RLD KidneyRLD KIDNEY Module 1 - Before Donation Introduction Page 1 Kidneys and kidney Disease Page 4 History of kidney transplantation Page 9 Benefits and risks of living donation Page 13 Becoming a living donor Page 18 Donor evaluation Page 24 Module 2 — Living Kidney Donation * Preparing for the operation Page 44 * The operation Page 49 © Post operative care Page 53 Module 3 ~ After Donation * After care Page 59 + Financial aspects of living donation Page 61Annexure: Pietures: © Kidney Disease 1-3 * Treatment of Chronic Renal Failures 4 a and b —5 * History of Kidney Transplants 6 — 12 * Compatibility Testing 13 - 18 * Tissue Matching 19-23 | * Medical Evaluation 24 * Preparing for the operation 25 ~ 26 ‘* Open Donor Nephrectomy 27 - 30 * The recipient 31 © Size of the incision 32 a and b * Complications 33 * Laparaospopic Donor Nephrectomy 34 - 36RLD KIDNEY Module 1 - Before Donation Introduction Kidneys and kidney disease History of kidney transplantation ‘The legal framework of living donation Benefits and risks of living donation Becoming a living donor Donor evaluation Introduction Welcome to OTIS, the Organ Transplantation Information System. ‘This programme has been developed to provide you with information about living kidney donation. * Perhaps you have only just heard about living kidney donation, Son rhsPS YoU are considering whether or not you can be or want tobe a living kidney donor. * Pethaps you are currently undergoing your medical evaluation, * Or pethaps you have already decided! and been approved as living kidney donor, Preparation for living kidney donation isa process that may take a few months and, along the way, you will have to make important decisions. Wherever you are in this process, we hope you will find this programme helpful, ‘The goa! of this programme is neither to convince you to donate, nor not to donate. tis intended to provide you with accurate and impartial information that my help you to make a decision that is right for you, Remember: this programme is not a substitute for speaking with your doctors and the transplant team. If, at any time, the information in this programme is different from what you have been told by your doctors or nurses, always follow their instructions, As you will see, transplantation is a team effort, and you should fel a ‘part of that team.To help you, you should: © Leam as much as you can about transplantation and living donation, © Never be afraid or ashamed to ask questions. If you have questions, write them down and bring them to your next meeting with the doctor. © Be open and honest in all discussions - this is to your benefit and the benefit of the recipient, * Talk to the transplant team about things that you hear or read that may be not consistent With the information you have been given. * Never be ashamed to ask for help ~ from your doctors, the transplant team, your family, or friends, * Follow the instructions given to you by the transplant team, and other healthcare professionals. The Language of Transplantation ‘There is an ancient Chinese proverb — “The beginning of wisdom is to call things by their right names.” ‘Throughout this programme, you will be introduced to many new, sometimes strange and often scemingly unpronounceable names — for parts of the body, diseases, medical tests or medications, While itis not necessary that you memorise all of these names, you should become familiar with them so that you can effectively communicate with your healthcare team and make informed decisions regarding your care. Kidneys and kidney disease This programme is about donating a kidney to a patient with kidney disease. It is helpful, therefore, if you understand the basics of how the kidneys work, kidney disease, and treatments options. ‘The term “renal” is used for anything related to the kidneys - such as renal function, renal disease, and renal transplantation, Most people are bom with two kidneys, éach about the size of @ fist and located in the middle of the trunk of the body, in the back, where they are well protected by muscles and the rib cage, iMlustration 1 Some people are born with only one kidney, while others have one of their two kidneys removed, as the result of injury. In the absence of any kidney disease, these individuals lead normal, healthy lives. The major role of the kidneys is to maintain the balance of chemicals in the body. They perform this life-sustaining job by filtering about 190 litres of fluid every 24 hours, removing metabolic waste products and excess fluids from the body through the production of urine,‘The kidneys have other critical functions, as well, including: © regulating the body’s salt, potassium, and acid content. © producing hormones and vitamins which affect the function of other organs. activating vitamin D, which plays an important role in maintaining calcium and phosphate, which affects bones © the control of blood pressure. © influencing the actions of other hormones such as insulin and growth hormone. Each of the two kidneys has an artery through which blood enters the kidney and a vein, though which the blood leaves the kidney. ‘As the blood flows through the kidneys, it passes through nearly a million tiny filtering units called glomoruli, where fluids and wastes in the blood are removed to create urine. The rate at which blood is filtered through the glomeruli is the glomerular filtration rate (GER), a measurement which is often used to determine renel function. This system is so efficient that normal health can be maintained with only 25% of glomeruli working. That is why people with only one normal kidney can lead a normal life. Hustration 2 The urine leaves the kidneys through the ureters and is collected in the bladder During urination, the urine flows out of the bladder, through the urethra. llustration 3 Kidney disease | Kidney disease can be caused by any condition that causes damage to the kidneys and stops them functioning normally. This may result in a build up of poisonous waste ‘materials in the blood as well as interfering with the other critical fnctions, previously described. This is called either kidney failure or renal failure. is is called “acute kidney Kidney failure can be of a short duration and reversible. failure.” When it continues over a long time and is not reversible, it is called “chronic kidney failure” and usually leads to what is called “end stage renal disease” - ESRD. ESRD can occur quickly or slowly, over a period of months or even years When a patient has ESRD, the only means to prevent death are dialysis or transplantation.Common causes of chronic kidney failure include: Diabetes. Diabetes mellitus is a leading cause of chronic kidney failure. Chronic kidney failure is related to both type 1 and type 2 diabetes. Glomerulonephritis. Inflammation of the glomeruli a condition that affects the filters of the glomeruli and damages them, High blood pressure (hypertension). Untreated or inadequately treated high blood pressure is another common cause of chronic kidney failure. The added force of elevated blood pressure exerted on the glomeruli can cause damage and scarring and the damaged glomeruli eventually lose their ability to filter waste fiom the blood. Kidney disease itself can also cause high blood pressure. Obstructive nephropathy. This occurs when urine outflow is blocked over time by an enlarged prostate, kidney stones or tumours. The backflow pressure in the kidneys reduces their function, Inherited Kidney diseases. These include clusters of cysts in the kidneys (polycystic kidney disease), Kidney infection (pyelonephritis). Renal artery stenosis. This is a narrowing or blockage of the renal artery before it enters the kidney. In older adults, blockages often result when fatty deposits accumulate under the lining of the artery walls (atherosclerosis). Renal artery stenosis can also affect young women in the form of a condition known as fibromuscular dysplasia, which causes the walls of the arteries to become thicker. Both conditions are often associated with high blood pressure, ‘Toxins. Ongoing exposure to fuels and solvents, such as carbon tetrachloride, and lead — in lead-based paint, lead pipes, and soldering materials can lead to chronic kidney failure. ‘Some medicines with long term use can also damage the kidneys, Treatment of chronic renal failure Dialysis ‘When renal function falls below 10% of normal - in other words, 90% of normal function has been lost- the blood must be cleansed and excess fluids removed by artificial means. This is called dialysis. Htustration 4 and 5 There are two forms of dialysis: In haemodialysis, needles are inserted into the patient’s artery and the blood is pumped 6through a mechanical filter - a haemodialysis machine, ‘The cleansed blood is retumed through a vein, To allow for