By Amy L. Friedman, MD

Emergence from the operating room with a new kidney transplant initiates many processes that may seem confusing and overwhelming, but are not mysterious. Each issue should be comprehensible enough to permit collaboration with the transplant team’s management strategy. With understanding, the recipient can cope with physical and emotional demands of rapid changes he or she is living through.

Understanding the Transplant Operation

The transplant operation requires construction of connections between three parts of the kidney and body. Most adult kidney transplants are placed through an incision in the pelvis, behind the peritoneal cavity that contains your intestines. In this space, the blood vessels that supply your legs are accessed. In small children and some adults, this “retroperitoneal” area cannot accommodate an adult kidney, and the blood vessels are accessed through the peritoneal cavity with an incision in the middle of the abdomen. In all cases, the arterial blood supply to the new kidney is attached to arteries. As many as one third of kidneys have multiple arteries (as many as five can be found) that require multiple small connections that have an increased risk of clotting. If so, the use of anticoagulation medications (blood thinners) may be prescribed. Similarly, the vein draining blood from the kidney is attached to the vein returning blood from your leg to your heart. Finally, the ureter (the tubular structure that collects urine from the kidney) is attached to your bladder, ureter or reservoir that has previously been constructed to collect urine. In some, a small plastic tube (stent) is left inside the urinary connection to promote healing. The stent will need to be removed between three and six weeks after transplantation through a minor urologic procedure.

Leakage can complicate every surgical procedure. If the problem occurs at the arterial or venous connection, bleeding occurs. If the leak involves the urinary connection, urine drains. Each connection can also be complicated by narrowing (stricture). Reoperation or another invasive procedure may be required to resolve problems. Finally, tissues that have been incised may weep fluid that collects beneath the incision or drains between the skin stitches (staples), but ultimately seals. Overall, it is important to be familiar with technical details about your specific operation (see Table 1) so you understand the rationale behind the treatment you are receiving, and so you may inform other healthcare providers who need to know.

Technical Aspects of Your Kidney Transplant (Table 1)

• Retroperitoneal or intraperitoneal (behind or inside the peritoneal cavity)

• Single or multiple arteries

• Single or multiple veins

• Type of ureteral connection

• Was urinary stent used?

• Leak or stricture of any surgical connection

When Will the Kidney Begin Working?

Without a crystal ball, no physician can specifically predict whether a transplanted kidney will work immediately, or whether it will regain function at all. Nevertheless, three factors are key to determining this outcome (see Table 2). First, since it is impossible to transplant a kidney from one person to another without temporarily interrupting the blood supply to the organ, it is clear this period should be kept as brief as possible. If the donor is alive, the period before blood flow is restored is usually one or two hours, but can extend to 30 or more hours in a kidney from a deceased donor. Second, age and overall health of the donor is important. On average, a younger kidney is more likely to quickly recover than an organ from an older donor. Finally, the course of the transplant operation (i.e. if blood pressure was low or there was substantial bleeding) and overall health of the recipient contribute significantly to recovery.

If the transplanted kidney does not function promptly, dialysis is provided until recovery occurs, usually within days to a few weeks. Until this happens, the transplant team is likely to continue to exclude causes of delay, including technical complications (i.e. whether the urinary narrowing prevents urine from entering the bladder) or rejection, which may require biopsy.

Prevention and Recognition of Rejection

Unless you have an identical twin or a clone, the transplanted kidney will be considered a foreign invader by the immune system. To prevent this, the transplant team will administer medications to suppress the immune system. With a large number of these drugs now in common use, most patients take a combination of two or three. All of these are potent and may cause side effects, such as infections, anemia or diabetes, and must be taken exactly as instructed. The transplant team is likely to make dose adjustments that must be specifically understood. If rejection is suspected because of increased creatinine, decreased urine output or fever, a biopsy will view a small sample of the kidney for microscopic examination. The treatment for rejection is often different, and more potent immunosuppressive medications will be administered during a hospital stay. While most episodes are reversible, the goal is prevention of rejection, since this may shorten overall duration of kidney function.     

Factors Influencing Early Transplant Function (Table 2)

• Period without blood supply

• Living or deceased donor

• Donor age

• Donor health

• Intra-operative factors (bleeding, low blood pressure)

• Recipient health

The Transplant Diet

With returning kidney function, comes freedom from the strict fluid restrictions required for successful dialysis. It is often necessary for new recipients to focus on drinking sufficient liquids, usually 2 to 3 liters each day, to hydrate the kidney. However, it is important to avoid excessive beverages with high sugar and caloric content, such as regular sodas and fruit juices, to prevent diabetes and excessive weight gain. In fact, controlling calories is a common challenge for many new recipients. With restoration of normal taste, fewer dietary restrictions and a sense of revitalization, the average transplant recipient gains 20 pounds in the first year. These unneeded pounds jeopardize heart function, bone and joint stability and energy levels. Most patients should focus on eating a controlled diet low in fat, including three to five servings of fruits and vegetables per day.

Your New Medication Regimen

With successful transplantation, medication regimen will be overhauled. Medications needed to manage renal failure, such as phosphate binders and erythropoietin supplements, will probably be discontinued. Immunosuppressive and anti-infective drugs will be started. Blood pressure, diabetes and heart medications may be changed to avoid drug interactions. The average patient will take eight to 10 types of medications each day. Over time, some may be stopped as risks of rejection and infection decrease. All must be taken as instructed. It is the patient’s responsibility to guarantee availability of these medications by thinking in advance of the need to obtain a new prescription or refill a pre-existing one.

When to Call the Transplant Team (Table 3)

• Fever above 100.5˚F

• Obvious infection

• Diminished urine output

• Increase in weight of >2 lbs/day

• Intervention planned by another physician

• New medication prescription

Which Issues Should The Transplant Team Know About?

Since caring for someone with a kidney transplant taking immunosuppressive medications can be extremely complicated, it is important to inform the transplant team about issues and events that may require judgment of a physician with transplant experience. While at home, this includes fever, significant weight change (more than 1 to 2 pounds per day), fluid retention or any reasons to require a doctor’s visit. In addition, significant medical and surgical procedures performed and/or planned by other physicians or at other hospitals, as well as infections of any type, should be indicated. It is also important to inform the team about new medications, since many may interact with immunosuppressive drugs, and blood levels may need monitoring.

The relationship between a recipient and the transplant team should be based on open, two-way communication. Together, a realistic approach to achieving the best kidney function and most normal lifestyle is developed, and challenges faced directly.

Amy L. Friedman, MD is an Associate Professor at the Yale University School of Medicine Department of Surgery in New Haven, Conn. She also serves on the AAKP Board of Directors and AAKP Medical Advisory Board.

This article originally appeared in the March 2005 issue of aakpRENALIFE, Vol. 20, No. 5.

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