Here is a typical conversation that I have with a potential kidney transplant recipient.
Dr. Barry: Good morning. Your Nephrologist has referred you to our center for evaluation of your kidney transplant surgical candidacy. I understand that the cause of your end stage renal disease is Diabetes Mellitus Type II and that you are not yet on dialysis.
Pt: yes, that’s correct.
Dr. Barry: Do you have any friends or family members that are interested in donating a kidney to you?
Pt: I’m not sure. How does one become a donor?
Dr. Barry: Living donor kidney donation involves identifying a family member or an emotionally related donor (e.g., spouse or good friend) who has a compatible blood type with the recipient, is in good health and has no risk of kidney problems in the future such as diabetes or high blood pressure. If a donor is identified who meets these initial criteria, he or she will then undergo an extensive psychosocial evaluation, physical exam, laboratory tests including more detailed screens for immunologic compatibility and imaging tests (X rays and MRI scan) to assure normal anatomy and absence of intrinsic kidney disease.
Pt: What is the risk to the donor?
Dr. Barry: If the donor passes our rigorous screening procedures, then we will arrange for a simultaneous surgical procedure in which the donor’s kidney is removed and immediately transplanted into the recipient. We almost always perform the donor surgery laparoscopically (see video of left kidney removal or right kidney removal), using small incisions, and the patient stays in the hospital for two to three days. The risks include adverse reactions to general anesthesia, bleeding, infection and possible conversion from a laparoscopic to open procedure. These risks are minimal and the chances of having to perform an open procedure are less than 1%.
Pt: What are the advantages of living donor kidney transplant?
Dr. Barry: The main benefit is that we can perform the transplant within months of identifying a suitable donor. The waiting time for a deceased donor transplant (formerly called cadaveric transplant) is 4 to 5 years here in our region. Also, living donor kidneys are more likely to function immediately, lessening the likelihood of the recipient needing temporary dialysis after the transplant. Finally, living donor kidney transplant recipients enjoy better long term graft survival.
Pt: Can I have a transplant before going on dialysis?
Dr. Barry: Yes, but if your kidney function is not too bad, we need to wait until you are closer to needing dialysis. If we perform a transplant too soon, the benefits of receiving a new kidney are cancelled out. We measure your creatinine and creatinine clearance to help us decide the optimal timing of your transplant before going on dialysis.
Pt: Will you remove my own kidneys during the transplant?
Dr. Barry: Usually we don’t have to do this. However, if you have a kidney disease that causes ongoing problems, for example, multiple blood transfusions, persistent kidney infections or intestinal blockage, then we would consider removing your own kidneys. The two most common medical conditions requiring “native nephrectomy” (removal of your own kidneys) are Congenital Reflux Disease and Polycystic Kidney Disease. If you have these diseases, we would decide based on your symptoms or complications whether you would need to have your kidneys removed.
Pt: If I needed to have my own kidneys removed, when would you do this?
Dr. Barry: My practice is to remove the native kidneys at the time of transplantation. This requires a slightly longer stay in the hospital because the surgical incision (cut) is bigger, but the benefit is that the patient only has to undergo one surgical procedure and one general anesthetic. Occasionally, we will perform the removal of your own kidneys prior to the transplant in a separate procedure.
Pt: Getting back to living donor kidney transplantation, what if I have no friends or family members who can donate, or what if I am uncomfortable about asking anyone to do this?
Dr. Barry: That’s perfectly fine. It’s especially important to realize that if you are uncomfortable about asking anyone to donate, then you shouldn’t do so. Organ donation is a gift and it should come from the heart, not by emotional coercion. Financial coercion for organ donation is illegal in the United States.
If you are on the deceased donor kidney transplant list, the waiting time can be up to 3-4 years. We do have a voluntary program, the “Extended Criteria Donor (ECD) Program”, that allows people on the list to wait for less time (2-3 years) if they are willing to accept kidneys that are slightly outside our normal criteria for acceptance.
Pt: What exactly do you mean by this?
Dr. Barry: Normally, when a donor becomes available, the surgeon is called to accept the organ. If the patient is older, has had diabetes or high blood pressure or has had a stroke, then the surgeon may not think that this is the best organ. But, if the donor is not too old and has not had diabetes or hypertension for a long time, we will perform additional tests on the kidney, including a biopsy, to determine if the kidney will work. We then offer this organ to our recipient patients participating in the ECD program. It is completely voluntary and if the patient does not want to accept the ECD organ, he or she will not be penalized in terms of their listing status. Patients participating in the ECD program are also on the “regular” list and they always have the option to choose between either types of organ.
Pt: What is the surgery like?
Dr. Barry: The kidney transplant operation is a straightforward procedure. The surgery takes about two hours and starts with an incision (usually about 6 to 8 inches) from your pubic bone up to your hip bone. We place the new kidney in your pelvis and connect it to the blood vessels in your groin as well as connecting the kidney to your bladder.
