Before, During, and After Kidney Transplant Surgery

How to Get on the Kidney Transplant List

A kidney transplant is a surgical procedure during which a patient receives a donated kidney to replace their diseased kidney. This is done as a treatment for end stage kidney disease, which is kidney disease that is so severe that it will shorten the lifespan of the individual because the kidneys are no longer able to do their job well enough to prevent illness.

The Kidneys

A healthy human body has two kidneys that work together to filter the blood and remove toxins from the body. The kidneys work to maintain the appropriate amount of fluid in the blood and also filter excess salts, electrolytes and minerals out of the blood.

The kidneys make urine with what is filtered from the blood. This urine is then eliminated from the body first by moving out of the kidneys through the ureters to collect in the bladder, then exiting the body through the urethra during urination.

Without the kidneys, water is not eliminated from the body, which can cause fluid overload making it difficult to breathe and causing serious swelling throughout the body. It also makes the work of the heart much more difficult, and if it continues without treatment, this excess water can lead to death.

Along with the excess water comes disturbances in how much salt, potassium, magnesium and other electrolytes remain in the blood.

 Imbalances in these substances can cause issues with the function of the heart and other serious complications. 

Kidney Disease

Individuals whose kidneys are no longer functioning well enough to support the needs of their body will need dialysis or a kidney transplant to prevent death. Kidney disease is usually a progressive issue, and worsens over time, so the individual is typically well aware of their worsening kidney disease and is able to take steps to prevent the disease from progressing rapidly.

One common cause of kidney disease and the eventual need for dialysis is poorly-controlled diabetes. For an individual who is diabetic and has kidney disease, getting glucose levels under control can add years to the functional lifespan of the kidneys, or even prevent the need for dialysis and transplant entirely.

For other individuals, kidney disease worsens over time despite medical interventions and lifestyle changes. Despite everyone’s best efforts, the kidneys become too diseased to function well. 

Rarer still is when sudden kidney issues, called acute renal failure, lead to permanent kidney disease. In these cases the damage is sudden and cannot be recovered. This may happen due to a trauma or as a side effect of a major illness. 

There are many stages of kidney disease, ranging from mild disease to severe and life-threatening conditions. End stage kidney disease is the final step in kidney disease. This is the level of disease that requires dialysis treatments, transplant or death will eventually occur.

Kidney Transplant

The process of being listed on the transplant recipient wait list is neither quick nor easy, but the effort is well worth it when a new kidney becomes available.

The process to be approved to be on the transplant list will start early in the disease process, when your kidney problem is first noticed, and a referral to a nephrologist—kidney doctor—is made. Your nephrologist may be able to treat your disease for many years, but when it worsens and it becomes clear that dialysis and the need for a transplanted kidney are becoming a reality, you can be referred to a transplant center. 

The transplant center will then determine if you are appropriate for a kidney transplant. Many questions will need to be answered, starting with the most basic issue of whether or not a kidney transplanted is needed by doing lab tests that determine how the kidneys are functioning.

If there is a need for a kidney transplant, many more questions will need to be answered. 

These issues range from whether or not the individual is a good candidate for a transplant, if they are healthy enough to tolerate the surgery and the stress the surgery will place on the body and if the reward of the transplant outweighs the potential risk of transplant surgery and recovery.

Answering these questions, though lab work, physical examinations and other testing is the starting point. After that, additional tests are done to determine the patient’s genetic fingerprint, so that a donated organ that is a good genetic match can be selected to reduce the risk of rejection.

The recipient will also undergo evaluations to determine if they have emotional and mental capacity to tolerate the wait for a transplant, the process of receiving a transplant and have the ability to take care of themselves and manage their health after surgery. 

Many transplant centers will not provide any type of organ transplant to patients who are not independent in their day to day needs.

A history or current issues with addiction can also exclude potential recipients from the transplant process, at least on a temporary basis. For example, if the patient abused cocaine and it caused kidney damage, they will not be transplanted if they continue to abuse cocaine. If they are continuing to use the drug they will not be placed on the transplant list until they are free of drug abuse for a length of time that is determined by the transplant center.

The financial aspects of transplant will also be addressed by the transplant center, making sure the patient has the ability and insurance necessary to pay for the transplant process from first visit to the medication needed to prevent rejection after surgery.

