The kidneys act as the body’s waste disposal system, filtering waste from the blood and maintaining the ideal balance of water and electrolytes. The kidneys also produce important hormones that make red blood cells, regulate blood pressure and maintain calcium regulation.
When both the kidneys are unable to function properly – due to glomerulonephritis (inflammation of kidneys), diabetes, infection, high blood pressure, or auto-immune disease – waste builds up and the water balance in the body is affected. You may feel weak, tired, nauseated and bloated. Left untreated, the fluid-electrolyte imbalances and toxins build up to dangerous levels in the blood, which can be life-threatening.
Having kidney failure means that 85 to 90% of the kidney’s function is lost. The damage is irreversible, and dialysis or kidney transplant is needed in order to sustain life.
Most kidney failure does not happen overnight. It could be due to conditions such as diabetes, glomerulonephritis or high blood pressure. Some people lose their kidney function gradually and may not be aware that their kidneys are failing as the symptoms could be subtle or absent. Hence, some patients present for the first time with renal failure.
Symptoms of kidney failure include a combination of the following:
If you suspect that you may have kidney problems, make an appointment with a doctor as soon as possible. If your doctor suspects that you are at risk of kidney failure, you will be referred to see a nephrologist.
If you have kidney failure, also known as End-Stage Kidney Disease (ESKD), you can choose between dialysis and kidney transplant for treatment. These treatments will support removing the waste and excess fluid-electrolytes from your body, reducing the symptoms you experience.
There are two types of dialysis - haemodialysis and peritoneal dialysis, which can help to remove the waste and excess fluid-electrolytes from your body. However, dialysis will not be able to replace a fully functioning kidney and you may experience some health problems that come with kidney failure.
You will have to be on dialysis while waiting for a kidney transplant from a deceased donor in Singapore, but a living donor kidney transplant can be planned before dialysis is needed.
Kidney transplant is considered the better treatment option as it increases your chances to live a longer and healthier life. The healthy transplanted kidney can function as usual. You can return to your normal life without dialysis and you will have to take anti-rejection and other medication strictly.
In order to be eligible for a kidney transplant, you will first need to undergo a full medical and psychosocial evaluation. Not everyone is suitable for a kidney transplant. You may be asked to modify your lifestyle so as to reduce certain risks and improve your chances of a successful transplant.
A donor kidney can come from a deceased donor or from a living donor. For deceased donor kidney transplant, you will have to be evaluated by a medical team before you can be added to the national waiting list.
A living donor kidney can come from your family or close friends, and in certain cases, an altruistic donor. In comparison to a deceased donor kidney transplant, live donor kidney transplant is better as:
The transplant team will assess your suitability for a kidney transplant based on:
A donor kidney can come from a deceased donor or from a living donor.
Living Donor
A living donor kidney donation can be from relatives (e.g. spouses, siblings, parents, uncles, aunties, cousins), friends or even a stranger (altruistic donation). We all have two kidneys and a healthy individual only needs one kidney to live normally.
A living donor kidney donation can be from relatives (e.g. spouses, siblings, parents, uncles, aunties, cousins), friends or even a stranger (altruistic donation). We all have two kidneys and a healthy individual only needs one kidney to live normally.
Deceased Donor
In deceased donor kidney donation, the organ is retrieved from deceased donors who are certified brain dead and have not opted out of Human Organ Transplant Act (HOTA) or have opted in to Medical (Therapy, Education and Research) Act (MTERA).
A brain dead patient does not have any brain function and will never regain consciousness again, although the other organs such as the kidney may still function normally. It is different from being in a coma, where a person is unarousable but tests confirm that some brain functions are still present. A comatose person may still recover or regain consciousness. Organs are never taken from a person in a coma. To be certified brain dead, two independent doctors will perform thorough clinical tests and they must not have been involved in the care or treatment of the patient being certified, or belong to the transplant team.
Once a patient is diagnosed brain dead, it is recognised both medically and legally as death of the person in Singapore and organ donation can then proceed. In cases where the patient had not pledged his/her organs before passing away, family members can decide to donate his/her organs under MTERA. Assessments will be done to determine if the organs are suitable for donation.
For more information on HOTA and MTERA, visit LiveOn.
