Rejection is the most common and important complication that may occur after receiving a transplant. Since you were not born with your transplanted kidney, your body will think this new tissue is “foreign” and will try to protect you by “attacking” it. Rejection is a normal response from your body after any transplant surgery. You must take anti-rejection medicine exactly as prescribed to prevent rejection.

Are there different types of rejection?

There are two common types of rejection:

• Acute Rejection – Usually occurs anytime during the first year after transplant and can usually be treated successfully.
• Chronic Rejection – Usually occurs slowly over a long period of time. The causes are not well understood and treatment is often not successful.

What are anti-rejection medications?

Anti–rejection (immunosuppressant) medications decrease the body’s natural immune response to a “foreign” substance (your transplanted kidney). They lower (suppress) your immune system and prevent your body from rejecting your new kidney.

Why do I need to take anti-rejection medication?

Kidney rejection is hard to diagnose in its early stages. Rejection is often not reversible once it starts. You should never stop taking your anti-rejection medication no matter how good you feel and even if you think your transplanted kidney is working well. Stopping or missing them may cause a rejection to occur.

How should I take anti-rejection medication?

Here are some tips to help you take your anti-rejection (immunosuppressant) medication as directed:

• Make taking your medicine part of your daily routine
• Use digital alarms and alerts to remember when to take your medication. Be creative because it is easy to forget, especially once you are feeling wellKnow all of your medications by name and dose. Know the reason for taking each medication. Click here for form.
• Ask for and review all written instructions for any change in medication dose or frequency
• Tell your transplant team of problems and concerns about medications during every clinic visit
• If a doctor other than a member or your transplant team gives you a prescription, notify the transplant team before taking. Certain medications can interfere with your anti-rejection medications and keep them from working.
• Continue to take your anti-rejection medication no matter how great you feel, even if you think your transplanted kidney is working well. Stopping them may cause rejection to occur.

Do anti-rejection medications have side-effects?

Anti-rejection (immunosuppressant) medications have a number of possible side-effects which are usually manageable for most patients. Blood levels of anti-rejection medications will be checked regularly to prevent rejection and lessen side-effects. If side-effects do occur, your doctor may change the dose or type of medications.

What are the side-effects of anti-rejection medications?

Some of the most common side-effects of anti-rejection (immunosuppressant) medications include high blood pressure, and weight gain, an increased chance of having infections, and increased risk of some forms of cancer.

What are the types of anti-rejection medications?

There are 3 groups of anti-rejection (immunosuppressant) medications:

• Induction agent – Powerful anti-rejection medication used before the transplant in the operating room, or immediately after the transplant surgery
• Maintenance agents – Anti-rejection medications you will take daily for as long as you have your transplanted kidney
• Rejection agents: Medications which are used for the treatment for rejection episodes

Prior to your actual surgery, you will undergo tests to ensure you are healthy enough to go through with the procedure, including: 6

• A chest X-ray
• An electrocardiogram (EKG)
• Blood tests
• A urinalysis
• An assessment of your vital signs, including blood pressure, heart rate, body temperature, and oxygen saturation

As with all pre-operative evaluations, you will be asked to sign a consent form authorizing the surgery and indicating that you understand the risks involved.

Once your transplant is complete, you will remain in the recovery room, where you will stay until the anesthesia wears off. Your vital signs will be monitored. From there, you will go to the ICU, where your kidney function will be closely monitored for early signs of rejection.

The typical patient returns home within a week of surgery with kidney function that is good enough that dialysis is no longer needed. Most people are able to return to their normal activities within a month or two of surgery. 

You will need regular follow-up visits with your healthcare provider for a year after your transplant. In the first few weeks, you'll go twice a week for lab work and a check-up; after one year, you'll go every three to four months.8

Organ rejection can be a serious issue after transplant surgery. This occurs when the body identifies the new organ as a foreign body and tries to reject it. To prevent this, you will be on immunosuppressant medications (calcineurin inhibitors) indefinitely.

Rejection episodes are most common in the six months after surgery but are possible at any time after a transplant. The faster rejection is identified and treated, the better the outcome. According to UNOS:8

• One out of 10 patients will have rejection symptoms.
• 4% of patients will lose their kidney in the first year due to rejection.
• 21% of patients will lose their kidney in the first five years due to rejection.