repeated insertion of the needles, a special access point is usually created by surgically joining an artery to a vein. This allows the vein to reccive blood at high pressure, leading to thickening of the vein’s wall. Now this “arterialized vein” can sustain repeated puncture and also provides excellent blood flow rates. The connection between ‘an artery and a vein can be made using blood vessels (an arteriovenous fistula, or AVF) or a synthetic bridge (arteriovenous graft, or AVG). Each haemodialysis treatment normally takes four to five hours, and usually three treatments a week are needed. More frequent, shorter treatments or longer treatments ‘may be indicated for certain patients. Only a small amount of blood is out of the body at one time. Therefore, the blood must circulate through the machine many times before it is cleaned. Mon." | Tues. "| Wed, | Thurs, Li Lo Sin) 6 30 T z Vidgets % WT w Digee Dilger Daler hte Tw T [a Dies f 1¢ Dies w w ar Digas f zi 1 ‘Some patients do quite well on haemodialysis. They are not terribly bothered by the needles, the treatment, or the restrictions in the amount of fluids they can drink, and remain active. Some continue to work and even travel, arranging for dialysis treatments at their hotiday destination, But many patients do not tolerate long term dialysis well. They develop health problems, some very serious, They find that the frequency and amount of time on the dialysis machine, plus the extreme fatigue they experience following treatments, keeps them from any sense of a normal life.Peritoneal Dialysis About a quarter of patients with ESRD use an alternative form of dialysis called “peritoneal dialysis” - PD. filustration & {In ED, a tube is inserted into the patient’s abdominal cavity. Several times a day, every day, the patient pours a special dialysis fluid into their abdominal space. The abdomen is lined with a membrane called the peritoneum. As the patient's blood flows through blood vessels on one side of the peritoneum solid and liquid waste materials pass through the membrane into the dialysis fluid on the other side, The body's own peritoneum acts Just like the filter in a dialysis machine. Patients who are placed on PD generally are in better physical condition and more independent than those on haemodialysis, when they begin treatments. Consequently, they also report better health and quality of life on PD. However, they are at high risk of infections and still must live with the necessity to be treated several times a day. Death among dialysis patients Although dialysis has been and continues to be a lifesaving treatment for patients with ESRD, the mortality rate (the chance of dying) of patients on long term haemodialysis is about tenfold higher than the general population. The major causes of death are cardiovascular (diseases of the heart and circulation) and infections, ‘Transplantation For many patients with ESRD, the altemative to dialysis is kidney transplantation. Not all patients ere suitable candidates for transplantation, due to many factors that need to be iscussed with the transplant team to decide what is right for the patient. Ina transplant, the patient receives a single kidney from either a living donor or a deceased donor. With advances in surgical techniques and medications to control rejection, the success rates for kidney transplantation are excellent, Dialysis vs, Transplantation Patients who receive a kidney transplant are free from the burden of routine dialysis treatments. In addition, they usually have fewer health problems, have an improved ‘quality of life and their risk of death is lower than that of dialysis patients.Complications of transplantation This does not mean that transplantation is without problems, Transplant patients must take medications to prevent ejection - for the life of the eapsblant. While these medications prevent rejection, they increase the risk of Infections and often have side effects that, over time, can damage the body, including the ‘ransplanted Kidney, sometimes leading to re-transplantation The history of kidney transplantation and living donation Kidney transplantation is part of a remarkable story that started more than 100 years ago and is still constantly changing. On the next pages you wil Team about the some of the Pioneering events and distinguished people whe helped to make transplantation possible, jpiams of researchers and surgeons in the United States, Russia, England, Sweden, and India worked forthe next 30 years to farther develop techniques for transplanting organs. Bat each time they transplanted an organ, it quickly Stopped working. The problem was rejection. ‘The study of rejection is part of a field of medicine called immunology. Rejection is the Jeenlt ofa process where the body recognizes the transplanted organ as being foreign — Hot a part of itself and sets out to destroy it. Teagitdy ofthe immunology of transplantation began in Russia, In the first years of the 1900's, as Carrel was developing techniques for connecting blood vessels, Rite Metchnikoff, biologist, discovered that certain white Dine cells could engulf and destroy foreign substances, like bacteria, making this one of he earliest descriptions of Fie {mmnune response, Metchnikoff was awarded the Nobel Prise in 1908, Unfortunately, his theories as to how the immune system wort were later found to not 9quite correct. Illustration 9 Meanwhile, in Austria, a doctor by the name of Karl Landsteiner discovered that it was Possible to predict how the immune system would react when individuals where exposed to the blood of other individuals, This lead to the ABO blood group system that we use today and opened the door to the entire field of tissue matching — called hhistocompatibilty. Dr. Landsteiner received the Nobel Prize for Medicine. illustration 0 The discoveries that would lead the way for organ transplantation came during World War Il In England, doctors had begun to use skin grafts to treat bum victims, taking pieces of unbumed skin from the patient to cover burned areas. In the case of one woman, her bums were so severe that there was not enough of her own healthy skin to cover all of her bumed areas. So Dr. Peter Medawar, a biologist, tried skin from the patient’s brother. He saw that the transplant worked, but also that patient’s own skin lasted longer than that from her brother. Over the next 10 years Medawar and his team would lay out the very basis for the Fejection process, including the role of antigens, antibodies and lymphocytes. For his work, Dr. Medawar was knighted and received the Nobel Prize. Mustration 11 By the early 1950's the techniques for transplanting organs had been pretty much established and it was understood that genetics played a role in the rejection of tansplanted organs. If the donor is genetically close to the recipient, there is less likelihood that the donor organ will be rejected. The only instance where a donor and recipient are genetically identical is, of course, with identical twins. The first successful living donor transplant was performed between 23-year-old identical ‘wins, in 1954. Dr. Joseph E. Murray at Peter Bent Brigham Hospital in Boston, MA, transplanted a healthy kidney from Ronald Herrick into his twin brother, Richard, who had chronic kidney failure. Richard Herrick went on to live an active, normal life, dying ‘eight years later from causes unrelated to the transplant, As of 2005, Ronald, the donor, was still living - 51 years later. Dr. Murray received the Nobel Prize for medicine, being the only surgeon to do so. Ulustration 42 In 1960, Sir Michael Woodruff performed the first kidney transplant in the UK, between identical twin brothers in Edinburgh, tllustratien 13renal disease and among all transplants, living donation affords the best possible outcome. Benefits and risks of living kidney donanation There are many advantages to receiving a kidney from a living donor over a kidney from deceased donor. These include the following: Planned pre-emptive transplantation As end stage renal disease progresses, the greater the impact on the individual’s health. ‘Therefore, the earlier a transplant can be performed, the better the overall health of the patient, and the Jong-term survival of the transplanted kidney. In the best of cases, this can mean transplantation before having to go on dialysis, also eliminating the need for the surgery to create the access for the dialysis needles, This type of transplant is planned for a set time and therefore can only be achieved with a living donor. You cannot plan to transplant a kidney from a deceased donor at a particular time. Shorter waiting time Patients who are placed on the national allocation list for a kidney from a deceased donor usually wait months, or even years for a suitable organ. With