The Transplant List

Once the patient is determined to be appropriate for an organ transplant they are placed on the transplant list by the transplant center. This means they are added to a national database run by UNOS that allows donors and recipients to be matched when an organ becomes available.

The “transplant list” is actually a very large database of over 114,000 individuals waiting for a variety of types of organ transplants. When an organ becomes available for transplantation, a complex mathematical algorithm is used to create the unique list of the potential recipients for that organ. Thousands of these lists are generated on a monthly basis, each one is unique to a specific organ being donated by a specific donor. 

Only individuals who are appropriate for that organ will appear on the list. A recipient who is too big or too small or a blood type that is incompatible will not appear on that list.

Contraindications

There are some issues that typically prevent an individual from receiving a transplant. How these are handled are unique to the surgeon and the transplant center, and may be different from center to center or even from one surgeon to another.

A contraindication at one transplant center may not prevent an individual from being listed at a different transplant center, these are not rules, they are general guidelines of suitability for recipients. Some of these would only prevent transplantation temporarily. 

For example, a current infection would only prevent transplant surgery while the infection is present. The patient would be eligible for a transplant as soon as they are well. A positive drug screening that shows the potential recipient has been using cocaine, on the other hand, could cause a delay of years in the process.

  • Active infection
  • Severe disease of another organ (for some a multi-organ transplant is available, including a heart-kidney or a kidney-pancreas) 
  • Active addiction to drugs that may include illegal drugs, alcohol, and/or nicotine
  • Cancer that is current, or likely to return.
  • Inability to manage their own health regimen 
  • Dementia
  • Severe vascular disease
  • A life-ending disease in addition to kidney disease
  • Severe pulmonary hypertension

Types of Kidney Donation

Deceased Donor Transplant

Most donated organs become available for transplantation when a person becomes brain dead, and the donor or their family members elect to donate their organs to a waiting recipient. This type of donation is called a deceased donor transplant.

Living Donor Transplant

In some cases, a healthy friend or family member will donate a kidney to a loved one, as the human body can remain well with one healthy kidney. This is called a living donor. In some cases, a living donor decides to donate to a waiting recipient they do not know out of kindness, this type of donor is referred to as an altruistic donor.

Not every donor kidney is fit for every person waiting for an organ. In order for a kidney donor and a recipient to match, they must be approximately the same body size. In some cases a kidney from a child might be appropriate for a small adult female, but would not be adequate for a large adult, depending on the size of the child. Similarly, a large kidney would be too big for a young child in need of transplantation.

The donor and recipient need to match genetically, and the better that match the better the outcome from surgery over the long term. A zero antigen mismatch is the technical term for a kidney donor-recipient match that is exceptional. This type of match, which is most often seen between relatives, can reduce the amount of anti-rejection medication the recipient needs in the years after surgery.

Barriers to Living Donor Transplantation

If a loved one wants to donate a kidney, they may or may not be able to do so for a wide variety of reasons. Some donors may find out, after starting testing, that they have kidney disease too. Others find out that they are the wrong blood type or have a health condition that makes the donation too risky. 

Some of the more common issues that prevent living donation include:

  • Kidney disease including some types of kidney stones. This is a particular risk when siblings are donating to a sibling with kidney disease, the donating sibling may also find out they have kidney disease.
  • Uncontrolled blood pressure, diabetes, heart disease or lung disease
  • History of bleeding problems: bleeding too easily or blood clots
  • Poorly controlled psychiatric issues
  • Obesity
  • Cancer
  • Communicable diseases, such as HIV

For some people, their loved one wants to donate a kidney but cannot due to blood type or another issue of compatibility. Modern medicine makes it possible for donation to occur anyway, with the pairing of matched donors and recipients.

For example, Mr. Smith needs a kidney and Mrs. Smith would like to give him one but they are not compatible. In another area of the state, Mrs. Brown needs a kidney and Mr. Brown would like to donate his, but they are not compatible. A computer program is used to determine that an exchange can take place, where Mr. Brown gives his kidney to Mr. Smith and Mrs. Brown receives Mrs. Smith’s kidney.