Because the process of organ transplantation involves removing an organ from one person (donor) and transferring it to another (recipient), the need to obtain informed consent from both persons (or their surrogate decision-makers) is compulsory. This is in keeping with the ethical principle of respect for persons and is expressed in many ethical guidelines today. To start the discussion about consent, it is important to mention the many sources of organs for transplantation, ie, living donor (related and nonrelated), cadaveric donor, and brain-dead patients. In countries where transplantation is well established, organs are sourced from both living and cadaveric donors using different strategies, ie, an opt-in (explicit consent), opt-out (presumed con- sent), donation after brain death, donation after controlled cardiac death, and extended criteria for deceased donors.⁵ The presumed consent strategy is now being applied in many developed countries as a way of increasing the availability of organs, but the results have thus far fallen short of expectations.⁶ The ethical issue associated with presumed consent is that by making people opt out of organ donation, do we respect their rights as individuals to self- determine? Are these people who are unwilling to donate organs going to be put under societal pressure or made to feel guilty about their decision to opt out? Proponents of the opt-out strategy, however, would argue that the end justifies the means, in that many more lives will be saved using this strategy, and this outweighs any violation of the rights of donors. This strategy of opting out has not been adopted in developing countries, probably due to the absence or gross

underdevelopment of organ transplantation programs for socioeconomic and cultural reasons in these countries.⁷ The living donor strategy remains the main source of organs in developing countries, and informed consent is nonnego- tiable. The ethical dilemma differs when considering related and nonrelated living organ donation. With the former, the dilemma is whether the decision to donate an organ is totally free of coercion from family members. This is especially important in the extended family setting prevalent in many African countries where the pressure (direct or subtle) could be enormous. Let us consider the case of Mr X who has end-stage kidney disease and needs a kidney transplant. He has been told by his nephrologists that his best bet will be to obtain a kidney from one of his family members. and he mentions this to his son every time he visits and begs him to save his life. Although this is a hypothetical scenario, it is played out in reality many times. In this scenario, how voluntary can a decision by the son to donate a kidney to his father be? Can we say that the decision is absolutely free of coercion, either subtle or explicit? Is there not a risk of the donor overlooking the risks to himself/herself because of the feeling of responsibility towards a loved one, and can we confidently say that the main motive for donation is altruistic? In the African setting, where the family is central to decision-making, the risk of coercion is even greater, and here the autonomy of the donor is totally eroded. For living nonrelated donors, the main motive for organ donation in many developing countries has been found to be financial. The nonheart-beating donor strategy is based on the “dead donor” rule which states that “vital organs should be procured from persons only after they are determined as dead”.⁸ Although this strategy is not being practiced in Nigeria or in most developing countries at the moment, it is expected to become an important source of organs when the practice of organ transplantation becomes established in these countries. This rule confirms the commitment of society to respect human life and the fact that persons are not used as a means to an end, but as an end in itself. At the moment, brain death⁹ and cardiopulmonary¹⁰ criteria are used to define death, although the moment or process of death is difficult to pinpoint. Another point that comes to mind is the assumption that these death criteria have been put in place to facilitate availability of organs for transplant, and that because of this, physicians would do little to resus- citate patients in cardiac arrest.¹¹ This argument has brought to the fore the need for widely accepted criteria for death and a protocol for organ recovery. The issues relating to the integrity and wholeness of the human body are also ethical

problems that need to be mentioned.¹² Some cultures still abhor any form of mutilation of the living or dead body for any purpose at all, even though most religions now approve of cadaver organ donation on the basis of brotherly love, doing good, and sustaining life.^13,14

Commodification of organs

The sale and trafficking of organs, especially in developing countries, has emerged as the major problem confronting the practice of organ transplantation worldwide.¹⁵ Although there is a worldwide consensus that no payment should be made for organs from either living donors or deceased individuals, the shortage and scarcity of organs for transplantation and the associated long waiting period has led to what is termed “transplantation commercialism” in developing countries where regulation of transplantation practices is inadequate.¹⁶ The ethical issues here are linked to the question of “body ownership”, and there seems to be no consensus on this issue.¹⁷ Some would argue that, based on the principle of autonomy and respect for persons, people may donate their organs for altruistic reasons as well as for financial gain. This, according to them, will greatly increase the availability of organs for transplantation. However, while this argument might be plausible, it is known that payment for organs can influence the decision to donate, and more people from the low socioeconomic classes would be enticed into doing this, leading to inequities in donation both within a country and internationally. There is also a danger of vital medical information being withheld by potential donors, which may lead to the transplanted organ carrying some unknown disease that could compromise the outcome of transplantation or the overall health of the recipient. Some workers have advocated a form of “compensated donation”, whereby donors will have some sort of reimbursement for lost time and assistance with health insurance,⁵ but this does not eliminate completely the risk of abuse. Indeed, the Iranian model of paid and regulated living-unrelated kidney donation⁷ is an example of the workability of this approach, although as mentioned earlier, it does not remove all the ethical dilemmas. The Declaration of Istanbul on Transplant Tourism and Organ Trafficking also supports such schemes that remove economic disincentives as a way of encouraging altruistic living organ donation.

