the kidney adapts. Problems arise when treatment is delayed; otherwise rejection is manageable and the kidney recovers function.

Question 11

Survival falls from 97% at one year to lower figures at five and ten years. Is rejection happening later on, or is something else responsible?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Rejection can happen at any time, and late rejections do occur, although the rate falls steadily as time passes. That is why follow-up is essential. International patients are given direct contact numbers for the surgeon, the secretary and the coordinators. Patients must be followed up every three months, test their creatinine routinely, adhere strictly to their immunosuppressive medicines and check their urine routinely; protein in the urine is the first marker that the kidney is in trouble. With this care, outcomes can be long-lasting: one patient transplanted some 15 to 16 years ago, with his mother as donor, still has a creatinine of 0.9, and his mother is also well.

Question 12

If, years after transplant, a patient back home shows rising creatinine and rejection is suspected, how much time is there to intervene, given that they would need to travel to India?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

If creatinine is rising, the urine shows protein and rejection is suspected, the patient is assessed with the local nephrologist, who most transplant patients follow up with. Where kidney biopsy is available, a transplant biopsy is done locally, sometimes sent to India for reporting, and if it confirms rejection the treatment is agreed by phone; the medicines, such as ATG and methylprednisolone, are now available in countries including Tanzania. If local treatment is not possible, the patient is advised to increase their immunosuppression to the right dose for the time being and then plan travel to India. Late rejection does not destroy the kidney overnight; it is manageable. Severe rejections usually occur very early, during the two to three months patients stay in India after transplant, and if that period goes well the chance of severe rejection later is very low.

Question 13

What is the cost of a kidney transplant?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Transplant packages are modest. The package for a routine mini-incision laparoscopic kidney transplant is around USD 13,000 to 14,000; a robotic transplant, for patients who want a more cosmetic result, costs about USD 3,000 more. Having mentored transplant centres in Africa, including in Ghana, the comparison is clear: even including the stay in India and medicines, patients save money.

Question 14

What are the criteria for selecting a donor?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

The initial donor workup comprises CBC, KFT, blood sugar, urine tests and ultrasound. If the blood group is the same and the other key parameters match, the next line of investigation is DTPA, CT renal angiography and cross-match. If these can be done locally, they should be; otherwise, send the investigations and the patient to India.

Question 15

At what stage of kidney failure is transplant advised, and is there an age cut-off?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Patients with advanced chronic kidney disease should be referred for transplant evaluation early, and a living-donor transplant can be done before dialysis is needed once the eGFR falls below about 20. Dialysis is started for symptoms rather than a single number: uraemia, fluid overload or hyperkalaemia that cannot be controlled medically, usually with a creatinine above 7, shrunken kidneys and reduced urine output. A PTH above the normal range points to long-standing chronic kidney disease rather than acute injury, which is why the kidneys will not recover. These patients should be stabilised on haemodialysis at home while a donor is identified within the family and travel to India is planned. On age, what matters more than the number is physiological age: an 80-year-old who is fully fit and active, has a donor and is not immunocompromised may still be considered. As a rule of thumb, however, transplant is not the best option above 80, and such patients should remain on dialysis; patients must be selected so that they get the best out of their donor's kidney.

Question 16

How long after transplant is meticulous surveillance for rejection needed?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

The first two to three months are the critical period. If patients do well through that, the later chance of rejection is lower. Later rejection usually results from problems on the patient's side, such as missing immunosuppressive doses: one young recipient who had been doing perfectly well forgot to take his immunosuppression for three days during a family celebration.

Question 17

Do transplant patients have to stay on immunosuppression for life?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Yes, without exception. Immunosuppression is taken morning and evening, by the clock, at exactly the prescribed dose. These medicines keep the immune system silent; without them the immune system is activated and destroys the kidney.

Question 18

Does lowered immunity raise the risk of other infections?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Managing this is an art of balancing. Immunity must be kept as low as is good for the kidney without exposing the patient to opportunistic infections, and proper immunosuppression is monitored to achieve that balance.

Question 19

Are anti-rejection drugs as expensive as cancer drugs, and are they available?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

No. Doses are higher for the first two to three months; after three months the medicines cost around USD 100 per month. Many patients come back to India every year, have a full check-up, and take a year's supply of medicines home, which saves money.

Question 20

What is the survival rate after kidney transplant, and after how many years would a patient likely need another transplant?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

It depends on how careful the patient is with immunosuppression and lifestyle. The problem is that some patients become casual after five or eight years and take things for granted; the kidney then runs into trouble, often with infection, and they end up needing a second transplant. A second transplant is done once the kidney has failed completely and the patient is back on dialysis; I have also performed a third transplant in one patient. Patients are counselled from the outset that the transplant is a new life and they must take every precaution to prolong graft survival. If failure does occur, it usually happens after 10 to 15 years, and a new donor must then be found for a second transplant.

Question 21

If a first transplant fails through rejection, does that affect a second transplant, or is it a fresh start?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

A second transplant carries slightly higher risk than the first, because the body is already sensitised to some antigens, but it still gives a better outcome than dialysis. When a graft fails very early, rejection is possible, but surgical technique also contributes. Meticulous surgery is paramount: the artery and vein must be handled very delicately, because any trauma to the kidney during surgery can cause thrombosis, which creates problems in the early phase. Good surgery prevents early surgical complications and protects graft outcome.

