Kidney Transplant Recipient

This is an educational document is designed to let you know what will happen when you have an organ transplant. The document describes:

• The medical tests you will have before the transplant
• The transplant surgery and follow-up care

This process is known as informed consent. It is important that you read this document and ask any questions about any of the information that you do not understand.

THE EVALUATION PROCESS

Patients Requiring a Transplant

Patients that go through an evaluation for a transplant are required to meet basic criteria, called selection criteria.

Selection criteria for kidney transplantation are listed below. For kidney transplants, patients must meet one of the following criteria:

• Being on dialysis
• Having significant kidney disease even if not on dialysis (may be described as having kidney function of 20% or less)
• Needs another organ transplant, such as a heart or liver, may be considered for transplant with slightly higher kidney function

Selection criteria for kidney-pancreas transplantation include:

• Being 18 years of age or older
• Having Type 1 Diabetes that is not well-controlled by medicines such as insulin
• Being on dialysis or having significant kidney disease even if not on dialysis (may be described as having kidney function of 20% or less)
• Having difficulty in daily activities or quality of life related to diabetes, such as not being able to tell that your blood sugar is dropping

Selection criteria for pancreas transplantation:

• Being 18 years of age or older
• Having Type 1 Diabetes that is not well-controlled by medicines such as insulin
• Having difficulty in daily activities or quality of life related to diabetes, such as not being able to tell that your blood sugar is dropping

There may also be some reasons that transplantation is not the best option. These reasons are called contraindications and may include:

• Having an infection that has not been treated
• Having cancer
• Not following your doctor’s advice (non-adherence or non-compliance)
• Having problems with alcohol or drugs
• Smoking
• Being overweight (kidney transplant patients need to have a Body Mass Index (BMI) of 38 or less; pancreas and kidneypancreas patients need to have a BMI of 35 or less)
• Having other significant medical problems, such as heart, lung, or blood vessel problems, that could make transplant more risky for you
• Having difficulty walking, driving, taking care of yourself (cooking, bathing, cleaning the house), etc.

There may be other reasons based on your specific situation that make the transplant team believe that transplant may not be the best option for you. The transplant team can further discuss the selection criteria and contraindications and how they apply to you during your evaluation.

You will have many tests to ensure that you are eligible for an organ transplant. In addition, before the surgery, you will meet with doctors and other members of the transplant team. These tests and appointments will help the transplant team decide if a transplant is the right treatment for you, if there are any other treatments besides transplantation that can help you, and if you are well enough to have transplant surgery.

Transplant Team Members

Program Director

The Program Director leads and oversees the transplant program.

Transplant Surgeon

The transplant surgeon meets with you to discuss the organ transplant process, including the transplant surgery itself, the risks of the surgery, and any problems you might have after your transplant. The surgeon will also talk to you about any other treatments that you might be able to have instead of the transplant.

Transplant Doctor

The transplant doctor meets with you to discuss the organ transplant process. This doctor will also look at your medical history to help determine if a transplant is the right therapy for you, why you have had organ failure and decide on the types of tests you should have before the transplant.

Transplant Coordinator

The transplant coordinator provides support throughout the transplant process and works with you to make sure your needs are met. The transplant coordinator will explain the entire transplant process and will answer your questions so that you can learn as much as possible about your transplant.

Social Worker

The social worker meets with you to see how well you can cope with the stress of a transplant, and how well you will be able to follow a demanding treatment plan. The social worker will also help you identify family and friends who can help you during this time. Alternative financial resources (e.g. fundraising, assistance programs) can be explored if needed.

Financial Counsellor

The financial counsellor discusses the costs of the organ transplant, medications and care. The financial counsellor also helps you understand your insurance coverage. It is important that you are aware of and understand any costs that may not be covered by your insurance.

Psychiatrist (if applicable)

The psychiatrist performs a more thorough psychiatric examination to make sure you are prepared for a transplant. Some patients who have abused drugs or alcohol may have to go through a rehabilitation program and stay away from drugs and alcohol for a period of time in order to start the transplant program.

Clinical Dietitian

Assesses your diet to learn what you eat on a daily basis and teaches you about eating a healthy diet.

