The first recorded kidney transplant took place in Ireland in 1964, and in the more than half a century that has followed, more than 5,000 organs have been transplanted. Nowadays, more than 3,500 people are alive in Ireland thanks to a successful organ transplant, having benefited from the increased life expectancy and enhanced quality of life the procedure can bring.
However, once the early threat of organ rejection is over, life with somebody else’s kidney or liver is not without its challenges. Transplant recipients have to make key adjustments to their lifestyles, and choices that others take for granted require careful consideration.
Prof Aiden McCormick of the specialist liver unit at St Vincent’s Hospital, Dublin, explains that different transplant patients will encounter different challenges, and adds that it depends on factors such as the age of patient and their general health beforehand.
Patients are not normally considered for liver transplant if their life expectancy is less than two years with their current liver. “Liver transplantation, in particular, is an excellent operation and for young people who have liver transplants, the life expectancy afterwards is believed to be 30 years plus. There really is an enormous bonus in terms of life expectancy if you have a transplant,” he says.
Between 70 and 80 per cent of those who were working before their transplant will return to work within about three to six months of their transplant, and people can get back to driving within about six weeks.
Pregnancy is a major issue for most young women who receive a transplanted organ, McCormick says.
“In general we don’t like people getting pregnant within about 12 months of a transplant because they are on a lot of immunosuppressive drugs afterwards. We reduce to maintenance doses, but we like to make sure the liver is working well on minimal doses first.
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“There are quite a lot of medications that we use for immunosuppression and many of these would be dangerous during pregnancy.”
A pregnancy in someone who has had a transplant is inherently high-risk, with certain complications of particular concern such as gestational diabetes. There is also a higher risk of needing a Caesarean section and having a premature birth and/or low birth weight.
“If it is managed carefully, we get very good results. We have had at least 20 babies born to ladies who have had liver transplants and they have done really well,” McCormick says.
While male fertility isn’t generally affected, in recent months there have been warnings about one of the immunosuppressant medications used post-transplant, mycophenylate, and a potential risk with men taking it whose partners are pregnant.
“We use it a lot and we have always been very careful to stop it in females before pregnancy but there are now concerns that it should be stopped in males too, as it may get into the sperm and cause problems with the foetus.
“This is a theoretical risk, and I don’t think there have been any other cases, but we will have to look at medications in males too.”
The interesting thing about liver transplant is that women with the condition autoimmune hepatitis often have trouble conceiving but following a transplant their fertility is hugely improved, he adds.
“Therefore, we have to have a conversation with those ladies to start using contraception as they may have not been, in order to avoid an inadvertent pregnancy.”
According to McCormick, one of the bigger problems in older patients is an increased risk of hypertension and diabetes, as well as obesity, meaning an increased risk of vascular disease, in terms of stroke and heart attack.
Typically, patients may be underweight before their transplant and they are encouraged to eat more and gain weight but this advice is reversed post-transplant.
“A lot of transplant patients tend to put on a lot of weight the first year or so after transplant, and we do warn them about that and advise them to watch their diet and get plenty of exercise,” he explains, adding that there is a specific transplant dietitian who works with the patients on these aspects.
One way in which they can be restricted is in their choice of holiday destination. McCormick explains that he prefers patients not to travel to countries where the quality of medical services may be poorer or where they might be at risk of major infectious diseases such as malaria or dengue fever, for example. Transplant patients are more prone to infections and are thus more likely to get common problems such as travellers’ diarrhoea and respiratory infections following long flights.
“The first few years after liver transplant we have to be careful about foreign holidays. We say to the patient, if you think you wouldn’t be happy to be in a hospital in the country you are visiting, or get a blood transfusion there, then don’t go. Stick to safer territory and countries with good medical services.”
Smoking and drinking should be avoided. With transplant patients there is an increased risk of cancer due to immunosuppression medication, and lung cancer is one they are particularly susceptible to if they smoke.
“Most of the transplant patients we see, it is not related to alcohol abuse, but none of them should really drink alcohol at all post-transplant,” adds McCormick.
Mark Murphy of the Irish Kidney Association echoes many of McCormick’s comments regarding the vastly improved quality of life that transplant patients enjoy, saying transplant medicine has progressed to allow this.
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“For example, years ago women were just told not to become pregnant but now they do and it is very successful.
“I often say that with dialysis you’ve got half a life but with a transplant you get back 95 per cent of your life.
“It isn’t a cure, however, and patients with kidney transplants still have end-stage kidney disease, albeit managed with a kidney transplant.”
Murphy reiterates that the increased risk of developing cancer is significant for a transplant patient due to the use of immunosuppression – by year 25 of a patient’s new kidney, some 80 per cent will have had a cancer episode, he says.
“The vast majority of these will be skin cancers, and what they say is that the kidney transplant patient is 250 times more likely to get a skin cancer than you or I, so they are closely monitored.”
For the 500-plus patients who receive transplanted organs each year in Ireland, their lives will never be the same again.
“It is modern medicine that has got us there. The longer we are dealing with immunosuppression, the more we are able to manage it, and the drugs have become more refined.
“There are between 3,500 and 4,000 people alive in Ireland today thanks to an organ transplant.”
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