You must be:
Once you have decided to go ahead with a transplant, you will be placed on the national waiting list, where you wait for a suitable organ from a deceased donor to be available. You will still be eligible for a deceased donor transplant if you have a living donor and the living donor evaluation is ongoing.
For those who are not medically suitable or more than 70 years old, you will only be eligible for a living donor transplant.
Both you and the potential living donor will be required to go through a series of tests to ensure the transplant can proceed, and an operation date will then be scheduled.
As of 2020, the average waiting time for a deceased donor kidney transplant is 9.3 years in Singapore1.
Each time a deceased donor kidney becomes available, it will be matched to the blood group, and urgency of the patients on the waiting list, as well as some other factors according to a complex algorithm. The best-matched patient will receive the kidney.
The wait can be a difficult and long one. It is normal to feel worried and uncertain. There may be some false alarms, for instance, if the donor organ is not ideal for transplant or if you happen to be ill that day. Our transplant team will be there to offer support during these challenging times.
Be sure to keep your contact details updated so that you can be readily contacted when an organ becomes available.
1Source: NOTU Annual Report 2020
In the time leading up to a transplant, our team will work to ensure that you are in the best of health, both physically and emotionally.
Living Donor Kidney Transplant
You will need to undergo a range of tests and screenings to ensure that you are a good match with the donor, and to identify any risks involved.
Step 1
You will need to undergo several tests and screenings such as:
| Recipient blood group | Compatible donor blood group | Incompatible donor blood group |
|---|---|---|
| O | O | A, B, AB |
| A | A, O | B, AB |
| B | B, O | A, AB |
| AB | A, B, AB, O | NIL |
A blood group-incompatible live donor kidney transplant may still be done, but there is a slightly higher risk of rejection.
Step 2
The kidney transplant doctor will evaluate your condition including a full physical examination, and advise on further tests required. You will then need to undergo a chest x-ray, electrocardiography (ECG) and more detailed heart scans, as well as other investigations as required. This will take at least two weeks.
Step 3
Appointments will be made for you to see doctors from various specialties as required by your medical condition(s). For example, if you have a heart problem, you will need to see cardiologist. You will also undergo the final step of tests as needed.
You will be seen by:
Your potential donor will also be evaluated alongside this and will be required to undergo blood tests, scans and specialist evaluation. He/she will also be evaluated by a kidney transplant doctor, surgeon and psychiatrist.
These pre-transplant assessments are aimed at ensuring the best chances for a successful organ transplant. The more matches there are, the more likely your body will accept the new organ.
Step 4
Once all the tests and appointments are cleared, the application for transplant will be reviewed by the Transplant Ethics Committee (TEC) to ensure that there is no commercial transaction taking place before and after the transplant. There is a compulsory one week cooling off period after the review.
The transplant surgery can go ahead after the TEC has cleared the evaluation. The surgery will take place at least nine weeks after your first appointment.
Deceased Donor Kidney Transplant
You will also need to undergo several tests and evaluation by a kidney transplant doctor to ensure that you are suitable and fit to undergo deceased donor kidney transplant. Once you have cleared the evaluation, you will be added to the national waiting list.
While you are on the national waiting list, you will be required to provide regular blood samples so that we have this on file to match with a potential donor when the time comes. You will also be seen at NUCOT regularly so that our medical team can ensure that you remain healthy and suitable for a transplant. A match from a deceased donor is likely to be from a person who has the same blood type as you.
As in other countries, Singapore faces a continuous struggle with organ shortage. With changes to HOTA in 2009 by the Ministry of Health, the upper age limit of a kidney donor is now removed. This means that increasingly, older expanded criteria donors (ECD) will be used. With ECD, both kidneys will need to be transplanted if we assess that a single kidney transplantation may not be able to prevent dialysis after transplantation.
Dual kidney transplantation started at NUH in 2009. Explant kidney biopsies performed during organ procurement helped decide whether the kidneys should be a single or dual implant and this has been shown to be better than clinical parameters. At NUH, we provide the availability of dual kidney transplantation to patients with adult polycystic kidney transplantation by performing synchronous native nephrectomy to create adequate space. Though complex, this has opened access to patients who might have been turned down for dual kidney transplantations.