Pharmacist

The pharmacist reviews your medications and assesses for potential drug interactions before and after transplant. The pharmacist can also review education regarding the transplant medications.

Please note that you may see other specialists, depending on your overall health.

Tests and Procedures

You will undergo a variety of tests to understand your eligibility for an organ transplant. The following is a list of the most commonly performed tests. Some of these tests may be included in your evaluation process, whereas other tests may need to be performed depending on the results of these tests.

Blood Tests

Blood tests help determine how serious your organ disease is, and whether other organs are also diseased. Blood tests will also determine your blood type for organ matching and will screen for immunity or the presence of specific viruses (including HIV/AIDS). You may have additional blood tests to see how well your other organs are functioning as well.

Chest X-Ray

A chest x-ray helps your doctor determine if there are any problems with your heart and lungs.

Urine Tests

Urine tests screen for any urinary tract diseases and may also test for drugs and alcohol in your system.

EKG, Echocardiogram, Stress Test and Cardiac Catheterization

These tests check your heart beat, heart valves and vessels to see how well your heart is working.

Ultrasound

An ultrasound helps your transplant team assess the size and shape of your diseased organ.

CT and/or MRI Scan

These scans help the doctor learn how badly diseased your organ is. They also check the blood vessels where the new organs will be connected.

Biopsy

A biopsy is not always necessary. When required, it is usually done with a needle to remove a tiny portion of the diseased organ. The sample is examined under a microscope to give the doctor information about what is causing your organ disease.

Pulmonary Function Test

This is a breathing test to examine how well your lungs are working. This test may be needed if you have a history of smoking or have problems with your lungs.

Colonoscopy/Endoscopy

This is a method of looking at your gastrointestinal tract with the use of a special flexible instrument. With this procedure, your doctor can look for abnormalities inside your body, check for any tumors or take a biopsy.

Additional health screening assessments and/or vaccinations or immunizations as required

The Decision-Making Process

Once you have completed all of the required tests, your case will be discussed by the transplant team during a Patient Selection Committee meeting. The decision about your organ transplant and your ability to actually have the transplant will be made by the team (no one person makes the decision alone). The team will consider whether you are medically, surgically, and psycho-socially ready for a transplant, and whether other treatments are available and/or appropriate.

If you are accepted as a candidate for a kidney transplant at Cleveland Clinic Abu Dhabi, you will be notified. If you have a living related kidney donor, he or she will be assessed for feasibility.

There is a chance that while waiting for an organ to become available, you may become too sick to have transplant surgery. If that happens, we may need to take you off the Transplant Program temporarily, or even permanently.

You will also need to be re-evaluated periodically while waiting for a transplant. It may be determined during the re-evaluation stage that you are no longer eligible for a transplant.

Please note:

YOU OR YOUR DESIGNATED FAMILY MEMBER(S) HAVE THE RIGHT TO REFUSE A TRANSPLANT PROCEDURE.

YOUR TRANSPLANT SURGEON AND DOCTOR WILL DISCUSS OTHER TREATMENT OPTIONS WITH YOU.

Transplantation Alternatives

Alternatives to kidney transplantation may include:

• Continued medical treatment
• Beginning or continuing with dialysis treatments

Alternatives to pancreas transplant include continued medical treatment which may consist of:

• Insulin injections
• Use of an insulin pump
• Continuous blood sugar monitoring

Types of Organ Donors

Deceased Donors

The donated organ is from a person who had shared his or her wish to donate one or more organs and has been declared dead by a doctor.

Brain Death Donor: The donor has suffered irreversible brain damage and is kept on a breathing machine so that the heart continues to beat and maintain blood flow in the body.

Donation after Cardiac Death (DCD): Organs may be used from people who have been declared dead because their hearts have stopped beating. This means that there is no blood circulating through the organs for a short period of time before it is recovered.

High Risk Donor: Organs may be used from people that have a social or medical history that may increase the chance of transmissible diseases or medical conditions.