Confidentiality

Confidentiality of information given to physicians by patients has always been a basic component of the ethics of the medical profession, and organ transplantation is no

exception. In this case, the most important information is the result of screening and compatibility tests which could affect the outcome of the procedure. However, circumstances whereby the health of third parties could be affected by these results are rare exceptions to the confidentiality rule, and even in these situations, the donors involved should be informed before the information is disclosed to the affected parties.

Fairness and equity

Fairness and equity in organ procurement needs to be viewed in terms of commodification of organs and of equitable access of the populace to organ transplantation, when indicated. In procuring organs for transplantation, efforts should be made to ensure a fair selection of donors, using explicit criteria, and without any form of discrimina- tion. To address the question of equitable access to organ transplantation in this age of shortage of organs, several rationing strategies have been put in place in transplanta- tion programs in many developed countries, and these strategies are also laden with ethical dilemmas.¹⁸ For example, if a donor kidney is available for transplantation, and two recipients, a 45-year-old teacher and a 70-year- old man, have good histocompatibility matching with the kidney, who gets the kidney? It is likely that most people would choose the younger patient, based on reasons of future productivity and better utility for the community, and most protocols for transplantation actually exclude patients older than 65 years, but recent studies have shown good results in transplanted patients over this age.¹⁹ So do we have any right to value the life of one person more than another based on years already lived? Let us take a look at another scenario of a patient with end-stage renal disease secondary to human immunodeficiency virus (HIV)-associated nephropathy and another with diabetic nephropathy being considered for the same donated kid- ney. By what criteria do we choose to whom to give the kidney? Can we be accurate in estimating the longevity of the transplanted kidney in both potential recipients? Now that HIV/acquired immune deficiency syndrome (AIDS) has become a potentially chronic treatable (albeit not curable) disease like diabetes, how do we proceed in this case? There are no ready answers to these questions, but raising them enables us to understand the complexity of the issues being discussed. With the increasing prevalence of HIV/AIDS and hepatitis B infection in many Sub-Saharan countries, the main ethical issue that will arise in the near future will be that of discrimination regarding access to organs.

Perhaps the most important problem limiting access to kidney transplantation in Nigeria is the cost of the procedure. The average cost of the procedure in Nigeria is in the range of 6–10 million Naira (US$ 40,000–70,000), with- out considering the financial implications of postoperative immunosuppressants, and this in a country where more than 70% of the population live on below two US dollars daily.²⁰ The situation is made even more difficult by the lack of central- ized health insurance, hence payment for health care is mainly “out of pocket” in these countries.^21,22 This is an contrast with developed countries where there is usually some form of health insurance to relieve the financial burden on patients. One dilemma that is peculiar to developing countries like Nigeria is the problem of continued access to maintenance immu- nosuppressant drugs post-transplantation. Our experience is that many patients find it very difficult to find the resources to sustain these medications because of their high cost, hence risking late rejection of the graft. We believe that a mechanism needs to be put in place by the World Health Organization and other international agencies to help resolve this problem, as was done in the case of antiretroviral drugs.

Quality assurance and safety

Two of the core principles of biomedical ethics are benefi- cence and nonmaleficence, and both are relevant when dis- cussing organ transplantation. While beneficence (to do good) is the main principle behind organ donation and transplanta- tion, nonmaleficence (to do no harm) is also relevant. While the aim of transplanting a “normal” kidney is to improve the health status and prolong the life of the recipient, it is important to ensure that the process of organ recovery is as safe as possible, and that both the living donor and recipient are followed up to detect and manage any short- or long- term sequelae.²³ The competence of the medical/surgical team responsible for the transplant process should also be of the highest order, so as to ensure outcomes comparable with those in developed countries. It is very necessary to ensure that the economic aspects of the procedure do not in any way compromise accepted worldwide standards. The informed consent process should ensure that all necessary information regarding the potential risks of the procedure, the possibility of graft rejection, and adverse effects of the immunosuppressant used by the recipient are made available to the potential donor and recipient.