Organ procurements for children started in 2010 through MTERA. With the availability of small kidneys, paediatric-en-bloc kidneys could then be performed. Advances in surgical expertise means we can now utilise healthy organs from extreme ends of the age spectrum to save more lives through organ transplantation.
TEC is a panel of three people, including at least one doctor and one layperson (non-medical), who have been appointed by the Ministry of Health. They will determine whether there has been coercion or financial promises made to the potential live donor.
Both coercion and payment for organs are illegal and punishable under Singapore law.
To ensure that you are fit for transplant, the kidney transplant coordinator will contact you regularly to arrange for health checkups. You will need to take good care of yourself, especially while on dialysis.
Some ways to increase your chances of a successful transplant include:
For living donor kidney transplant, you should fast eight hours before your surgery.
For those on the national waiting list, it is important to remain contactable as a deceased donor kidney may be available any time. You must come down to NUCOT at NUH for the transplant immediately as the surgery must happen within a few hours after the organs are removed from the deceased donor. Do not eat or drink once you have been contacted.
You can prepare a standby bag with necessities for your hospitalisation needs.
Some of the risks include:
Your surgeon will explain the risks in detail to you during your appointment.
The transplant operation is a major procedure and your medical team will need to monitor you closely while it happens. While you are under general anaesthesia, a number of drips and devices will be put in.
An incision will be made in the lower abdomen, at the front. The donor kidney will be placed on one side of the lower abdomen.
The blood vessels from the donor kidney will then be connected to your blood vessels. The urine tube from the donor kidney will also be connected to your bladder. Your kidneys are usually not removed during the surgery.
The surgery will take about three to four hours.
After the surgery, you will be monitored in a High Dependency Unit for about three days before moving to the General Ward for another three to four days. You can be discharged six to seven days after the surgery if there are no complications.
You will also be placed on a two months' medical leave for your recovery before you resume any normal activities. The quality of life usually improves dramatically and most patients lead a healthy, fulfilling life.
The biggest challenge is to prevent organ rejection. Since the donated organ is not your own, you body’s natural response is to attack it. To prevent your immune system from attacking the transplanted kidney, you will need to take lifelong anti-rejection medications called immunosuppressants. You may also be given other medications that help the anti-rejection drugs perform better or control their side effects. If you have other medical conditions, you may need to take medicines for these as well.
Do not self-medicate or consume any traditional medicines. If you miss a dose, inform your transplant coordinator immediately. Do not take a double dose.
You will also need to do lifelong follow-ups with your kidney doctor to ensure that you are in good health and to prevent any new complications:
If you are experiencing any side effects, inform your kidney doctor.
Taking care of your transplanted organ requires utmost care and living a healthy lifestyle: exercise regularly, eat a balanced diet, manage stress and get adequate sleep.
Physical Health
Take more precautions against falling ill. Your weakened immune system (to prevent rejection) will mean you may be more susceptible to infections. Practice good hygiene at all times and stay away from people who are ill with an infectious disease (cold, flu, fever, etc.).
It is also important to monitor your health. Be aware of how you feel and do self-monitoring if required. This includes checking your weight, temperature, blood pressure and pulse daily. If you are diabetic, monitor your blood sugar.
Mental Health
It is normal to have a mix of emotions as kidney transplant is a major life change. There could be several reasons, such as mood changes due to the immunosuppressants or feeling stressed about your new lifestyle. You are not alone.
Let your transplant team know how you are feeling so that they can help to support you and adjust your medicine if needed. They may also refer you to a psychologist.
Dental Health
Practice good dental hygiene and make regular appointments to see your dentist.
Diet and nutrition
Maintaining a healthy diet and exercising regularly can help to prevent some common post-transplant complications such as heart attacks. It will also help to keep your kidney healthy.
Your transplant team will refer you to a dietitian who will work around your nutrition and diet needs and recommend you foods for your nutrition plan. You can also discuss with the dietitian if you have any questions.
Exercise
You can explore walking, jogging, cycling, swimming, and other low-impact physical activities. Check-in with your transplant team if you want to start or change your post-transplant exercise routine.
Travelling
It is important to have recovered fully before you travel overseas. Your transplant team may recommend that you wait between two and twelve months after your surgery before you travel. You will need to have enough immunosuppressants for your overseas trip too. Let your transplant team know your travel plans as you may need to take vaccines or avoid certain foods depending on your destination.