Examples of behaviors leading to a donor being considered high-risk may include:

• Donors that engaged in sexual intercourse with someone that was known or suspected to have HIV, Hepatitis C or Hepatitis B within the past 12 months
• Donors who have high risk behavior
• Donors that injected drugs for non-medical reasons or donors that had sexual intercourse with someone fitting this description within the past 12 months
• Donors that have been in jail, prison or a juvenile correctional facility for 72 consecutive hours or longer in the past 12 months
• A child 18 months old or younger that was born to a mother known to be infected with or at increased risk for HIV, Hepatitis C or Hepatitis B
• A child who has been breastfed within the last 12 months and the mother was known to be infected or at increased risk for HIV
• Donors that have been on hemodialysis within the past 12 months

You may also be asked to consider donors with positive lab results such as Hepatitis B or C depending upon your circumstances.

Living Donors

Receiving a transplant from a living donor is an option for some patients requiring a kidney transplant. In this case, one healthy person’s kidney is removed and transplanted into you. The donor must be in good health and have the appropriate blood type in order to donate.

The living donor must be a relative. The donor’s evaluation is overseen by his or her own care team. A decision is then made as to whether this person is an appropriate donor for you. If this is an option for you, you and your potential donor will be given more detailed information.

If the living donor is not an acceptable match to you but is otherwise a suitable donor, you may have the option of participating in a paired donation program, where your donor’s kidney goes to a different recipient, and in return you will receive a living donor kidney from another individual.

Transmissible Diseases or Medical Conditions

The Transplant Center and the Organ Procurement Organization strive to minimize the transmission of diseases from the donor to the recipient. Screening tests are performed on all potential donors to determine medical acceptability.

Although rare, and even with screening, there is a risk of the transmission of diseases and medical conditions. These include, but are not limited to, the human immunodeficiency virus (HIV), Hepatitis B virus (HBV), hepatitis C virus (HCV), cancer and malaria.

The Organ Offer and Related Risk Factors

When a donor organ becomes available, a transplant coordinator will contact you and discuss the offer with you. The coordinator will share information with you regarding the donor, such as age, medical history, social history, and condition of the organ(s). You and the transplant coordinator will make a decision together regarding the acceptance of a donor organ. If you accept the organ, you may need to come to Cleveland Clinic Abu Dhabi immediately.

If the transplant team decides that the organ cannot be used, you will be sent home until another potential donor is identified.

Please note:

YOU OR YOUR DESIGNATED FAMILY MEMBER(S) HAVE THE RIGHT TO REFUSE A DONOR ORGAN.

THE SURGICAL PROCESS

The Surgical Team

The procedure is performed in the Operating Room and you will be supported and monitored by anesthesia Caregivers. One of the Cleveland Clinic Abu Dhabi Transplant surgeons will perform the transplant surgery. This may or may not be the same individual you saw during your evaluation for transplant. There are also additional Caregivers in the room to assist with your surgery.

The team includes the following Caregivers:

• Surgeon
• Scrub Nurse
• Circulating Nurse
• Anesthesia Staff Physician
• Organ Preservation Specialist
• Perfussionist (if applicable)

The Transplant Operation

During the transplant operation, you will be put under general anesthesia, which means that you will be given medications to put you to sleep, block pain and paralyze your body throughout the surgery. You will also be placed on a machine to help you breathe. The anesthesiologist will talk with you in more detail about the anesthesia before your surgery.

Once you are asleep, a breathing tube, intravenous lines, and a urinary catheter will be placed in your body. To keep you from throwing up, you may have a tube placed through your nose into your stomach to drain the contents of your stomach.

The transplant surgeon will make a relatively large incision (cut) in your abdomen and/or flank (side). Through this incision, the donated organ will be placed into your body. Generally, your own organ(s) will not be removed unless the surgeon decides it is necessary.

At the end of the surgery, the surgeon may place drains in your abdomen to allow fluids and blood to drain and may place a stent and a catheter to assist you with urination. It is normal to have some blood or fluid loss during the surgery. Special mechanical boots or sleeves will be placed around your legs to keep blood flowing through your legs in order to prevent dangerous blood clots.

