By Mia Vincent, Amy L. Friedman, MD, FACS, and Thomas G. Peters, MD, FACS, FASN
The answer is both easy and complex at the same time. Easy, because virtually all living kidney donors do well. Complex, since there are different operations for living kidney donation and different transplant centers may have plans for care which vary from neighboring institutions. In all cases, however, transplant center professionals start with the most important question of all: Should I donate a kidney?
The evaluation of a person to become a living kidney donor takes time, careful analysis and sound medical judgment. The basics required to donate a kidney include willingness to undergo major surgery, ability to give informed consent, presence of two normal kidneys (one of which will serve the donor for the rest of a natural and normal lifetime) and general good health. The donor must be able to not only withstand the surgery but also to recover quickly and return to normal activities of daily living. While our initial question relates to expectations following kidney donation, we will review several features of the donor operations, the hospitalization following these operations, and the long-term recovery of kidney donors.
There are two operations commonly employed to remove a living donor kidney for transplantation. The open nephrectomy (kidney removal) is the classic approach to kidney surgery and is performed through an incision just below the rib cage or toward the mid flank. The open technique may be accompanied with certain pain control measures following surgery such as epidural pain management; in-hospital recovery time is usually three or four days. The second surgical approach to living kidney donation is called laparoscopic donor nephrectomy, and involves the use of small cameras and instruments inserted through the abdominal wall. During this procedure, the kidney is separated from its surrounding structures. The operation is performed using TV imaging.
Once entirely separated from its surrounding structures, the kidney is removed through a small incision usually in the mid portion of the lower abdomen. Both operations can take from one and one-half to four hours or more depending on the complexity of the surgery. Both operations are followed by routine measures of care, commonly following protocols developed by the transplant center.
After a kidney donation, as with most major operations, the patient is monitored in a post anesthesia care unit or recovery room. Blood pressure, heart rate and temperature are observed as are oxygen levels and wakefulness. The level of pain is also monitored. Most donors will come from the operating room with a Foley catheter draining the urinary bladder and with at least one intravenous line allowing fluid administration in the early post operative period. Patients are not permitted to eat or drink anything until they are fully awake, and until they have no nausea and vomiting.
After the immediate recovery period, the donor is transferred to either an intensive care/monitored bed, or to a medical-surgical ward. In either case, post operative pain control is ordered and may take the form of patient controlled analgesia (PCA), or epidural pain management. Usually, the PCA technique, which the patient can control by pressing a button, is used for the laparoscopic donor surgery and epidural pain management is considered for the patients having an open donor nephrectomy. All patients are encouraged to begin walking within 12 to 24 hours following surgery, and self-care including routine hygiene such as showering, shaving and brushing teeth can begin very soon. As a rule, the intravenous fluids are discontinued when the patient can drink or eat food by mouth. The Foley catheter is discontinued when the patient is walking and beginning self-care.
Some treatment plans related to prevention of post operative complications are part of the post donation protocols, just as they are part of patient care for any major surgical procedure. Compression stockings or elastic hose are applied to the feet and legs to prevent blood clots from forming, and small injections of heparin or a similar drug may be given at eight or 12 hour intervals to also address prevention of abnormal blood clots. This is important because one of the major complications that can occur following kidney donation is a blood clot traveling to the lung (pulmonary embolus). This infrequent, but well known, complication can be life threatening and measures to prevent blood clots traveling through the body are standard in all hospitals. As activity and walking increase, these preventive measures are stopped. As the first day or two passes, most kidney donors begin to return rather quickly to the usual activities of daily living. Food and fluid intake resume, less pain medication is needed and patients begin to anticipate discharge from the hospital to their home.
Usually, the only discharge medication required is a standard pain medicine taken by mouth; it may contain some amount of narcotic. Pain control, therefore, may be accompanied by advice not to operate a vehicle, power tool or other machine. Further, most surgeons recommend patients do not drive until they are entirely comfortable with operating a vehicle. Patients are also instructed not to lift any object heavier than approximately 10 pounds for a three to six week period following donation.
This activity restriction is to prevent the occurrence of hernia in the incision. Usually, discharge planning is completed and the patient is ready to go home on the second, third or the fourth post operative day.
