Living Kidney Donation

Patient Education

This is an educational document is designed to provide you with information to consider in deciding whether to participate as

a living kidney donor. The document describes:

• The medical tests you will have before donation
• The donor surgery and follow-up
• The role and function of the Organ Procurement Organization (OPO)

All potential kidney donors must demonstrate that the decision to donate is made freely, electively and without coercion or valuable compensation.

The Evaluation Process 

Living donors will receive a thorough medical and psychosocial evaluation. You will take a variety of tests to ensure that you are an eligible candidate for living donation. In addition, before the surgery, you will meet with doctors and other members of the donation team. The tests and consults will help the donation team decide if you are well enough to be a living donor and if you match a recipient. Parents, siblings, and other relatives can donate to a family member.

Transplant Team Members

• Program Director

The Program Director leads and oversees the transplant program.

• Transplant Surgeon

The transplant surgeon meets with you to discuss the organ transplant process, including the transplant surgery itself, the risks of the surgery, and any problems you might have after your transplant.

• Transplant Doctor

The transplant doctor meets with you to discuss the organ transplant process.

• Transplant Coordinator

The transplant coordinator provides support throughout the transplant process and works with you to make sure your needs are met. The transplant coordinator will explain the entire transplant process and will answer your questions so that you can learn as much as possible about your transplant.

• Social Worker

The social worker meets with you to see how well you can cope with the stress of a transplant, and how well you will be able to follow a demanding treatment plan. The social worker will also help you identify family and friends who can help you during this time. Alternative financial resources (e.g. fundraising, assistance programs) can be explored if needed.

• Financial Counsellor

The financial counsellor discusses the costs of the organ transplant, medications and care. The financial counsellor also helps you understand your insurance coverage. It is important that you are aware of and understand any costs that may not be covered by your insurance.

• Psychiatrist (if applicable)

The psychiatrist performs a more thorough psychiatric examination to make sure you are prepared for a transplant. Some patients who have abused drugs or alcohol may have to go through a rehabilitation program and stay away from drugs and alcohol for a period of time in order to start the transplant program.

• Clinical Dietitian

Assesses your diet to learn what you eat on a daily basis and teaches you about eating a healthy diet.

• Pharmacist

The pharmacist reviews your medications and assesses for potential drug interactions before and after transplant. The pharmacist can also review education regarding the transplant medications

Please note that you may see other specialists, depending on your overall health.

Tests and Procedures

You will undergo a variety of tests to understand your eligibility to be a donor. The following is a list of the most commonly

performed tests. Some of these tests may be included in your evaluation process, whereas other tests may need to be

performed depending on the results of these tests.

•  Blood Tests

Blood tests will determine your blood type for kidney donation, your health status, your match to the recipient and will screen

for immunity or the presence of specific viruses (including HIV/AIDS).

• Urine Test

Urine tests screen for urinary tract infections, protein, blood and other abnormalities. They may also test for drugs and alcohol in your system.

• 24 hour Urine

Urine is collected for 24 hours to determine creatinine clearance and total protein. If applicable, a stone panel test will be performed as well.

• 24 hour Blood Pressure monitor

Your blood pressure will be monitored every 15-30 minutes for a 24 hour period as needed to determine if you have normal blood pressure.

• EKG, Echocardiogram and Stress Test

These tests check your heart beat, heart valves and vessels to see how well your heart is working.

• Chest X-Ray

A chest x-ray helps your doctor determine if there are any problems with your heart and lungs.

• CT and/or MRI ScanPulmonary Function Test

These scans help the doctor visualize your organs and vessels (renal arteries and veins).

• Pulmonary Function Test

This is a breathing test to examine how well your lungs are working. This test may be needed if you have a history of smoking or have problems with your lungs.