Potential Surgical Risks

There are risks in all surgeries, especially surgeries that are done under general anesthesia. Many complications are minor and get better on their own. In some cases, the complications are serious enough that you might need another surgery or medical procedure.

Included is a general list of the most commonly reported adverse outcomes and complications that may affect kidney and pancreas transplant recipients. Please be aware that there may be other potential medical complications (short and/or long term) that have not been listed or are currently unforeseen.

POST-TRANSPLANTATION

Potential Risks Post-Transplantation

Delayed Graft (Transplanted Organ) Function

There may be a delay in the function of your transplanted organ; in other words, the organ may not work properly right away. Such a delay may increase the length of your hospital stay and increase the risk of other complications. It’s possible that the transplanted organ will never function normally. If this occurs, you may need to be re-evaluated for another transplant.

Primary Graft (Transplanted Organ) Non-Function

In this situation, the organ does not work at all after the transplant. The reason this happens is not known, and it is not possible to predict when this may happen. If this occurs, you may need to be evaluated and listed for another transplant.

Thrombosis

This is a clot that develops in one of the major blood vessels going to your transplanted organ. Thrombosis can cause organ failure. Most patients who develop thrombosis will need a second operation to remove the blood clot and/or the transplanted organ.

Rejection

Rejection occurs when your immune system sees your new organ as foreign body (not a part of your body) and tries to attack it. Your body deals with this “foreign” body the same way it deals with germs, by attacking it and trying to destroy it. After your transplant, you will be taking medications (known as immunosuppressive medications) for the rest of your life to try to prevent rejection from happening.

There are two types of rejection: acute rejection and chronic rejection.

Acute Rejection

Although you will be taking immunosuppressive medications for the rest of your life, your body may still reject the new organ. Rejection happens most often in the first three to six months after transplant, but it can occur at any time. Generally, if the rejection is diagnosed early, it can be treated with medications. The only way to confirm this is with a biopsy. Rejection episodes may be treated in the outpatient setting or may require hospitalization.

Signs and symptoms of acute rejection may include the following:

• Fever
• Flu-like symptoms (chills, aches, headaches, nausea, vomiting, diarrhea)
• Fluid retention and/or sudden weight gain
• New pain or tenderness around the transplanted organs
• Worsening organ function (decrease in urine output, abnormal lab results)

Chronic Rejection

This type of rejection occurs over time. It is caused by scarring of the organ tissue that is not always reversible. It can take a long time for chronic rejection to develop and damage the organ. Sometimes we may adjust your medication to slow down the process or to try to reverse it, but there is no definitive treatment for chronic rejection. The causes of chronic rejection are not totally understood, but may include: not taking the correct doses of immunosuppressive medications, missing doses of immunosuppressive medications or several episodes of acute rejection.

Transplanted Organ Failure

In some situations, the transplanted organ stops working. This may happen suddenly or gradually over time.

Infection

The most common types of infections that transplant patients get are the same as everyone else, such as the common cold or bronchitis. However, the infection can last longer and be more serious in transplant patients.

Signs and Symptoms of Infection

Because of the immunosuppressive medication you are taking, symptoms of infection might be less obvious. Even if you have mild symptoms, you should report them to your transplant coordinator.Signs and symptoms of infection include the following:

• Fever (37.8 degrees Celsius or higher)
• Flu-like symptoms (chills, body aches, fatigue, dizziness, nausea, vomiting)
• Cold symptoms that last longer than one week
• Chest discomfort, cough, or shortness of breath
• Abdominal pain, tenderness over the transplant site, diarrhea
• Problems with urination, including pain, burning, or having to go more often
• Redness, warmth, swelling, or drainage from a skin wound
• Headache
• Myalgias (muscle aches and pains)
• Tiredness and weakness

You are at a slightly higher risk than most people for getting the flu, and you may have a more severe case. You are also more likely to pick up a secondary infection, like a sinus infection or bronchitis.

Transplant recipients get pneumonia at about the same rate as the general population. Transplant patients are encouraged to get the flu and pneumonia vaccines.