a living donor, the transplant can be done as soon as the evaluations have been completed and a suitable donor identified. The evaluation process may take a few months but, usually, this is less than the waiting time for a kidney from a deceased donor. A scheduled event It is never known when a kidney from a deceased donor will become available. ‘Therefore, the recipient is always in a state of uncertainty. With a living donor, however, the timing of the transplant can be scheduled for a time that is convenient for the recipient and donor. Living donation is being increasingly used for patients who require a kidney transplant. A better matched kidney ‘You will learn more about tissue matching, later in this programme. For now, let it suffice o say that matching is an important part of the decision making process for living donation. Its particularly important for young adults and children who may require a Bsecond transplant in the future. This can be explained to you by your clinical team. Jn general, family members are more likely to be closely matched to the recipient than non-related donors. When possible, several potential living donors can be evaluated and the best match selected, A better quality kidney Kidneys from living donors are of better quality than those from deceased donors. There ate several reasons for this, including: * More time for testing. Deceased donors can be maintained artificially for only a few hours, leaving litle time for thorough testing of medical conditions that could affect the success of the transplant. With living donors, there is sufficient time to do all necessary tests, meaning a better organ, * Shorter storage time, When a kidney is removed for donation, it must be quickly cooled to prevent damage to the sensitive tissues. Although cooling reduces this damage, the longer the kidney is without circulating blood and oxygen, the greater the chance of damage. With deceased donors, the kidney is kept in cold storage for up to 24 hours, With living donation, the storage time is only a few minut Better kidney = better results Because of the factors just listed, the success of kidneys from living donors is better than that for kidneys from deceased donors. Living donors - 95% after one year Deceased donors - 90% after one year Not only do these recipients survive, they enjoy a high quality of life. In Europe, 79% of those with functioning living donor transplants are working fall time, with the remainder either working part-time or capable of work, Risks to the recipient Kidney transplantation is a major operation and carries with it all of the risks related to anaesthesia and surgery, including a range of short tenn and long term complications. These can be minor or they can be life threatening. In general, the risks are low. Following transplantation, recipients face increase risk of: ‘* High Blood Pressure (Hypertension) * Diabetes © High cholesterol * Bone loss © Certain cancers 14Many of these risks are duc to Jong term usc of certain anti-rejection medications. The aim is to keep these medications to a minimum. Relationship to the donor With kidneys from a deceased donor, there is no ongoing relationship between the donor and the recipient, other than a senso of gratitude to the family who consented to the donation. With a living donation, however, there may be a profound effect on the relationship between the donor and recipient. In some instances, it strengthens the relationship, bringing them closer together. On the other hand, it can also have a negative impact, if the recipient feels or the donor imposes a feeling of obligation - “I owe you” or “You owe me” for donating. Although such a situation may be of benefit to the donor, it may not be good for the recipient. : Whet sf the tranenlont foleyee which suggests that kidney donation is associated with a low level of medical risk ina healthy donor. Peri-operative Deaths Estimates of living donor mortality (deaths) are available from three large American surveys, covering nearly 10,000 operations. 1 death out of 3,300 operations is accepted as an accurate assessi f the risk. TheLong term survival ‘The causes of death in individuals who have donated a kidney are similar to those seen in the general population: cardiovascular disease and cancer. In one well known study of patients in Sweden, the survival rates (those still alive) 20 years after donation was 85% for the kidney donor group compared to an expected survival rate of 66% for the general population. This has Jed to the belief that individuals who donate kidneys live longer than those who do not. The explanation for this is that living donors go through such an extensive medical evaluation, that the ones who are selected to donate arc healthier than the general public and, therefore, live longer. Emotional risks to a living donor ‘The greatest emotional risk to the donor is when the transplant fails. The donor can feel that everything he or she gone through was in vain. ‘There is a possibility that the donor expected a positive change in the relationship to the recipient which may or may not happen, regardless of whether the transplant is successfull or not, Finally, the donor may have expected that following the transplant, the recipient would have achieved a better state of health than may be possible, given the total medical condition of the recipient, A transplant is not a cure or solution to all problems. Itis important to have realistic expectations, before going forward with living donation, Careful discussion is important and you can have as much advice and discussion on this subject as you require. This will help you prepare to make a decision about donation. ‘Time off from work Although most of the medical evaluation can be done on an outpatient basis, you will need to take time off during the months of testing. Depending on the type of operation performed, you will spend 4-10 days in hospital and you may need 6 to 12 weeks of recovery, before you can return fully to work. ‘This leads to two important questions: ‘© Can you take the time off from work or other duties to be a donor? © Can you afford to be off work for this period? We will discuss the financial aspects of donation later in the programme. The evaluation - a benefit or risk? The evaluation for organ donors is very complete - more so than most individuals would 7make the decision whether to accept the donor organ or to wait for a living donor. Who can be a living kidney donor? ‘There are several basic requirements to being a living kidney donor. * You must want to donate and are free from any pressure to do so. There can be no payment or other financial reward involved, * Your kidney must be compatible with the recipient - in terms of blood and tissue matching, * Your health must be such that you can donate a kidney that is free of any disease and vill function well in the recipient. * Your health must be such that by donating a kidney you will not inerease your future risk of kidney or other disease. + You must be mentally capable of making this deci + You must be aware of the potential risks associated with donating a kidney. Iti the duty of the transplant team and the Independent Assessor to ensure that all of these requirements have been met. ‘Types of living kidney donors ‘Genetically related donation: Where the potential donor is a blood relative of the potential recipient. . Emotionally related donation: Where the potential donor has a meaningful relationship with the potential recipient, for example, spouse, partner or close friend. Paired donation: Where a close relation, friend or partner is fit and able to donate an organ but is incompatible either with tissue type or blood group with the potential recipient, that couple can be matched to another couple in a similar situation, so that both people in need of a transplant receive a compatible organ. Pooled donation: Pooled donation is similar to paired donation, except that it involves ‘more than one incompatible pair. Kidneys from paired and pooled donation will be run on the basis of a national register and matching scheme ‘Non-directed altruistic donation: A form of non-directed living donation, where an ‘organ or part organ is donated by a healthy person who does not have a relationship with the recipient and who is not informed of who the recipient will be. This is also known as “good Samaritan donation”. The donated organ is allocated through a process that is similar to the standard procedures used for organs from deceased donors, Genetically related donors In over 50 years of kidney transplantation, most living kidney donors have been relatives 20- individuals related by blood to the recipient: parents to children, children to parents, between brothers and sisters, from aunts and uncles, or