Driving
It is recommended to wait for at least two weeks after your discharge before you start driving. Some of the medications you need to take right after the surgery may cause tremors and vision changes. It will be safer to have a company in your ride when you start driving again.
Sex Life and Pregnancy Plans
Avoid having sex for four to six weeks after your transplant until your surgery site has healed to prevent the wound from opening again.
For females, your menstrual period may become more regular after the transplant. This means that you will more likely to become pregnant. It is recommended to wait one year after your transplant before getting pregnant. Check in with your doctor to find out which birth control method will be more suitable for you. If you want to conceive / get pregnant, this should be planned carefully with your transplant doctor.
The side effects may include:
Signs and symptoms that your body may be rejecting your new kidney include:
Inform your transplant team immediately if you experience any of the symptoms. However, most of the time, rejection may have no symptoms and may only be detected during your routine lab tests.
There are two types of kidney rejection that may happen after your surgery:
Acute Rejection
This happens usually within three to six months after your transplant. The acute rejection episodes mean that the body is fighting the new kidney. Less than 5% of transplant patients will have an acute rejection episode that causes a complete failure of the new kidney within the first 12 months.
Chronic Rejection
This is more common and usually occurs slowly over the years. Your new kidney may deteriorate and stop working because your immune system is constantly fighting it.
Having a rejection episode does not mean that your new kidney is not working or will be completely rejected. Your doctor will prescribe the appropriate treatment for the rejection episode to stabilise the kidney's condition. It is extremely important to follow your prescription strictly to prevent kidney rejection.
With the increased incidence of chronic disease leading to organ failure, there is a gap between organ demand and supply of donor organs.
As of 2020, more than 330 people are on the kidney transplant waiting list. The average wait time for a suitable organ donor can be as long as nine years.
Living kidney donation is key in easing the ever-present problem of organ shortage. Compared to deceased donor kidney transplantation, living kidney transplantation has significantly better graft and patient survival in the long term. Other than improved viability of the donated organ, recipients can undergo the operation earlier in a better state of health.
The success rate for living donor kidney transplant is over 99% after the first year of surgery, although after around 20 years, some kidney transplants may be lost to rejection or other causes.
Living donation is a sacrifice and anyone can be a potential organ donor. It is the noblest gift an individual can give. The criteria to determine if an organ is suitable for donation is based on a set of medical standards and not dependent on age* or gender. All that is required is a willing and suitable donor.
* If you are below the age of 21 and are interested to donate your organ, parental consent will be required.
If you are interested to donate your kidney to your family member, friend or even stranger, you must:
* If you are below the age of 21 and are interested to donate your organ, parental consent will be required.
The living donor assessment is a rigorous process to ensure that the potential organ donor is in a good state of health and that the donation will not compromise his/her own well-being. You will need to undergo a range of tests and screenings to ensure that you are a good match with the recipient and also to identify any risks.
Step 1
You will need to undergo several tests and screenings such as:
| Recipient blood group | Compatible donor blood group | Incompatible donor blood group |
|---|---|---|
| O | O | A, B, AB |
| A | A, O | B, AB |
| B | B, O | A, AB |
| AB | A, B, AB, O | NIL |
A blood group-incompatible live donor kidney transplant may still be done, but there is a slightly higher risk of rejection.
Step 2
The kidney transplant doctor will evaluate your condition, including a full physical examination and advise on further tests required. You will then need to undergo a chest x-ray, electrocardiography (ECG) and more detailed heart scans, as well as other investigations as necessitated by your medical conditions. This will take at least two weeks.
Step 3
Appointments will be made for you to see various specialty doctors as required by your medical condition(s). For example, if you have a heart problem, you will need to see a cardiologist. You will also undergo the final step of tests as needed.
You will be seen by:
Your potential recipient will also be evaluated alongside this and will be required to undergo blood tests, scans and specialist evaluation. He/she will also be evaluated by a kidney transplant doctor, surgeon and psychiatrist.
Step 4
Once all the tests and appointments are cleared, the application will be reviewed by the Transplant Ethics Committee (TEC) to ensure that there is no commercial transaction taking place before and after the transplant. There is a compulsory one-week cooling-off period after the review.