Once home, patients should slowly resume all of their normal daily activities. Many patients who have office type jobs can return to work within 10 to 14 days, and persons who have more physically demanding jobs may need to be out of the workforce for four to six weeks. The return to full activity and employment does vary from patient-to-patient, and professionals at the transplant center are well versed in how to advise patients having had a kidney donor operation.
An interesting psychological situation may arise following a living kidney donation. Many have heard or experienced the “post-partum blues” or an emotional letdown with depression following the birth of a baby. Pregnancy and birth are much like living kidney donation in that a rather important biologic event is going to occur, and the anticipation over the course of weeks or months build expectations in the new mother or, in our case, the kidney donor. With the birth of the child or the removal of the kidney, the process is virtually finished, and a new set of expectations and feelings suddenly come in to play. This abrupt change in a complicated process sometimes results in sadness or a feeling of depression, even when the donor and recipient operations go well. It is this quick change in course following a rather long period of expectation that seems to contribute to the “post-donation blues.” Fortunately, many donors have no feeling of depression whatsoever, and those who do experience this usually have “depression” for a very short period of time. In virtually all cases, donors are pleased with the outcome of donation and transplantation and would even go through the process again were that possible.
An additional question relates to what may occur in the long-term for a patient with only one kidney. The pre-donation evaluation is quite thorough, and the kidney which remains is perfectly capable of taking on the function of two kidneys almost immediately. The donor may be advised to refrain from high-impact contact sports such as football and ice hockey. And, certain military regulations may not permit a person with one kidney to enter the service or to undertake certain military occupations. However, most living donors can go about their lives without restriction and with the sound knowledge that their chances for a long, healthy and normal life is the expectation of all. The two dangers to complete loss of kidney function relate to removal of the sole remaining kidney for medical reasons such a tumor, or surgery for trauma such as a gunshot wound. Fortunately, kidney tumors are extremely rare in patients who have donated a kidney, and injury seldom results in the need to remove a solitary kidney.
The transplant center in which the donor’s operation was performed is required to report to the government on the donor’s well-being for the first two years. In the long-term care plan of a kidney donor, it is important to have a primary care physician who monitors and helps manage the donor just as though no kidney operation had occurred. Important elements of healthcare relate to avoiding tobacco, moderate use of alcohol, monitoring of blood pressure and heart function as well as screening for diabetes and other common diseases. As years go by, the living kidney donor should have a yearly urine analysis and check of the creatinine level. There are no other recommendations regarding medical monitoring of a living kidney donor that are substantially different from the normal population.
If some mishap should result in loss of kidney function in the remaining kidney, the United Network for Organ Sharing (UNOS) has established a policy that living kidney donors be placed closer to the top of the kidney transplant list should that be their wish. This policy recognizes the selfless sacrifice of kidney donors who ultimately lose function of the remaining organ and must, therefore, begin dialysis treatment. Fortunately, over the course of many decades and many thousands of kidney donors, fewer than 150 people are known to have required dialysis care after donating a kidney to someone else.
Living kidney donation has grown rapidly in the last two decades because the need for kidney transplantation has increased markedly. Almost all medical professionals recognize the general safety of the surgical procedures for kidney removal when the donor is appropriately evaluated and there are no reasons to avoid surgery. Both the open and laparoscopic surgical techniques have evolved to permit short post-operative recovery periods and good long-term post donation results. So, in the vast majority of cases, the kidney donor can expect a short hospitalization, a rapid recovery and a healthy lifetime if routine measures of medical management are followed.
Mia Vincent is a Certified Clinical Transplant Coordinator and has over a decade of experience at the Shands Jacksonville Transplant Center in Jacksonville, Fla.
Amy L. Friedman, MD, FACS, is the Director of Transplantation and Professor of Surgery at SUNY Upstate Medical University in Syracuse, NY.
Thomas G. Peters, MD, FACS, FASN, is the Chief, Transplantation Surgery, Shands Jacksonville Medical Center and Professor of Surgery at the University of Florida Jacksonville, Fla.
Drs. Friedman and Peters serve the AAKP on its Board of Directors and the Medical Advisory Board. Dr. Friedman is Secretary of the AAKP Board of Directors. Dr. Peters is Co-Medical Editor for aakpRENALIFE.
This article originally appeared in the September 2008 issue of aakpRENALIFE.
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