cousins. Are you compatible with the recipient? ‘Tissue matching Donors and recipients should have compatible blood groups (A, B, AB, 0) and compatible tissue types. {As explained before, members of the same family often have similar tissue types and can bbe a good match for the recipient. Itis important to understand, however, that close family members may not be closely matched or may even be totally incompatible - meaning that they definitely cannot donate. Tissue matching is explained fully later in this programme. In the addition to the biological connection within familics, itis also understood that there may be close ‘emotional ties and reasons that would justify donating an organ, This is why living donation from family members has always been so readily accepted. But family ties can also be the source of problems. Some family members may not have a good relationship to the recipient or they may fec] that they are under some obligation to donate, because itis « family member who needs the organ. This can result in feeling pressured into donation, even though they may not really want fo. Some reasons why you may want to donate Here are some reasons why you may want to donate a kidney to a family member: «© You believe that living donation will provide the recipient with the best chance for g00d health and a good quality of life. + You don’t want the recipient to have to wait, possibly years, for a kidney from a deceased donor. © You have a deep emotional connection to the recipient and sincerely want to help. © You believe you will benefit by having this member of family well, independent and productive, ‘* You know that even though there is chance that the transplant may not succeed, you to the possible benefits. Some reasons why you may not want to donate 2Here are some reasons why you may not want to donate a kidney to a family member: * You do not believe that living donation has an advantage over kidneys from a deceased donor. * You believe that the recipient would most likely receive a kidney from a deceased donor in a short time, * You have no real emotional connection to the recipient and feel no deep desire to help. * You believe that you benefit little or nothing from the recipient being transplanted. * You are fearful of the operation. * You believe that the time needed to be a donor would disrupt your life. * You believe that donating a kidney might negatively affect other relationships you have.A potential problem with “related” donors As just mentioned, part of the evaluation for living donation will be genetic testing to confirm the relationship between potential donors and recipicnts. Ut should be noted that occasionally these tests suggest that a certain donor and recipient are, in fact, not related, This, obviously, can raise anxieties for the parties involved. You will be advised when your blood is taken for this purpose and you will be able to discuss this with your clinical team, This is a sensitive area and no one case is the same but it would be handled sensitively by your clinical team should it arise. This would not rule out a person, as a potential donor; they would just not be considered as a “related” donor. The evaluation for related donors ‘The evaluation process for related living donors is the same as for non-related donors and is described in the next section of this module. Paired / Pooled donation If you agree to be evaluated as a potential donor, it is possible that tests will determine that you and the recipient are not compatible. Today, this does not mean that you cannot beadonor. Different centres will have a range of options available in this situation. One of which may be paired/pooled donation but may also include options such as antibody removal (antibodies and HLA are explained in this programme in the section on donor compatibility). You should discuss with your clinical team which options are available and what may be suitable for you. Ifyou wish, you may continue with the medical evaluation and if it shows that you are healthy enough to donate, you may be able to exchange kidneys another donor-recipient pair who are in a similar situation, Emotionally related donors In some cases, a potential donor is not genetically related to the recipient, For example, a husband and wife or step parents and a child are legally and emotionally related, but have no biological connection, There are also circumstances where long time friends may be considered as donors. There is no significant difference in outcomes for a donor kidney from a related or non- related living donor.Genetically unrelated donors and recipients are required to provide proof of their relationship, such as certificates, letters and photographs. 23Are you compatible with the recipient? Donors and recipients should have compatible blood groups (A, B, AB, 0) and compatible tissue types. Keep in mind that not everyone who is genetically related to the recipient is a good match or even compatible. In many instances, non-relatives can be compatible and can be excellent donors, Tissue matching is explained fully later in this programme, Emotionally related donors, as the name implies, have close emotional ties to the recipient and often have sufficient reasons to justify kidney donation. This is why this ‘group has been accepted as living donors. Just because two people are emotionally related, it doesn’t mean that one necessarily wants to donate a kidney to the other. Emotional relationships can be complex - not always totally positive. Most non-genetically related donations are between husbands and wives or similar partnerships, The desire to donate can depend upon the length of the relationship and certainly the current state of the relationship. This can be highly varied and complicated. Donor Evaluation Introduction Donor-recipient compatibility Medical evaluation ‘The decision Introduction Donor Evaluation - Are you a suitable donor? ‘The goals of a donor evaluation are to minimize the risk to the donor and are as follows: * To establish if you are compatible with the recipient and how the process continues 24‘o play an important role in transplantation - 3 pairs of antigens called HLA-A, HLA-B and HLA-DR. Hlustration 26 We each inherit our HLA type from our parents, with half of the code coming from the mother and half from the father. Children, therefore, will always be a half match to either Parent. Mothers, because they have been exposed to the antigens of their husband and their children, may have formed antibodies to these foreign antigens and may, therefore, not be suitable donor-recipient matches, Different centres will have a range of options available in this situation, You should discuss with your clinical team which options are available and what may be suitable for you, Hlustration 21 Depending upon how the antigens combine, children of the same parents have the Possibility of the best matches. They can be a total match meaning they have the same HLA. This is called HLA identical or a 0 mismatch. Illustration 22 (Or, they can be a half match Hitustration 23 ora total mismatch. Hlustration 24 Unlike the red blood cells, where there are only two antigens and 4 blood groups, there are nearly 100 HLA antigens which can combine to forms thousands of HLA types. As you move further away from your family, it becomes less likely that you will find a perfect or even close match. Less likely, but not impossible - if the donor pool is large enough. That is why, especially for kidneys, there is a regional organ sharing network. In general, the closer the HLA of your donor organ matches the recipients HLA, the less likely it will be seen as foreign and, therefore, less likely it will be rejected. HLA Testing Part of your evaluation will be to determine your HLA type. All that is required is a blood sample. You should note that although there is an advantage when the HLA of the donor and recipient are closely matched, this advantage is small and that transplants between total mismatches can be very successfil As you will learn on the following page, compatibility is not just about matching HLA, but also screening for antibodies, Antibody Screening As you have just leamed, each time someone is exposed to any cells with foreign 28treatment or procedure. For example, a donor with kidneys with more than one artery would make donation difficult. So multiple arteries in a donor's kidney would be a contraindication. If it is known that older patients do less well with a particular type of treatment, then advanced age would be a contraindication, Some contraindications are said to be “absolute” because the risk they present would be so high as to endanger the life of the patient or make the treatment useless. For example, following transplantation, patients are given medications to prevent