The type of infections that we are most concerned about after your transplant are called opportunistic infections. These may be caused by viruses, fungi, or bacteria and may affect people who do not have a “normal” immune system. The organisms that cause opportunistic infections may be in the environment, or may be in our body in limited numbers. Ordinarily, the body’s natural immune system controls the numbers of these organisms and prevents them from causing harm. However, after a transplant, the immunosuppressant medications you will be taking will weaken your body’s natural response.

Examples include:

Cytomegalovirus

Cytomegalovirus (CMV) is very common in the general population, but has little or no effect on a person with a healthy immune system. The virus can be activated when you have transplant surgery, or you may receive the virus from your donor. This virus is treatable and you will be screened on a regular basis after your transplant surgery to make sure it has not activated. Many patients also receive preventative treatment with the medication Valcyte.

Herpes (HSV)

Transplant patients are at greater risk of developing viral infections, including herpes simplex (“cold sores”) and herpes zoster (“shingles”). As with CMV, much of the adult population has been exposed to the herpes viruses in the form of cold sores, shingles, or chicken pox. In some cases, the virus, which usually remains inactive, will be reactivated because your immune system is weakened. The medication Acyclovir may be prescribed for you.

Pneumocystis Carinii Pneumonia

All patients with weakened immune systems are at risk for developing pneumocystis carinii pneumonia (PCP), a bacterial lung infection. Your doctor can reduce your risk of getting this disease by treating you before you get it. The treatment includes the medications trimethoprim/sulfamethoxazole (Septra), Dapsone or pentamidine (Nebupent) for those who are allergic to sulfa drugs.

BK Virus

BK Virus is a member of the polyoma virus family. Many people in the general population have been exposed to this virus, but are not affected by it. It will remain in the body in an inactive state in those with a healthy immune system. After receiving a kidney transplant, the virus can be reactivated and cause damage to the transplanted kidney. There are treatments available for BK Virus, and you will be screened for activation periodically after transplant.

Toxoplasmosis

Toxoplasmosis is a protozoan disease that affects the central nervous system in humans. The disease can be lifethreatening to patients with weakened immune systems. The toxoplasmosis organism is found in many mammals and birds. The occurrence of this infection can be reduced with proper precautions. The infection can be treated with the medications sulfadiazine (Microsulfon) and pyrimethamine (Daraprim).

Other Risks

• Discomfort or acute pain or chronic pain
• Fatigue
• Gastrointestinal symptoms, including bloating, gas, constipation, nausea, vomiting, slowing of the gastrointestinal activity
• Post-operative infections, including urinary tract, wound, or bloodstream. These may require antibiotics
• Bleeding which could possibly require a transfusion of blood products. If you have bleeding during or after your surgery, you may need blood transfusions or blood products. You may also need another operation to control the bleeding. Although screened, blood transfusions may contain bacteria and viruses that can cause infection. Although rare, these infections include, but are not limited to, the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV)
• Blood clots. Despite attempts to prevent them, blood clots may occasionally develop in the legs. These clots can break free and move through the heart, lungs, or brain which may cause serious problems with breathing, circulatory function,stroke, or death. Blood clots are treated with blood-thinning drugs that may need to be taken for a long time and/or other treated with other therapeutic procedures
• Nerve damage. This can happen from direct contact with the chest or abdomen, or from pressure or positioning of the arms, legs, or back during the surgery. Nerve damage can cause numbness, weakness, paralysis, and/or pain. In most cases, these symptoms are temporary, but in rare cases they can last for long periods of time or even become permanent
• Cardiac complications such as an irregular heartbeat, heart attack or failure
• Pulmonary complications such as atelectasis (collapse of the air sacs in the lungs) or pneumonia
• Death
• Scars
• Injury to parts of the body in the chest and/or abdomen
• Pressure sores on the skin due to positioning of the body
• Burns caused by the use of electrical equipment during surgery
• Damage to arteries and veins
• Lymphocele (fluid collection) around the transplanted organ(s)
• Obstruction due to scar tissue causing narrowing of kidney or pancreas drainage systems
• Leaks in the connections of the kidney or pancreas drainage systems
• Multi-system organ failure
• Sleep disturbance
• Complications from anesthesia (examples include but are not limited to nausea, vomiting, allergic reaction to medications, sore throat from the breathing tube, sleepiness, headache)