• Health Maintenance

A pap test is required for women 18 years of age and older. A colonoscopy is required for both women and men 50 years of age and older. These tests could be completed by your primary care doctor and forwarded to CCAD depending on your preference. Please note: Health information obtained during your evaluation will be subject to the same regulations as all records and might reveal conditions that the Transplant Center is required to report to the health authorities. The following are inherent risks associated with your evaluation:

• Allergic reactions to contrast
• Discovery of reportable infections
• IDiscovery of serious medical conditions
• Discovery of adverse genetic findings unknown to the donor
• Discovery of certain abnormalities that will require more testing or create the need for unexpected decisions on the part of The transplant team

The Decision-Making Process Once you have completed all the medical tests and consults, your case will be reviewed and discussed by the Transplant Team during a Patient Selection Committee meeting. The decision will be made by the team (no one person makes the decision alone). The team will consider whether you are medically, surgically and psycho-socially prepared for the procedure. If you are accepted as a candidate to proceed, the transplant coordinator will work in conjunction with the doctors and the transplant team to arrange a procedure date. The Transplant Center may determine that you are not medically, surgically or psycho-socially ready and refuse you. Alternative Treatment for Transplant Recipients Recipients may begin or remain on dialysis or choose no treatment for their kidney disease. Other Considerations Transplant recipients might have risk factors for increased morbidity or mortality that are not disclosed to potential donors.There is also a chance that while the transplant candidate is waiting for a kidney to become available, the transplant candidate may become too sick to have the transplant surgery. Please note: AT ANY TIME DURING THE KIDNEY DONATION PROCESS, YOU HAVE THE RIGHT TO CONFIDENTIALLY OPTOUT OF THE PROCESS.

The Surgical Process

The Kidney Donor Operation

During the kidney donor operation, you will be put under general anesthesia, which means that you will be given medications to put you to sleep, block pain and paralyze your body. You will also be placed on a machine to help you breath. The anesthesiologist will discuss with you in more detail about the anesthesia prior to your surgery. 

Once you are asleep, a breathing tube, intravenous lines and a urinary catheter will be placed in your body. To keep you from vomiting, you may have a tube placed through your nose into your stomach to drain the contents of your stomach.

The kidney donation surgery involves removing a healthy kidney from your body and placing it into a recipient's body where it can perform all the functions that a failing kidney cannot. Your kidney will be removed using one of two methods: laparoscopic nephrectomy or open nephrectomy.

• Laparoscopic Nephrectomy

This is a minimally invasive procedure in which a special camera called a laparoscope is used to produce an inside view of

the abdominal cavity to remove a kidney. Laparoscopic kidney removal is considered minimally invasive because it minimizes

abdominal incisions required to remove the kidney.

This can be done using three to four small skin incisions to perform the surgery, and then remove the kidney from a low

incision in the pelvis or through a new approach by placing one incision in the navel area. During the procedure, carbon

dioxide gas is passed through one of the incisions into the abdominal cavity to lift the abdominal wall away from the organs

below, creating more operating spaces to perform the surgery. The surgeon will use laparoscopic instruments to separate the

kidney. Once your kidney is separated, your surgeon will remove it through a non-muscle cutting incision in the lower abdomen

area or the navel area (six to seven centimeters).

• Hand Assisted Laparoscopic Nephrectomy

One approach to laparoscopic donor nephrectomy is where the surgeon uses the small incision needed to remove the kidney

during the surgical procedure. Generally, a seven centimeter incision is made over the navel in addition to two small incisions

for laparoscopic operative ports.

A laparoscopic camera and laparoscopic instruments are placed into the ports. Each of these incisions avoid dividing any

muscle. Laparoscopic instruments are used to remove the kidney after the abdomen is inflated with carbon dioxide gas. Once

the kidney is divided, it can rapidly be removed through the navel port, so the recipient surgical team can begin preparation for

transplant.