rejection. These ‘medications reduce the immune system which keeps cancers under control. Ifa patient has cancer prior to transplantation, with these medications, the cancer would quickly grow, killing the patient. Cancer, therefore, is an absolute contraindication for ‘transplantation. Some contraindications are said to be “relative” because they may increase risks, but the inereased risk is not enough to rule out donation or the problem can be treated before the ‘transplant is done. Contraindications for living kidney donation ‘The medical evaluation for potential living kidney donors is designed to identify contraindications for donation. Absolute contraindications for living kidney donation include: « kidney disease * chronic infections, such as Hepatitis B, C or HIV © certain cancers © heart disease © diabetes Relative contraindications for living donation include: * high blood pressure (hypertension) - if minor and well controlled on treatment * infections which can be treated * obesity - depending upon the degree of overweight istory of kidney stones Your medical history Like any good medical examination, the donor evaluation begins with a complete medical history. Its very important that you be open, honest and complete when talking about your 31history. On the following page is a list of some of the things that will be of importance during the taking of your medical history. As you look at this list, think about what you might need in order to properly answer. For example, do you need to ask others about a family history of illness? Do you need to check on dates of previous tests or perhaps you have old X-rays or other test results. Points of particular importance in the medical history include: * Any symptoms of kidney disease - such as: bloody urine, urinary tract infections, kidney stones, or difficulty urinating * A family history of kidney disease © Heart problems + Hypertension - high blood pressure Diabetes mellitus - including a family history Previous jaundice * Any episodes of blood clots * Infections, such as tuberculosis, hepatitis, or malaria © Smoking © Drug and alcohol use ‘* Pregnancies - full erm, miscarried or aborted * Any previous medical testing you may have had for illnesses or insurances Physical examination The next step in your evaluation is a very complete physical examination. A particular focus will be on your kidneys and kidney function, looking to identify any discase or increased risk of future disease. In addition, they will look at your general health. The pages that follow list or describe many of the tests that may be used. This Jong list is simply to prepare you for the extensive testing and to familiarise you with some of the names and procedures. General examinations Measures of your general health may include: + Body mass index - discussed later, being obese (overweight) is a problem for donation * Blood pressure measurement - hypertension can damage the kidneys and kidney diseases can increase hypertension + Examination of the cardiovascular and respiratory system (heart and lungs) 32© Examination for abdominal masses or hema - these can interfere with the donor ‘operation and your recovery + Examination for swollen lymph nodes - a sign of infection or possibly cancer + Examination of the breasts - for signs of cancer + Examination of the testes - for signs of cancer Laboratory testing Laboratory tests include the following:© Heart stress test (as routine or where indicated) * ECHO - ultrasound of the heart (where indicated) Assessment of renal anatomy ‘The anatomy of your kidneys must be assessed to confirm the presence of two kidneys, of normal size and to identify abnormalities. Testing may include: © Abdominal ultrasound + X-rays with an iodine dye - IVP or IVU Assessment of renal function For a potential kidney donor, a major area of concem is whether donation will cause impaired kidney function. Accurate measurement of renal function in a potential donor is, therefore, essential to: * ensure that the donor’s remaining kidney will have adequate function for the rest of the donor’s life, and © ensure | ynated LidmasCreatinine Clearance Creatinine is a substance that is produced naturally in our bodies and is normally removed by the kidneys. If the kidneys are not functioning well, the amount of creatinine in the blood increases. Measuring the level of creatinine in the blood and the amount being excreted in the urine over a 24 hour period, provides a good way to assess kidney function. ‘The renal blood vessels Although most people have one renal artery and one renal vein for each kidney, approximately 25% (1 in 4) of potential donors will have multiple arteries to one kidney and around 7% (7 in 100) will have multiple vessels to both kidneys. Hlustration 25 ‘A donor kidney with multiple blood vessels is more difficult to transplant and is subject to more complications, Therefore, a donor kidney with a single renal artery should, whenever possible, be chosen for transplantation. If both kidneys have single vessels, the left kidney is usually selected for donation because it has a longer renal vein which makes it easier to attach in the recipient. ‘When the recipient is a small child, some surgeons prefer to use the right kidney because of the special way in which the kidney will be attached in the abdominal space of the child, Condition of the renal blood vessels Lis important to know not only how many renal blood vessels there are, but also, what is the condition of these blood vessels? Are they open or clogged with fatty deposits - in other words - atherosclerosis? A diagnosis of atherosclerosis of the renal vessels would preclude a donor. Assessing the renal blood vessels Renal angiography Renal angiography is a test to view the renal blood vessels. Most centres now use CT (Computerised tomography) or MR (magnetic resonance) angiography to reveal the number and size of blood vessels taking blood to and from the kidneys. A dye containing iodine is injected into a vein in the arm and repeated scans show how it travels through the kidneys. Both techniques also show the detailed anatomy of the kidney, the ureters and the bladder, ‘The test takes around 30 minutes and is done on an outpatient basis. Donor age ‘The young and the old each raise different issues with respect to consideration as potential living kidney donors. 35evaluation is you have this problem. Diabetes mellitus Diabetes mellitus is a major cause of kidney disease, leading to transplantation. Any Person with diabetes will not be considered as a kidney donor. Prospective donors with an increased risk of Type 2 (mature onset) diabetes mellitus, because of family history, ethnicity or obesity, will undergo a glucose tolerance test and only be considered if this test is normal. Proteinuria & pyuria Proteinuria describes a condition in which urine contains an abnormal amount of protein, Proteins are the building blocks for all body parts, including muscles, bones, hair, and nails, Proteins in your blood also perform a number of important functions, They protect you from infection, help your blood clot, and keep the right amount of fluid cireulating throughout your body. As blood passes through healthy kidneys, they filter the waste products out and leave in the things the body needs, like proteins, Most proteins are too big to pass through the kkidneys’ filters into the urine unless the kidneys are damaged. The presence of proteins in the urine, therefore is an indication of present or future kidney disease and in a potential kidney donor would rule out donation. Proteinuria is determined with a 24 hour urine collection. Pyuria The presence of white cells in the urine is called pyuria and may indicate a urinary tract infection or a more severe underlying kidney disease, The cause of the pyuria must be determined before a potential donor proceeds for further assessment. Kidney stones ‘The presence of kidney stones is a relative contraindication to kidney donation because the donor is at risk of further stone disease. Patients who have passed a stone are likely to ‘pass additional stones and up to 50% of patients with a calcium stone will pass another stone within 5 years. If a potential donor has passed a single stone more than ten years previously it may be acceptable to proceed to living donor donation, if a tendency to new stone formation has been excluded. However, it must be understood that if the donor has a history of kidney stones, a stone ‘may form later in the donor’s remaining kidney anda stone may form in the donated kidney - in the recipient - as well. If'a kidney is used from a donor with a history of kidney stones, lifelong follow-up is required for the donor and the recipient, 38Inherited renal disease When the cause of renal failure in the recipient is