Psychosocial Risks

• Potential for body image problems
• Possibility of post-surgery adjustment problems
• Potential impact of transplantation on the recipient’s lifestyle
• Emotional/psychological disturbances
• Depression or Generalized Anxiety
• Post-Traumatic Stress Disorder (PTSD)
• Anxiety related to depending on others
• Feelings of guilt

Financial Risks

• Personal expenses of travel, housing, and lost wages related to the transplantation process might not be reimbursed
• Child care costs
• Possible loss of employment
• Potential impact on the ability to obtain future employment
• Potential impact on the ability to obtain or afford health, disability and life insurance
• Possibility that future health problems related to the transplant may not be covered by insurance

Post-Transplantation Recovery and Care

After your surgery, you will be taken to the Post Anesthesia Care Unit (PACU) or Intensive Care Unit (ICU) until you have recovered from the anesthesia and there are no signs of immediate or early complications.

Your breathing tube will be removed as soon as you are awake and alert and able to breathe on your own.

After your stay in the PACU or ICU, you will be transferred to a specialized transplant recovery floor, where you will be closely watched until you are discharged. Immediately after the surgery, some pain and discomfort is normal. The nursing staff will carefully monitor this and will give you medication to control the pain. Most transplant patients see a sharp decrease in pain two to three days after surgery. Getting out of bed and starting to walk will greatly help.

How long you have to stay in the hospital will depend on how quickly you recover. You will remain in the hospital as long as your doctor feels it is necessary. The time can vary, depending on how sick you were before the transplant, and/or if there are any problems after the surgery.

After you leave the hospital, you will still be recovering. For the first four to six weeks, you will have some limits on your daily activities. If you have any complications after the surgery, your recovery time may be longer.

The transplant team will follow your progress very closely. You will need to come in for frequent examinations, laboratory tests, and other procedures to see how well your transplanted organ is working. The frequency of laboratory tests and clinic visits will decrease over time as you become more stable. You may have to have biopsies to diagnose possible complications (including rejection of the new organ or your original disease returning). Patients who receive a kidney transplant will also have routine biopsies periodically to look for potential problems. If you have any signs of rejection, infection or any other complication of transplantation, you may have to be re-admitted to the hospital.

The benefits of organ transplantation cannot come from surgery alone, but they also depend on you. You have to follow the demanding treatment plan that the doctors and multidisciplinary team prescribe. However, even then, there are risks and complications to having an organ transplant. You must be aware of the potential risks and complications that may result in serious injury and even death.

Your doctors cannot predict exactly how your body will respond to an organ transplant. It is never fully known how the condition that caused your organ disease will affect your new, transplanted organ. The operation itself is complex and the risks remain high for many patients. After the transplant, you may still need to have biopsies, surgeries, other procedures or readmissions to the hospital.

Immunosuppressive Medications

Immunosuppressive medications work to keep your body from rejecting your transplanted organ. On the day of your transplant, you will start taking antirejection (immunosuppressive) medications.

The first type, called induction immunosuppression, is used the day of the transplant. Induction immunosuppression is usually achieved by using strong antibodies that block the cells that are involved in rejection. These drugs, which include Thymoglobulin and Simulect, may also be used during episodes of rejection.

The second type of antirejection medication, called maintenance immunosuppression, is used after the procedure for the lifetime of your transplant.

The following is a list of the most commonly used maintenance immunosuppressive medications and some of their side effects. You may be taking some of these medications.

It is important to remember that not every patient will get every side effect. Generally, the side effects are related to the dose you are taking; this means that the higher the dose, the greater the possibility of having side effects. However, over time, we may be able to reduce the dosage of your medications, which should lessen the side effects.