• Open Nephrectomy

Most people are eligible for laparoscopic nephrectomy, but for some donors it may be best to remove the kidney through a traditional open procedure. During open surgery, the surgeon makes a nine to eleven centimeter incision on your side to remove the donor kidney. Sometimes the lower rib is removed. Your surgeon will complete a preoperative evaluation and discuss your options of laparoscopic nephrectomy vs open nephrectomy and which is the most appropriate for you. Note that a small percentage of laparoscopic procedures must be converted to open procedures. Once your kidney is removed, another surgical team will immediately prepare the kidney for transplantation into the recipient while your surgeon completes your procedure. In most cases, your donated kidney will begin performing the work of the recipient's failed kidneys soon after transplant.

Post Surgery

Care and Recovery

After your surgery, you will be taken to a specialized Post-Anesthesia Care Unit (PACU) until you have recovered from the anesthesia and there are no signs of immediate or early complications.

After your stay in the PACU, you will be transferred to the surgical inpatient unit where you will be closely monitored until

you are discharged. Immediately after the surgery, some pain, gas and discomfort is normal. The nursing team will carefully

monitor this and administer medication to control the pain. Most kidney donors see a sharp decrease in pain two to three days

after surgery. Getting out of bed and starting to walk will greatly help.

You may need to remain in the hospital longer than expected depending on how quickly you recover, or as determined by your doctor.

After you leave the hospital, you will still be recovering. For the first few weeks, you will have some limits on your daily activities. If you have any complications after the surgery, your recovery time may be longer. During the recovery period,the kidney donor team will follow your progress very closely including a post-surgical clinic visit, usually 2-6 weeks after the kidney donation. If you have any signs of infection or any other complication from kidney donation, you may have to bereadmitted to the hospital or return for additional clinic visits.

Long-Term Follow Up After Donation

You will require long-term follow-up after the kidney donation procedure. It is requested that all living donors commit to having the post-donation follow-up coordinated by the living donor team. If you are unable to return to CCAD for this follow-up, arrangements can be made with your Primary Care Provider (PCP) to ensure that CCAD receives the necessary information.

Follow-up care will consist of clinic visits, blood work, urine samples and vital signs. Your name and clinical information will also be placed in a CCAD database registry for tracking and follow-up purposes.

Any infections disease or malignancy pertinent to acute recipient care discovered during the donor's first two years of postoperative follow-up care will be disclosed to the donor and will be disclosed to the recipient's transplant team at CCAD.

Post Donation Kidney Function

• On average, donors will have a 25-35% permanent loss of total kidney function at donation.
• Baseline risk of End Stage Kidney Disease (ESRD) does not exceed that of members of the general population with same demographic profile.
• Donor risks must be interpreted in light of the known epidemiology of both Chronic Kidney Disease (CKD) and End Stage Kidney Disease (ESRD). When CKD or ESRD occur, CKD generally develops in mid-life (40-50 years old) and ESRD generally develops after age 60. The medical evaluation of a young potential donor cannot predict lifetime risk of CKD or ESRD.
• Donors may be at a higher risk for CKD and sustain damage to the remaining kidney. The development of CKD and subsequent progression to ESRD may be more rapid with only one kidney.
• Dialysis is required when reaching ESRD.
• Current practice is to prioritize prior living kidney donors who become kidney transplant candidates.

Benefits Associated with Living Donation

Kidney transplant surgery can be scheduled at a mutually agreed upon time rather than performed as an immediate operation.

A potential psychological benefit for the recipient is that the recipient may experience a positive feeling knowing that the gift came from a loved one, friend or a caring stranger. In addition, the donor may experience the satisfaction of knowing that he or she has contributed to the improved health of the recipient.

Potential Risks Advese outcomes & Complications of Donation

There are risks with all surgeries, especially surgeries that are done under general anesthesia. Many complications are minor and improve on their own. However, in some cases, the complications are serious enough that you might need another surgery or medical procedure. Some patients may require readmission to the hospital for medical care.