due to an inherited renal disease or there is a family history of renal disease, it is possible that a genetically related donor will also be at risk and thorough testing is required. This may include assessment by an expert in clinical genetics. Some renal diseases that may be inherited include: ‘* Autosomal dominant adult polycystic kidney disease (ADPKD) ‘* Autosomal recessive juvenile polycystic kidney disease * Alport’s syndrome ‘* Congenital nephritic syndrome © Vesico-ureterie reflux * Von Hippel-Lindaw disease « Familial juvenile byperuricaemic nephropathy © Anderson-Fabry disease © Familial Haemolytic Uraemic syndrome # Dent’s Disease © Familial FSGS ‘The presence of any of these diseases in the donor would rule out donation. Cancer It is well known that cancer can be transmitted from an organ donor to a recipient, whether the donor is living or deceased. To minimise this risk, care must be taken during the evaluation of the donor to ensure that there is no past medical history of malignant disease or symptoms consistent with undiagnosed malignancy. Tests will be done to rule out the presence of abdominal tumours, breast lumps, testicular swelling and swollen lymph nodes. Any indication of cancer in a potential donor, would be an absolute contraindication for donation, Infection If'an organ donor - living or deceased - has an infection, it can be passed on to the recipient. Since transplant recipients take drugs which reduce their immune system - in ‘order to prevent rejections - they are less able to fight off infections and even a “minor” infection could prove to be life-threatening, Identification of current or previous infection in the prospective donor is an important aspect of donor evaluation. The presence of an active infection usually precludes donation. 39Viral infections that pose a threat to the recipient include: ‘+ Human immunodeficiency virus (HIV-1 and HIV-2) ¢ Human T lymphotrophic virus (HTLV) © Hepatitis C virus (HCV) * Hepatitis B virus (HBV) © Cytomegalovirus (CMV or HHV 5) * Herpes simplex virus (HSV or HHV1 and HHV2) * Varicella-zoster virus (VZV or HHV3) « Epstein-Barr virus (EBV or HHV4) * Kaposi’s Sarcoma virus (KSKV or HHV8) Itshould be understood that with certain viruses, itis possible that the donor has no active disease or symptoms, but the virus would be a very powerful threat to the recipient. Bacterial infections include: * Mycobacterium tuberculosis (MTB) © Syphilis Fungal and parasitic infections include: © Malaria * Toxoplasmosis © Schistosomiasis Prion-associated diseases include: * Creutzfeld-Jakob disease (CJD) and variant CJD (vCJD) Because these infections are such a threat to the recipient, every effort will be made to ‘ensure that they are not present in the donor, ‘The evaluation of the prospective donor will include a detailed clinical history, a psychosocial evaluation, and a sexual history to define at-risk behaviour. Prospective donors may require additional evaluation, HTLV The presence of human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. HTLV serology is not routinely tested but should be performed if the prospective donor comes from an endemic area e.g. Africa, the Caribbean and Japan. 40HIV ‘The presence of HIV infection is an absolute contraindication to living donation. Kidney donation should not be undertaken if significant doubt remains about the possibility of HIV infection in the donor. Hepatitis B and C ‘The risk of hepatitis B or C transmission from an positive donor to the recipient is nearly 100% .The presence of hepatitis B or C in a donor, therefore, is a strong contraindication to living donation, All potential living donors will be tested for hepatitis B and C. CMV - Cytomegalovirus CMV is a member of the herpes family and is present in more than half of all adults before they reach middle age. These viruses are easily transmitted from one person to another through urine, saliva, blood, tears, semen and breast milk. For most people, CMV causes only mild symptoms, including a low fever and tiredness. Like all herpes infections, although these symptoms disappear, the virus remains in the body forever. But when the immune system is suppressed, following a transplant, the CMV can be reactivated and can cause a range of infections, some of which are minor and some of which are very serious and can lead to rejection or even be life threatening, In modern practice, CMV infection can be diagnosed early and successfully treated. ‘Some transplant recipients have already been exposed to CMV and are said to be “CMV positive.” In such cases, it may be possible to use a kidney from a CMV positive donor, ‘who is otherwise an acceptable donor. Following the transplant, any reactivation of the CMY infection in the recipient can be treated with antiviral medications. If, however, the recipient has no history of CMV - is “CMV negative”, it would not be advisable fo knowingly use a CMV positive donor kidney. Psycho-social evaluation of the donor {As part of your evaluation, it may be appropriate for you to see a clinical psychologist, psychiatrist and/or social worker. This offers you the opportunity to speak with someone who can provide you with additional emotional support that you may need at the time of donation. He or she can help explore the reasons why you want to donate and any concems that you may have. It is important that your motivations and concems are clear to you and the donor assessment team to ensure that every aspect of your health is assessed. © They can help you and the transplant team to be sure that you fully understand the risks of donation and that you are able to make an informed and free decision to go forward 4lwith donation, if you are found to be medically suitable. * Finally, they can help identify emotional factors that could stand in the way of your full recovery, if you are the donor, These factors could include depression or deep concems about the operation or taking medications. Itis very important that you are open and honest with them and view him or her as someone who is there fo help you. The Decision ‘Who makes the final decision? * The clinical team, with responsibility for you, decides if you have meet all of the requirements to be a living donor and if you are the best of possible donors. * The Independent Assessor decides if all required procedures have been followed, and that the letter of the law has been met on behalf of the HTA. The HTA gives final approval for a transplant to go ahead, * The recipient decides if he or she wants to be transplanted. * But ONLY YOU can decide if you want to be a kidney donor. What if you are the donor? Consent Ifyou are found to be a suitable donor, the best suited donor, and you want to donate, you will be asked to sign a consent form once you have made your decision to donate and then again before surgery. Read this document very carefully. If you have any questions, ask for a full and clear explanation. ‘The basic idea of the consent is that you have been told and understand: * the risks of donating a kidney. ‘© what will happen during and after the operation and the risks associated anaesthesia and surgery. «* that even if laparoscopic (keyhole) surgery is planned, it may become necessary to switch to an open procedure, * that it may be necessary to give you a blood transfusion during or after the operation. and that you understand the risks associated with blood transfusion. ‘* and finally, that you make the decision to donate a kidney without any pressure and of ‘your own free will. 42You will be given a copy to keep. Remember - even after you have decided to donate and have signed the consent form, you can change your mind - up to the time of the operation. The scheduled date of the operation ‘When the evaluation process is completed and it is clear that you will be the donor, a date for transplant will be scheduled which is convenient for you, the recipient and the transplant team, As that date approaches, it is important that you advise the transplant team: + if you have any illness, including a cold, dental problem, or infection. © if you are taking any new medications, including over the counter, herbals or food supplements as some of these can affect blood clotting or interact with anaesthesia or other medications you will be given at the time of your transplant. * if you are planning any trips away from home. « if there is any change in your contact information, Although things should proceed as planned, be aware that if you, or the recipient, have any illness at the time of the transplant, the procedure may have to be postponed Final preparations Your doctor will tell you if you must stop taking certain routine medications before the operation. Some medications thin the blood, while others may interact with anaesthesia. Be certain to tell your doctor all medications you are taking, including over-the-counter remedies, vitamins, herbals, and food supplements. If you are taking oral contraceptive pills, you must stop taking them one month before the operation and use an altemative form of birth control until several months after the ‘operation, when your doctor tells you itis safe to either resume the pills or if you wish to become pregnant All results of your evaluation are strictly confidential. You can discuss with the evaluation team what may or may not be told to your family or the recipient. Your donor team is there to protect your interests. Even if you cannot be the donor, you can help the recipient in so many ways during the wait for a donor kidney, during the time of the transplant and for the many years that will follow. 