“Sacrifice for love” A couple shares their kidney transplantation experience. 
A new life under the same skin.

“Between a father and child related by bloodline, compatibility is more likely. As for me and my wife, there was a high chance of incompatibility.”

Kidney transplantation is an option for patients with end-stage kidney disease wherein doctors transplant a donor kidney to a recipient patient. If patients wish to replace their diseased kidney with a cadaveric kidney, the wait could be mentally agonizing as they do not know how long they must wait. As for receiving a kidney from a living donor, a compatible match is not a guarantee. This issue of Patient Story shares a kidney transplantation experience from Noppol Trirothphutthiphong and Viraya Thitiwattanakan.

This issue of Patient Story recounts the kidney transplantation story of a couple - Mr. Noppol Trirothphutthiphong and Ms. Viraya Thitiwattanakan. Although a kidney donation takes away one of your organs, it is a noble sacrifice if the health of your loved one becomes wholesome again. It is another way of showing how much you love someone without saying it out loud. Let’s follow their story.

Symptoms leading to chronic kidney disease 

In 2021, Noppol noticed something unusual happening to him. After a preliminary examination, the doctor found no definite cause. Concerned, he traveled from Udon Thani to Bangkok for a thorough checkup.

“Salient symptoms include hypertension, foamy urine, frequent urination, and hair loss. A health checkup at Udon Thani found nothing out of the ordinary. So, I decided to see a doctor in Bangkok for a blood test and health examination. I was diagnosed with a chronic kidney disease due to hereditary cystic kidney disease.”    

In this disease, the enlarging cysts damage the kidney, leading to kidney failure. At an early treatment stage, Noppol saw Dr Sira Sooparb, an internist specializing in Nephrology. He recommended lifestyle modifications to slow down the deterioration of Noppol’s kidney function. They had seen each other for quite some time until Dr. Sira moved to MedPark Hospital. Noppol followed him for continuing treatment.

“Dr. Sira focuses on dietary control, telling me to avoid red meat and reduce fat, salt, and sugar intake while taking the prescribed medicines and exercising regularly. Following him to MedPark Hospital, I had follow-up visits from time to time, receiving conservative care until one day he told me that it had reached the end-stage kidney disease.”

Sacrifice a kidney for a new lease on life.

Chronic kidney disease is a stealthy killer that relentlessly progresses to the fifth stage of kidney disease, where kidney function drops below 15 percent. The symptoms are no longer manageable with a disease-specific diet or medications. Noppol had no way out but to prepare himself for renal replacement therapy.

“Dr. Sira offered me two options: chronic dialysis and kidney transplantation. He described each alternative in detail for me, including advantages and disadvantages. Ultimately, he recommended that I have a kidney transplant. So, I decided to go for it.”

Although a kidney recipient can choose to receive an organ from a living or a deceased donor, in Thailand, if the recipient has not previously undergone dialysis, the transplanted kidney must be from a living donor only. Viraya, who had witnessed how bad her husband’s condition was, having taken care of him for a long time, made a resolute decision.  

“I decided to donate my kidney to Noppol. I wanted his quality of life to improve. At first, I was terrified of the pain as it would be a major surgery. I had never undergone something like this before. However, after a conversation with the team of medical staff and transplant nurse coordinator at MedPark Hospital, I felt confident. They guided us through the kidney transplant journey before and after surgery. I was much relieved.” 

Partial tissue compatibility

During the pretransplantation workups, Viraya and Noppol underwent detailed health examinations, including appointments with physicians in various specialties, computerized X-ray imaging and ultrasound examination, a lung scan, a colonoscopy, tissue typing, and psychological assessment. If patients don’t qualify, transplantation cannot proceed. One crucial test is tissue typing, usually performed by the Thai Red Cross Society.

“The nurse coordinator told us that our tissues were not a perfect match. Usually, matching tissue between parent and child with the same bloodline will likely be more compatible. As for me and my wife, there was a high chance of incompatibility. We were anxious and kept asking the nurse for the final result. There were six incompatible markers, but sufficient to qualify for the transplantation based on the Thai Red Cross Society criteria.”

The long-awaited transplantation day

October 9, 2022, was a fateful day of our surgeries. After passing the physical and psychological tests, Noppol and Viraya arrived at the hospital a day before surgery for preparation. A nurse took blood samples, and we underwent echocardiographic examinations. They abstained from food and water after midnight. In the morning, staff whisked them off to the operating theatre.

“We were not in the same, but adjacent rooms. She entered the operating room one hour before me. By the time I went into my operating room, it was around noon. I left the room at about five or six p.m. Dr Akanae (Dr Akanae Wongsawat) operated on my wife. Her hand-length incision was on her left, below the rib cage. Dr Chatchai (Dr Chatchai Mingmalairaks) and Dr Aekkaphod (Dr Aekkaphod Liwatthanakun) operated on me. My incision was on my right, in an L shape, like the imprint of my wife’s kidney in that location.”
  
The transplantation was a success. Variya had little incisional pain. She took five days to recover. As for Noppol, he needed to be under the close care of the medical team in the ICU ward.