Question 22

Looking to the future, is there a possibility that xenotransplantation, using animal kidneys such as from a sheep, could work in humans?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

It is being tried, but the outlook is not promising, because of tissue problems and the risk of transmitting viruses and other microbes from the animal, so the success of xenotransplantation is still questionable. Greater success is coming from artificially engineered kidneys, which are likely to become a reality in the near future. A related advance already in use is the tissue-engineered buccal mucosa graft for urethroplasty in men with a short urethral stricture: a small piece of tissue is taken from the cheek, the cells are regenerated and grown in tissue culture in the laboratory, and they are then implanted into the urethra. Technology and biology are merging, and biotechnology is producing practical, technology-driven solutions for patients.

Question 23

How does one ethically find a living donor without pressuring family or friends?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Donation must come from love and compassion; a donor cannot be pressured. The opening statement to potential donors is that a donor who passes the workup goes on to live a normal, long life, and most often they choose to donate. Where pressure would otherwise be needed, it is sometimes better for the recipient to stay on dialysis and be cared for there. The larger answer is deceased donation: there is a huge gap between demand and supply, more organs must be harvested from deceased donors, and young people and their families should be taught the act of sharing. That starts with healthy thinking: take care of your own body, get yourself investigated, and do not shy away from pledging your organs for donation.

Question 24

How are patients with hepatitis B or C managed for kidney transplant?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Hepatitis B and C are very common in recipients on dialysis, often transmitted through dialysis machines. Good medicines are now available for both. Once the viral parameters are in the safe range, the transplant is done, and the patient continues hepatitis B or C treatment afterwards.

Question 25

What happens to a transplant patient with delayed graft function?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

In a living related transplant, delayed graft function should not happen; if it does, it points to a problem with organ harvesting, which is why choosing a good centre and a good surgeon is so important. If it occurs, it must be managed properly so that early graft function is recovered. In deceased-donor transplants, delayed graft function does occur. Cold ischaemia time must be reduced by preparing the recipient promptly so the organ is not wasted: engraftment should be within 12 hours, ideally within 6. Everything runs simultaneously to minimise delayed graft function. When it does occur it is usually acute tubular necrosis, which generally recovers with supportive care, dialysis if needed and modified immunosuppression, such as ATG induction with a delayed or reduced calcineurin inhibitor dose.

Question 26

What diet is recommended after kidney transplant?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Patients should eat properly cooked, hygienically prepared food; street food is strictly ruled out. Otherwise they can eat normally, including chicken and the local foods available in their country, as long as it is properly cooked and hygienically prepared.

Question 27

If a transplanted kidney fails, can it be removed and used for another patient?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

No, never. A failed kidney has been damaged, and that damage cannot be reversed; it cannot be reused and is discarded.

Question 28

Have you treated a patient who needed transplant for both kidneys, and how is that handled?

Dr. Yajvender Pratap Singh Rana · Accepted Answer

Normally only one kidney is transplanted, and a single kidney is enough. The recipient's own failed kidneys stay in place; nephrectomy is done only when they pose a risk of infection, for example very large kidneys or kidneys with stones. The new kidney is placed in the iliac fossa.

Live Discussion with Dr. Yajvender Pratap Singh Rana

What is the role of shock wave therapy and PRP in erectile dysfunction?

How do you manage kidney transplants in patients with HIV, or whose immunity is already compromised?

When screening family members for a suitable donor, which investigations are done, and how is a match determined?

Blood group-incompatible transplants are increasingly reported. Can you explain how they are done?

Can we risk a transplant even when the HLA match, for both donor and recipient, is low?

How is a compatible deceased-donor (cadaveric) kidney obtained for transplant, and how long does the process take?

What are the success rates of kidney transplantation?

After donation both the donor and the recipient live with one kidney. Are there lifestyle risks, complications or general health challenges for the donor?

What can be done for cases of transplant rejection where the antibody attacks the new kidney?

Survival falls from 97% at one year to lower figures at five and ten years. Is rejection happening later on, or is something else responsible?

If, years after transplant, a patient back home shows rising creatinine and rejection is suspected, how much time is there to intervene, given that they would need to travel to India?

What is the cost of a kidney transplant?

What are the criteria for selecting a donor?

At what stage of kidney failure is transplant advised, and is there an age cut-off?

How long after transplant is meticulous surveillance for rejection needed?

Do transplant patients have to stay on immunosuppression for life?

Does lowered immunity raise the risk of other infections?

Are anti-rejection drugs as expensive as cancer drugs, and are they available?

What is the survival rate after kidney transplant, and after how many years would a patient likely need another transplant?

If a first transplant fails through rejection, does that affect a second transplant, or is it a fresh start?

Looking to the future, is there a possibility that xenotransplantation, using animal kidneys such as from a sheep, could work in humans?

How does one ethically find a living donor without pressuring family or friends?

How are patients with hepatitis B or C managed for kidney transplant?

What happens to a transplant patient with delayed graft function?

What diet is recommended after kidney transplant?

If a transplanted kidney fails, can it be removed and used for another patient?

Have you treated a patient who needed transplant for both kidneys, and how is that handled?

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In This Series: Advances in Urology, Uro-Oncology and Kidney Transplant