4Bor blood replacement. If you have any other medical conditions, your anaesthetist will know of these from your pre-operative assessment and be able to treat them during surgery. Benefits of anaesthesia Many people believe that the role of anaesthesia is to put the patient to sleep during the operation. But the role is actually much greater, and includes: * Blocking of pain ‘ Support ofall vital functions ~heart, lungs, temperature, blood chemistry ‘# Relaxation of muscles # Blood clotting and blood volume Risks of anaesthesia In order to achieve these benefits, the anaesthetist must use a range of procedures and medications, each of which carries certain risks, These risks are in addition to those associated with the surgery itself. Anaesthetic risk, for an individual patient, depends upon such factors as: ‘* Your general physical condition * Specific medical conditions - such as heart, lung or kidney disease ‘* Allergies or sensitivities to medications used during anaesthesia * Smoking *# The length of the operation Risks of anaesthesia, like those for surgical procedures or medications, fall into two categories. Side effects ‘These are effects other than those that are intended. In most cases the side effects are known, even unavoidable, and therefore anticipated. Most side effects disappear as soon as the anaesthetic drugs leave your body - usually a matter of hours, perhaps days. Some are best left to wear off and others can be treated. Examples would be nausea or confusion after general anaesthesia, Complications These are unexpected and unwanted events that occur during or after treatment, Examples would be an unexpected allergic reaction to a drug or damage to your mouth or windpipe caused during the placeinent of the breathing tube. 47What are some of the risks and how common are they? Risks are categorized as follows: * Very common - occurs in one or more out of every ten cases + Common - occurs in one out of every 100 cases * Uncommon - occurs in one out of every 1000 cases + Rare - occurs in one out of every 10,000 cases + Very rare - Occurs in one out of every 100,000 cases Very common and common side effects and complications of anaesthesia include: ‘+ Nausea and vomiting - usually goes away, but may be trested with anti-nausea medication © Sore Throat - caused by the ventilator tube. Goes away in few hours or days. * Dizziness, blurred vision - caused by anaesthetic and fluid loss, Goes away or may be treated with intravenous medications, © Shivering - treated with warming blankets, * Headache - treated with medication, * Itching - can be due to certain pain medications. Will stop or be treated with medications, * Aches and pains in back and joints. This is due to lying for many hours on the ‘operating table. Will go away or be treated with medications, * Bruising and soreness at sites of intravenous lines. These go away in time. * Confusion or memory loss. This is common with general anaesthesia and may last for a few days or several weeks, Uncommon side effects and complications of anaesthesia These include: ‘* Chest infection. This is more likely to occur in patients with respiratory problems or those who smoke, + Damage to teeth, lips, tongue or windpipe. These can occur during the insertion of the ventilator tube (breathing tube) and occurs usually in patients with abnormally small mouth opening, such as arthritis of the jaw. © An existing medical condition may get worse. Patients with an unstable heart condition of uncontrolled diabetes may experience a worsening of their conditions during the period after anaesthesia and surgery. Rare or very rare complications of anaesthesia include: + Injury to the eyes. Anaesthetists take great care to protect your eyes. Your eyelids are held closed with adhesive tape, which is removed before you wake up. However, sterilising fluids could leak past the tapes or you could brush your eyes as you wake up after the tapes have been removed. These could cause damage to the surface of your eye, which is usually temporary and responds to drops, 48© Setious allergic reaction to medications. Allergic reactions will be noticed and treated very quickly. Very rarely, these reactions lead to death even in healthy people. It is essential that, before the operation, you tell the anaesthetist of any drug-related allergies or reactions you or members of your family may have had in the past. © Death, Deaths caused by anaesthesia are very rare, and are usually caused by a ‘combination of four or five complications arising together. There are approximately five deaths for every one million anaesthetics given. ‘The operation ‘Types of donor nephrectomy Living donor nephrectomy can be undertaken using either of two surgical approaches: * Open donor nephrectomy Laparoscopic donor nephrectomy ‘There are two types of laparoscopic donor nephrectomy, standard or pure laparoscopic donor nephrectomy and ‘hand-assisted’ laparoscopic donor nephrectomy which will be ‘explained later in this module. Your surgeon will discuss with you which procedure is best for you. You may want to consider another transplant centre with alternative procedures. ‘The surgical procedures described here are for left kidney nephrectomy. The removal of right kidney is similar, but is not the side of choice as the length of the artery and vein are shorter on the right side compared to the left, which makes the implantation procedure in the recipient slightly difficult, which may result in complications in some patients. This is true for both open and laparoscopic nephrectomy. Regardiess of which type of nephrectomy will be done, the procedure for preparing you for surgery is the same, Ilustration 27 Once you are asleep, the following tubes and monitoring lines are placed in or on your body. ‘A tube which passes into the windpipe fiom the mouth - this is attached to a ventilator to assist your breathing. It remains in place until you wake up and are able to breathe on your own in the Recovery Unit. ‘A tube that passes into the stomach via the nose - this is to prevent your stomach becoming distended or bloated during the operation, It may remain in place until you are 49ready to drink fluid depending on the type of surgery. I Several drips, placed in your veins, are used to give fluid and drugs. They remain in place until your condition is stable and you are able to drink fluid on your own. ! ECG electrodes, which are placed on your chest to monitor your heart rate during the operation. | A catheter (tube) will be inserted into your bladder. This allows an accurate measure of how much urine is made, It will usually be removed the day after the operation. ' Open Donor Nephrectomy - ODN ._______Open nephrectomy is the “traditional” method used tn remove kidnev and was the.7‘Today, LDN has surpassed ODN as the procedure of choice for living donation. At is important to know that even if LDN is scheduled, or even begun, it is possible that the surgeon may have switch to ODN if it becomes clear that the kidney cannot be otherwise safely removed. This conversion to ODN occurs in 2-6% of LDN operations. LDN is not for everyone ‘You may not be suitable for LDN if ‘* You have had multiple previous abdominal surgeries * You are significantly overweight + The kidney to be donated has abriormal anatomy - such as multiple blood vessels. © You are donating your right kidney The operation Once anaesthesia is induced, the patient is positioned on the operating table lying on one side - the donor kidney side up, Ilustration 36 ‘The surgeon will insert a small needle into the abdominal cavity. The needle is connected to sterile tubing through which carbon dioxide is passed into the abdominal cavity to lift the abdominal wall away from the organs below. This space provides the surgeon with an excellent view and more operating space. Two, three or four tiny incisions - each less than ¥ inch (1 - 1.Sem) long - are made in the abdominal wall. One opening will be used for the laparoscope and the others for the surgical instruments. A longer incision, 2-3 inches (5-7em) is made, through which the donor kidney will be removed. This incision can be made either near to the navel or along the bikini line, ‘While watching the TV monitor, the surgeon uses the miniature instruments to reach the kidney and carefully cut it away from the surrounding tissues that keep it secured in place. ‘When the renal artery, the renal vein and the ureter have been cut, and the remaining portions carefully closed off, the kidney is slipped into a plastic bag and then removed through the larger incision, In some procedures, the surgeon’s hand is inserted through the larger incision and helps to remove the donor kidney. This, not surprisingly, is called “hand assisted laparoscopic donor nephrectomy” or HA-LDN. When the donor kidney has been removed, it is flushed with a special solution and immediately cooled to protect it from damage of being without blood and oxygen. Itis ‘then quickly carried to the recipient operating theatre for transplantation. 