“The tissue typing result indicated that ours are not one hundred percent compatible. There was a risk of kidney rejection. At first, the level of immunosuppressants I took after the transplantation was inadequate. So, the doctor adjusted the dosage many times until it was optimal. Dr Kawin (Dr Kawin Tangdhanakanond) cared for me and advised me on everything. I was on IV the whole time since the first day after the operation. I passed urine frequently, with 12 liters measured; the urine bag required emptying every hour. At first, I was too afraid to walk due to the incisional pain. My weight decreased from 67 to 58 kilograms after a few days of recovery.”

“I am grateful to my wife for her kidney donation. It improves my health and removes the need for dialysis. Anyone experiencing kidney disease right now, don’t be scared or worried. Doctors at MedPark Hospital will give good, congenial care. The kidney transplant nurse coordinators are very helpful.”

End-stage Chronic Kidney Disease and Renal Replacement Therapy Through Renal Transplantation

In chronic kidney disease, the kidney function will gradually deteriorate, occurring over several months or even years, ultimately leading to frank kidney failure with failure to excrete waste products from the body.

In the early stages of the disease, patients display no glaring signs and symptoms, making it difficult to detect without specific blood and urine tests. By the time patients discern abnormalities and seek treatment, the kidneys have typically suffered significant damage, reaching the advanced stages of the disease, resulting in the dangerous accumulation of fluid, electrolytes, and waste products within the body.

Common symptoms of advanced chronic kidney disease include swelling in the legs and feet, increased frequency of urination, paleness, fatigue, reduced appetite, and high blood pressure.

Is Chronic Kidney Disease Curable?

End-stage chronic kidney disease is not curable. To minimize the need for dialysis or peritoneal dialysis, a physician may recommend patients avoid damaging the kidney by doing the following actions to slow down the degeneration of the kidney.

• Avoid sugary, fatty, and salty food. 
• Balanced nutrition, especially limit daily protein intake. 
• Avoid taking NSAIDs and COX-2 inhibitors.  
• Avoid smoking
• Avoid herbal medications or medicine that may affect the kidney unnecessarily, or always notify your physician before taking them.

Kidney Transplantation for Chronic Kidney Disease Patients

A significant number of individuals with end-stage kidney disease, particularly the elderly, require treatments like hemodialysis and peritoneal dialysis. Kidney transplantation is an alternative renal replacement therapy for those who find dialysis inconvenient.

Kidney transplantation involves surgically supplanting a chronic kidney patient's damaged kidney with a healthy one from a living or brain-dead donor, without removing the recipient's own kidney. This procedure significantly enhances the patient's quality of life post-transplant.

To be eligible for kidney transplantation, patients must meet these criteria:

• Have end-stage chronic kidney disease
• Willingly consent to undergo kidney transplantation
• Do not have physical or psychological conditions that would hinder transplantation or immunosuppressive therapy.
• Not have cancer or be undergoing cancer treatment
• Not have forbidden infections

For individuals willing to donate their kidneys, they must meet these conditions:

• Be aged between 18 and 60 years old.
• Be closely related to the recipient (parent, child, sibling)
• In the case of partners, be legally married for at least three years (unless they have a child together)
• Voluntarily donate their kidney without coercion or threats.
• Have a compatible cross matched blood and HLA typing results
• Possess good mental health, a clear understanding of the advantages and disadvantages of kidney transplantation, and competent to make informed decisions
• Be free from forbidden diseases.

Kidney transplantation is a complex surgical procedure with specific donor requirements. Whether the kidney is sourced from a living or brain-dead donor, a well-planned approach is essential. Recipients must also be adequately prepared. In the case of living donors, compatibility tests, including blood, tissue typing, and psychological evaluations for both donor and recipient, are necessary. The process involves submitting candidate names for consideration by a subcommittee and scheduling the transplant date.

In Noppol's case, Dr. Kawin Tangdhanakanond prescribed immunosuppressive medications following the surgery. A blood test was conducted to assess the impact of these immunosuppressants. Additionally, kidney function and waste product levels were monitored to evaluate the risk of kidney transplant rejection and complications, as well as to ensure the efficient functioning of the transplanted kidney. Dr. Kawin gave the following comment:

“The transplanted kidney is foreign to the body. Immunosuppressive medications are required as long as they remain inside your body. Initially, the dosage of immunosuppressants is relatively high after the transplantation and gradually decreases over time. In Mr. Noppol's case, the blood test indicated insufficient levels of immunosuppressants despite the initial high dosage. Therefore, it required an extended period to fine-tune the immunosuppressant dosage for him.”

Noppol had frequent urination because of the kidney failure before the transplantation. This condition led to a buildup of retained fluid within his body as the failed kidney couldn't excrete it. After successful transplantation, the new kidney functioned effectively, gradually eliminating the excess fluids. Patients should remain mindful of the potential for dehydration after the procedure. Physicians may prescribe intravenous (IV) fluids to replenish lost fluids and prevent dehydration.

Both Noppol and his wife have now resumed their regular lives. They have no detectable complications despite close regular follow-up assessments after the transplantation. They received dedicated care from transplant nurse coordinators; they are available 24 hours daily, offering guidance and scheduling appointments.

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