The transplant surgery can go ahead after the TEC has cleared the evaluation. The surgery will take place at least nine weeks after your first appointment.
Yes, the decision to donate is 100% voluntary. You can withdraw from organ donation any time, up till the day of surgery. Inform your primary doctor about the withdrawal and your decision will be kept confidential.
You can choose who you want to donate your kidney to, as long as the assessments have deemed that you are healthy and a match to the recipient, and you have made a completely voluntary decision. You may also choose to be an altruistic donor.
If your blood group is incompatible with your intended recipient, the transplant team may suggest a paired kidney exchange transplant. This happens when there is another donor who is also incompatible with his/her recipient but both donors are a good match for the other's recipient. This results in two new compatible pairs, lowering risks of rejection and amount of immunosuppression required. Other patients on the national waiting list are also able to move up.
TEC is a panel of three people, including at least one doctor and one layperson (non-medical), who have been appointed by the Ministry of Health. They will determine whether there has been coercion or financial promises made to the potential live donor.
Both coercion and payment for organs are illegal and punishable under Singapore law.
You can live a normal healthy life with one kidney. Donating your kidney will not affect your general health, life span or energy level. Compared to the general public, most kidney donors have equivalent or better survival rate.
There are no risks to fertility after kidney donation and female donors can have successful pregnancy and bear children as per normal, although there is a slightly increased risk of high blood pressure during pregnancy.
Donors will be monitored lifelong, as some kidney donors may be at slightly higher risk for having:
Medicine is an ethical profession. No doctor will risk one life to save another. As a potential organ donor, organ donation will only be considered after every effort to save your life has been exhausted by the medical team. There are seven strict criteria that must be confirmed by two independent doctors, who were not involved in your medical care, before brain death can be certified and organ donation is considered.
In Singapore, Singapore Citizens and Permanent Residents above the age of 21 and above, and are not mentally disordered, are included under the Human Organ Transplant Act (HOTA) unless they have opted out. HOTA allows for organs (kidney, liver, heart and cornea) to be donated in the event of death for the purpose of transplantation.
Over the years, HOTA has been widened in scope so as to grow the organ donor pool. This has meant more people waiting on the transplant list have successfully gotten a life-saving organ. Despite the widening of HOTA, hundreds of people are still waiting for an organ to become available. This is where living organ donation comes in, an area also under the regulation of HOTA. Living organ donation further increases the chance that a suitable kidney can be found.
Those who are under HOTA will not only have a chance to help others, but also have a higher priority on the waiting lists should they need an organ transplant. For those who had opted out of HOTA, you will receive a lower priority for receiving an organ on the national waiting list should you require an organ transplant in the future. This will apply specifically to the organs which you have opted out from.
If you have opted out before and would like to opt back in, you will need to complete the Withdrawal of Objection Form and send it to the National Organ Transplant Unit.
For deceased donor organ donation, bodies of those with chronic illnesses or cancer may still be used for education or research purposes under the Medical (Therapy, Education and Research) Act (MTERA).
To find out more about HOTA and MTERA, visit LiveOn.
Yes, anyone above 18 years old can opt into Medical (Therapy, Education and Research) Act (MTERA) to donate their organs and/or tissues for the purposes of transplant, education, or research after they pass on.
Fill in the Organ Donation Pledge Form and send it in to the National Organ Transplant Unit. You are encouraged to discuss your decision to pledge your organs and/or tissues with your family members so that they are aware of your decision and can advocate for your wishes in the event of your death.
MTERA is an opt-in scheme, whereby anyone aged 18 years old and above can pledge your organs or any body parts for the purposes of transplant, education or research, after you pass away. You can choose to donate all your organs and tissues or specify those you wish to donate.
In cases where you have not pledged your organs before passing away, your family members can also decide to donate your tissues and/or organs under MTERA on your behalf, if they wish to do so.
For more details on MTERA, visit LiveOn.
You will not be able to choose who you donate your kidneys to. Your kidneys will be matched to the blood group, weight and urgency from the pool of patients on the national kidney transplant waiting list.
The hospital bills for any organ removal-related procedures and tests will not be charged to the donor's family.
All bodies are cared for with utmost respect. Any incisions made during the removal of organs are carefully repaired during the procedure and you will still be able to have an open casket funeral.
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