52Meanwhile, the laparoscope and surgical instruments are withdrawn, The gas is released from the abdomen and the small incisions are closed with adhesive strips. The larger incision is closed with absorbable sutures and adhesive strips on the outer layer of the skin, ‘The operation takes 3-4 hours, about 1 hour longer than the open procedure, Benefits and risks of laparoscopic donor nephrectomy ‘The benefits of LDN are all related to the fact that 2-5 small incisions are made, all of which are non-muscle cutting, That means: Less pain ‘» Faster recovery ‘© Smaller scars - cosmetically more acceptable ‘These photographs show the wounds shortly after the surgery. Hlustration 37 ‘In most cases, they arc barely visible after several months. Complications following LDN Laparoscopic and open donor nephrectomies have similar rates of complications. ‘The complications seen in LDN include: # Damage to sensitive blood vessels and the bowel when the abdomen is inflated with gas. ® Accidental damage to blood vessels, the bowel or other structures within the abdomen. Tn some cases, the problem is minor, in others, additional operations may be required to correct the damage. ‘© Pneumothorax ~ when the abdominal cavity fills with air through an incision. « Infections - within the abdomen or at the wound site, © Pain - lasting for long periods of time ‘The UK NHS National Institute of Clinical Excellence (NICE) issued its guidance on LDN in May 2004. It concluded that current clinical evidence on the safety and efficacy of LDN appeared adequate to support its use in the NHS. Post operative care Following the operation, you will be carefully monitored and cared for until you are awake and medically stable. This is rarely more than an hour or two. Your family will be able to visit you briefly at this time, ‘Most patients, when they awake from the surgery, feel groggy or dazed from the anaesthetic and sore around the site of the incision. 53,‘You may still be receiving supplemental oxygen and the urinary catheter will, most likely, still be in place as itis important to continue to monitor your urine output. How did it go? For most donors, there are two things that enter their minds as soon as they are awake: ‘© Imade it - I survived ‘How is the recipient? Was the transplant a success? Similarly, transplant recipients with living donors always ask - “how is my donor?” as soon as they awake, ‘The post operative care is somewhat different following ODN or LDN, while some aspects are care are the same. Click on the buttons below for further information, Open Donor Nephrectomy Laparoscopic Donor Nephrectomy Usual postoperative care ‘Open Donor Nephrectomy Postoperative care following ODN Following open donor nephrectomy, you will be moved to the Intensive Care Unit (ICU) for further observation and monitoring of all vital functions, urine output and any signs of bleeding or infection. ‘Your family will be able to visit you, but visiting hours in the ICU are often restricted. It is possible that you will be in the same ICU as the recipient, In most cases, the stay in the ICU is only one day and then you will be moved to the regular ward. Pain In an open nephrectomy, there can be a long incision, large muscles have been cut and perhaps a rib has been removed or parily removed. Let’s be honest - it is going to burt. The good news is that effective pain management is available and itis essential that you have little or no pain so that you can begin to move about - insuring an early rehabilitation and uneventful post-operative recovery. 34Pain Management——— —_ -— - - em and the recipient can be enormous. For the recipient, there may be: © Guilt that the donor's gift was in vain ‘* Guilt that perhaps another living donor may be used * Fear that if'no living donor is available, there may never be a kidney from a deceased donor For the donor, there may be: ‘ Anger and disappointment that their gift could not be used or failed ‘ Sadness that they were, in the end, not able to help * Concem over the future of the recipient It is important to discuss these emotions with your clinical team, who will provide you with support during this time. Tests You can expect frequent blood tests and urine analyses. Tests-of your heart and lungs will be necessary only if there are indications of some problem. Discharge from hospital 7 ‘When your doctors are certain that you are clinically ready and you have completed post donation education, you will be discharged from hospital. ‘You will be given: * pain medications, if you still require them. * prescriptions for any medications that may be required. ‘ an appointment for your first control visit - usually between 4 and 6 weeks after discharge. * advice about the skin closures you still have in place when you leave the hospital. * advice on caring for your wound, * Documentasion on your scheduled Dr visits Ifyou live out are geographically distant from the transplant centre If you live far from from the transplant centre, you may be asked to remain nearby until you have had your first follow-up visit. Following this, you will be given instructions for follow up care by your local doctor. 58Weeks after discharge ODN LDN Shopping and housework 4 2 Driving a car 6 46 Exercise and sports 8 4 Work 8-12 24 ‘These are averages. Each person is different and recovers at different rates. Diiving a car is not just about how well you feel. Your insurance actually defines how soon after surgery you are allowed to drive. Check your policy or contact your insurance company. Retuming to work is very much a matter of what you do. Ifyou sit at a desk, you may refum sooner than if you work is very physically demanding. Be sensible. Don’t return. to work sooner than you are truly ready Sexual activity ‘There is nothing about donating a kidney that would affect your sexual behaviour. You may retum to sexual activity as soon as you feel physically ready to do so. Avoid positions that would put pressure or strain on the surgical wounds, Pregnancy following kidney donation Pregnancy has a number of well-known effects on the kidneys, which raises the possibility that an individual with a single kidney may be at greater risk, Several studies, have shown that the presence of a single kidney does not appear to pose a significant risk during the course of a normal pregnancy. However close monitoring is recommended to ensure complications can be avoided. ‘Therefore, if you are pregnant or considering pregnancy, itis advisable to have close monitoring of blood pressure and kidney function throughout the pregnancy. The Financial Aspects of Living Donation Background ‘Transplant regulations forbid the offer or payment of any inducement for the supply of a numan organ, However, it does not prohibit the payment of reasonable expenses to a donor for travel and accommodation if directly attributable to his/her donation of an organ, 61RLD KIDNEY Kidneys and kidney disease ‘Mustration 1 Mlustration 2 : 1Mlustration 10 Dr. Peter Medawar, Ilustration 11 Herrick Twins -1954 Dr. Murray & Ronald - 2004 istration 12 Sir Michael WoodruffNe ef He ae Compatibility Testing Donor-recipient compatibility Mustration 13 Your body is made up of building blocks called cells. Tustration 16 Specialised white blood cells called T- lymphocyteslustration 17. Cells with wrong codes Mlustration 194 q 5 2 <: i ohne eS ee PSS oF fo aa em eee ee eee‘The operation This provides the surgeon with excellent exposure of the kidney and allows the kidney to : be removed easily and quickly. ay | ‘The transperitoneal approach, Illustration 29‘The kidney is removed, Illustration 30Size of the incision Illustration 32 a and b Complications [Herniation Ilustration 33,Laparaoscopic Donor Nephrectomy - LDN Mlustration 34Iustration 36