Pt: How long do I stay in the hospital?
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Dr. Barry: Most people stay five days.
Pt: What are the potential complications?
Dr. Barry: Complications for this surgery are rare, but include adverse reactions to the general anesthetic medicines, bleeding, infection, blood clots in the artery or vein going to the kidney, twisting or “kinking” of these blood vessels, a leak of urine where we connect the kidney to the bladder, a narrowing of the connection to the bladder, or a fluid collection around the kidney after the surgery, usually either blood or lymphatic fluid.
Pt: What happens if I get one of these complications?
Dr. Barry: Often, they can be treated without surgery, but sometimes another surgery is required. For example, problems with the blood vessels, leaking of urine or a collection of lymphatic fluid all may need an additional surgery to fix definitively. We rarely have to perform a second surgery, but they are usually minor procedures and most always result in a complete resolution of the problem.
Pt: Does the new kidney start working right away?
Dr. Barry: Usually it does, but sometimes the new kidney is “stunned” or “sleepy” and it doesn’t start working immediately. This is more common with deceased donor kidney transplants but can, very rarely, happen even with living donor kidney transplants.
Pt: What happens if my new kidney is “sleepy”?
Dr. Barry: Sometimes patients will require dialysis after their transplant operation until the kidney starts working. If it is a simple matter of delayed kidney function (that is, if there are no technical or surgical complications and there is no rejection), then kidney will most always “wake up”. In these cases, the need for dialysis can last anywhere from a few days to a few weeks.
Pt: What about rejection?
Dr. Barry: You will have to take anti-rejection medicines every day after you receive your kidney transplant. These days, our medicines are so effective in preventing and treating rejection that it’s extremely unusual for someone to lose their kidney because of rejection in the first several years after transplant. Nonetheless, about 20% of all kidney transplant recipients experience an episode of rejection in the first few years.
Pt: How can I tell if I am experiencing rejection?
Dr. Barry: Usually, there are no symptoms, but occasionally patients have tenderness over their new kidney, fevers or decreased urine output. More commonly, you will be feeling fine and we detect an abnormally elevated creatinine level on your routine blood tests. First we will make sure that your anti-rejection drug levels are not too high, that you do not have a urinary tract infection and that you have been keeping yourself well hydrated: all of these things can cause the creatinine to be elevated. Then, we will perform an ultrasound of your new kidney to make sure that there are no technical problems such as blood clots in the kidney, problems with the connection to the bladder, or fluid collections around the kidney. If the ultrasound is normal, then we will perform a biopsy of your kidney.
Pt: Is that another operation?
Dr. Barry: No. A biopsy is performed by placing a small needle through the skin after numbing the skin with local anesthesia. It can be performed as an outpatient procedure.
Pt: What if the biopsy shows rejection?
Dr. Barry: Depending on the type of rejection and the degree of rejection, we will treat you with the appropriate anti-rejection medicine. If the rejection is mild, we will give you intravenous steroids for two or three days. If it is more severe, then we will use more powerful antibody medicines for up to five days. These treatments almost always completely reverse the rejection. So, as long as we catch the rejection in a timely fashion, losing the new kidney would be a very rare occurrence.
Pt: What are the risks of taking anti-rejection medicines?
Dr. Barry: In general, there are risks of certain types of infection and certain types of cancer. In the first three months, your risk for infections is highest, so we give you medicines to prevent certain types of bacterial, viral and fungal infections. After three months, we stop these prophylactic medicines and keep your anti-rejection medicines going at reduced doses. The risks for cancer, particularly skin cancer and lymph node cancer, is slightly higher than the general population. We recommend that you avoid prolonged sun exposure and that you always use appropriate protection from the sun. Regular routine physical exams and blood tests are important for early detection of cancer.
Pt: Do the anti-rejection medicines have any other side effects?
Dr. Barry: Ironically, one of the major side effects of Cyclosporine and tacrolimus is kidney toxicity. We are able to avoid this by regularly checking the levels of these drugs in your blood and adjusting your doses appropriately. Cellcept, another anti-rejection medicine, can cause stomach upset, abdominal pain, or diarrhea. Sometimes we have to lower the dose of this medicine or substitute another very similar drug that is less likely to have these side effects. Finally, steroids can have many die effects such as diabetes, growth delay in children, osteoporosis, facial and skin changes, or neurologic problems such as difficulty sleeping or euphoria. However, we are very aggressive about rapidly decreasing your steroid dose over a period of several weeks after your transplant, so that many of these potential problems are avoided. Many patients have to take insulin shots after their transplant, but often the need for insulin shots eventually goes away as the steroid dose is lowered.
That essentially covers all that you need to know about your kidney transplant operation. Do you have any other questions?
Pt: Not at the moment, but I’ll contact you if I do. Thank you very much for your time.