The following medical, surgical, psychosocial and financial risks are associated with living kidney donation. These risks may betransient (e.g. temporary or occasional) or permanent and include, but are not limited to the following:

Medical or Surgical Risks

• Discomfort or acute pain or chronic pain
• Fatigue
• Gastrointestinal symptoms, including bloating, gas, constipation, nausea, slowing of the gastrointestinal activity
• Post-operative infections: urinary tract or wound. These may require antibiotics.
• Bleeding which could possibly require a transfusion of blood products. If you have bleeding during or after your surgery,you may need blood transfusions or blood products. These may contain bacteria and viruses that can cause infection.Although rare, these infections include, but are not limited to, the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV)
•  Scars
• Fever
• Increase risk with the use of over the counter medications and supplements (avoid NSAIDS)
•  Hernias

Rare Complications

• Cardiac complications such as an irregular heartbeat or heart attack
• Pulmonary complications such as atelectasis (collapse of the air sacs in the lungs) or pneumonia
• Blood clots. Despite attempts to prevent them, blood clots may occasionally develop in the legs. These clots can breakfree and move through the heart, lungs, or brain which may cause seriousproblems with breathing, circulatory function,stroke or death. Blood clots are treated with blood-thinning drugs that may need to be taken for long time and/orothertherapeutic procedures
• Abnormal kidney function which may progress to the point of needing dialysis or a kidney transplant
• Nerve damage. This can happen from direct contract with the chest or abdomen, or from pressure or positioning of the arms, legs, or back during the surgery. Nerve damage can cause numbness,weakness, paralysis, and/or pain. In most cases, these symptoms are temporary, but in rare cases they can last for long periods of time or even become permanent
• Rhabdomyolysis. Muscle breakdown from positioning can cause pain, and the by-products can be toxic to the remaining kidney
• High blood pressure
• Protein in the urine
• Chylous Ascites: the accumulation of milky white fluid in the peritoneal cavity usually associated with abdominal distention. This may require re-operation
• Corneal Abrasions: eye scratches that cause pain and temporarily compromise vision
• Pregnancy-related complications post-donation, including high blood pressure, gestational diabetes, protein in the urine or preeclampsia
• Testicular Swelling/Sensitivity/Pain
• Adrenal gland, spleen, or pancreas injury resulting in adrenal insufficiency, splenectomy, or pancreatitis
• Bowel obstruction
• Donor death

There may also be risks associated with your personal medical conditions (i.e. high blood pressure, obesity) that may impact your future health.

Psychosocial Risks

• Problems with body image
• Post-surgery depression or anxiety
• Feelings of emotional distress or bereavement if the transplant recipient experiences any recurrent disease or in the event of the transplant recipient's death
• Potential impact of donation on the kidney donor's lifestyle

Potential Financial Risks

• Personal expenses of travel, housing, child care costs and lost wages related to live kidney donation might not be reimbursed
• Need for life-long follow-up at the donor's expense
• Loss of employment or income
• Negative impact on the ability to obtain future employment
• Negative impact on the ability to obtain, maintain, or afford health, disability, and life insurance
• Future health problems experienced by living donors following donation may not be covered by the recipient's insurance

Additional Information 

Health and Life Insurance

After organ donation, health insurance companies might consider that you have a pre-existing condition, and might refuse payment for medical care, treatments or procedures. After the surgery, your health insurance and life insurance premiums may increase and remain higher. In the future, insurance companies might refuse to insure you.

Right to Opt-Out of the Donation Process

You do not have to participate as a living kidney donor.

If you decide to participate, you may change your mind at any time, including the day of your scheduled surgery. If you change your mind, simply notify any member of the Living Kidney Donor Team or Kidney Transplant Team. If you change your mind about participating, your decision and reasons are kept confidential.

Confidentiality

Communication between the donor and the Transplant Center's Living Donor office will remain confidential. Only information crucial to assuring the safe donation/transplantation of the organ will be shared with the corresponding teams.

Please note: You will be asked to sign a consent form acknowledging that you have received this document and stating that you agree to proceed with the evaluation process at your first appointment.