These paired exchanges are becoming more common, and the “chains” of donor and recipient matches are getting longer. As of December of 2017 the longest chain, known as the “UAB chain”, was at a record 88 transplants, meaning 88 donors gave a kidney to a person in the chain they did not know, and 88 recipients in the chair received a kidney from someone they did not know. 

Kidney Transplant Surgery

Finding a Surgeon and Surgery Center

Most transplant centers have multiple surgeons who are competent to perform a given transplant procedure, but not all transplant centers do all types of transplants. Many centers do offer kidney transplants, but less offer heart or lung transplants, so the nature of your issue and your location may determine where you seek treatment.

You may have many centers to choose from or the nearest transplant center may be a significant distance away from your home, which may limit your options.

The Procedure

The kidney transplant procedure starts with the donor’s surgery, during which the kidney is removed. Once the kidney is determined to be healthy and of high enough quality to be transplanted into a recipient, the process begins for the recipient. They will be sent to the hospital where labs are drawn, IVs are placed and other preparations are made for surgery.

The surgery begins with general anesthesia being given, typically by an anesthesiologist, and the placement of an endotracheal tube.

Once the patient is asleep, the incision is made in the abdomen, where the new kidney will be placed. For most individuals, the native kidneys—kidneys the patient was born with—will remain in place unless they are causing circulation problems or other issues that require their removal.

The kidney is sewn into place by one or two surgeons, with great care to make sure blood flows well through the kidney, and that the kidney begins to make urine within minutes of being connected to the blood supply.

Once the kidney is in place and actively making urine, the surgery is completed and the incision can be closed. The entire process takes two to three hours in most cases.

In the vast majority of surgeries only one kidney is transplanted as one kidney is more than capable of filtering the blood of the recipient. If the donated kidneys are very small, both may be transplanted into the recipient to make sure that the kidneys are able to filter well enough to keep the recipient well.

Risks

In addition to the general risks of surgery and the risks associated with anesthesia, kidney transplant surgery has unique risks. These risks vary from person to person, but also increase with age and the severity of illness. 

Risks of kidney transplant include but are not limited to:

  • Bleeding--the kidney filters the blood, so bleeding has the potential to be severe in rare cases.
  • Blood clots
  • Stroke
  • Anoxic brain injury, or brain damage due to a lack of oxygen
  • Death. All surgeries have a risk of death, but the risk is higher than typical with kidney transplantation due to the complex nature of procedure and care after surgery.
  • Acute rejection. The donor's body does not accept the donated kidney.

Recovery

The typical patient returns home within a week of surgery with kidney function that is good enough that dialysis is no longer needed. Most individuals are able to return to their normal activities within a month or two of surgery. 

Some patients experience immediate kidney function that is excellent, others have a delay in kidney function that may make dialysis a necessity until the kidney reaches its full potential. In rare cases, the kidney never works well enough to allow the patient to stop having dialysis treatments.

Organ rejection can be a serious issue after transplant surgery. This occurs when the body identifies the new organ as a foreign body and tries to reject it. To prevent this, many medications can be used, and some individuals never have an issue with rejection.

Rejection episodes are most common in the six months after surgery but are possible at any time after transplant surgery. When rejection happens, the faster it is identified and treated the better the outcome.

Prognosis

For the kidney recipient, the patient is up to seven times less likely to die than when they were on dialysis. Ninety percent of recipients, whether they received an organ from a living or deceased donor, are alive three years after surgery. At ten years after surgery, 67 percent of deceased donor recipients and 90 percent of living donor recipients are alive.

For those that are not, it is important to remember that these statistics show all causes of death including natural causes, car crashes, heart attacks and many others that may not be kidney or transplant related.

Of the transplant recipients living 10 years after their kidney transplant, 81 percent of deceased donor recipients and 90 percent of living donor recipients have a kidney functioning well enough to stay off of dialysis.

A Word From Verywell

A kidney transplant is a complex and serious surgery that can take months of preparation, testing and frequent doctor visits just to turn around and wait for years for an organ to become available.

For most, the frequent dialysis treatments and all of the time spent wondering and waiting if an organ will become available is absolutely worth it when a kidney becomes available. Transplant surgery leads to a dramatic change in the feelings of fatigue and exhaustion that come with dialysis and kidney disease, a change that is often notable and dramatic before leaving the hospital.

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