Tacrolimus (Prograf)

• Nephrotoxicity (weakened kidney functions)
• Headaches, tremors, confusion, sleep disturbance, anxiety
• Hair loss
• Nausea, diarrhea
• Increased blood pressure
• Increased blood sugar (diabetes)
• Increased potassium levels
• Increased risk of infection
• Increased risk of cancer

Sirolimus (Rapamune)

• Increased cholesterol and triglycerides
• Decreased platelets
• Decreased white blood cell count
• Increased cholesterol and triglycerides
• Skin rash
• Acne
• Joint pain
• Low potassium levels
• Diarrhea
• Swelling

Mycophenolate (CellCept or Myfortic)

• Decreased white blood cells
• Decreased red blood cells (anemia)
• Infections (especially viruses)
• Diarrhea (or other gastrointestinal issues)

Prednisone

• Weight gain
• Acne
• Sodium and fluid retention
• Increases in blood pressure
• Muscle weakness
• Osteoporosis (loss of bone mass)
• Increased cholesterol and triglycerides
• Increased blood sugar (diabetes)
• Cataracts
• Stomach ulcers, heartburn
• Mood swings
• Increased risk of infection
• Sun sensitivity
• Fragile skin

Other Medications

Your doctor will prescribe anti-infection medications to protect you from the opportunistic infections described above. As your immunosuppressive medications are gradually reduced during the first year, we may be able to discontinue the antiinfection medications. You may also be on additional medications, such as blood pressure medications, cholesterol-lowering medications, diabetic medications and others, depending on your overall health.

NATIONAL AND TRANSPLANT CENTER-SPECIFIC OUTCOMES

Outcomes, including graft and patient survival for Cleveland Clinic and other kidney and pancreas transplant programs in the United States, are available at www.ustransplant.org and www.optn.org. These outcomes for patient and graft (transplanted organ) survival are listed below.

Kidney Transplant SRTR Report:	Release Date: 12/16/15
	Cleveland Clinic	United States
Adult 1 yr. Graft Survival	95.15%	94.96%
Adult 1 yr. Patient Survival	98.98%	97.42%
Pediatric 1 yr. Graft Survival	100%	96.11%
Pediatric 1 yr. Patient Survival	100%	99.33%

Kidney-Pancreas Transplant SRTR Report:	Release Date: 12/16/15
	Cleveland Clinic	United States
Adult 1 yr. Graft Survival: Kidney	88.89%	95.65%
Adult 1 yr. Patient Survival: Kidney-Pancreas	88.98%	97.40%
Adult 1 yr. Graft Survival: Pancreas	Pancreas graft survival is not currently reported by SRTR.

Pancreas Transplant SRTR Report:	Release Date: 12/16/15
	Cleveland Clinic	United States
Adult 1 yr. Patient Survival: Pancreas alone	100%	96.78%
Adult 1 yr. Patient Survival: Pancreas after Kidney Transplant	100%	94.66%
Adult 1 yr. Graft Survival: Pancreas	Pancreas graft survival is not currently reported by SRTR.

ADDITIONAL INFORMATION

Notification Regarding Availability of Transplantation Services

The Cleveland Clinic Abu Dhabi Transplant Center makes every attempt to provide transplantation services to our patients based on the availability of the Transplant Team. It is expected that each program will function continuously and without interruption. However, there may be circumstances under which the Transplant Center or a specific program may be either temporarily or permanently closed. These circumstances may include but are not limited to:

• Lack of required doctor or surgeon coverage
• Environmental catastrophe/natural disaster

If any of these were to occur, the Transplant Center would notify you of the closure and assist you in making alternative transplant arrangements if needed.

Health and Life Insurance

After you have an organ transplant, health insurance companies might consider that you have a pre-existing condition, and might refuse payment for medical care, treatments, or procedures. After the surgery, your health insurance and life insurance premiums may increase and remain higher. In the future, insurance companies might refuse to insure you.

Right to Refuse Transplant

You have the choice not to undergo transplantation. If you choose to have an organ transplant, you have the right to refuse a particular organ offered. If you do refuse a particular organ, you will not lose your place on the waiting list.

However, if you continue to refuse to accept healthy organs, this may indicate that you do not want a transplant and that you should be removed from the waiting list. If you do not undergo the transplant surgery, your condition is likely to worsen and shorten your life.

Please note: You will be asked to sign a consent form acknowledging that you have received this document and stating that you agree to proceed with the evaluation process at your first appointment.