At the heart of the transplant candidate’s patient experience at The Kidney Transplant Center is our Patient Navigator, a consultant-level Crozer-Keystone professional available to help kidney transplant patients and their primary care providers navigate the transplant process—from options and evaluation through surgery and recovery to post-acute care.
The evaluation appointment is four to six hours long and focuses on a variety of tests and analyses to determine if the patient is a good candidate for transplantation. At the evaluation appointment, your patient will also learn more about kidney transplantation as a treatment option and how it will fit into his/her life.
There is a tremendous amount of information discussed at this evaluation meeting, and candidates are encourage to ask as many questions as necessary. In fact, we encourage patients to bring their families to this meeting so that everyone's questions can be answered.
The following tests are given to all transplant candidates. Sometimes, there are additional tests specific to a candidate’s personal health and care situation or based on any results of the testing that need further investigation.
- Physical Assessment: A physical exam and a complete medical and surgical history.
- Social Work Assessment: To discuss and determine the candidate’s family/friend support before and after transplant and to identify any additional resources that will be needed.
- Cardiac Stress Test
- Electrocardiogram (EKG or ECG)
- Blood Tests: A variety of blood tests will be done during the evaluation period, including an HIV test.
- Chest X-ray
- Cardiac Catheterization: Depending on the candidate’s condition and history, this test can be performed on either the right or left side of the heart.
- Colonoscopy: This test is required if the candidate is 50 years of age or older. If the candidate has signs of cancer, the issue may need to be addressed before the candidate can be considered for transplant.
- Bladder Studies: An x-ray and/or camera examination of the bladder.
- Dental Evaluation
- 24-Hour Urine Test
- Panel Reactive Antibody (PRA)
- Tissue Typing/Cross-Matching: Tissue Typing tests characteristics about the candidate’s tissues. Cross-matching is then done to determine if a prospective donor and recipient are compatible for transplantation.
- Nutrition Assessment: To help the candidate plan a diet to stay as healthy as possible.
- Mammogram: For female candidates. If the candidate has signs of cancer, the issue may need to be addressed before the candidate can be considered for transplant.
- PAP Smear: For female candidates. If the candidate has signs of cancer, the issue may need to be addressed before the candidate can be considered for transplant.
- PSA-Prostate-Specific Antigen: For male candidates. If the candidate has signs of cancer, the issue may need to be addressed before the candidate can be considered for transplant.
It can sometimes take several weeks for the results of the evaluation tests to come back and for the evaluation to be complete. When the candidate’s pre-transplant evaluation is complete and all test results are received, the selection committee meets to determine if the candidate is ready to be placed on the Transplant List—“The List.”
Even if the team decides the patient is a good candidate for transplant, the final decision to proceed rests with the patient himself/herself. If a patient is recommended as a candidate, it is important that he/she quickly finish all the requirements necessary to be registered on the national organ transplant waiting list—so that the candidate does not miss an opportunity to receive an organ simply because the required testing or paperwork is not finished.
The Kidney Transplant Team’s Transplant Coordinator will contact the candidate by telephone to let him/her know about the decision, and he/she will receive a letter informing the candidate of the decision that he/she has been placed on the transplant list. ONLY after the candidate receives such correspondence is he/she officially on “The List.”
Of course, all candidates have the option to be listed at other centers (called a “multiple listing”), and candidates have the option to refuse transplantation at any time.
It is after a candidate is placed on The List that any potential living donors can begin their screening process. The Kidney Transplant Team’s Transplant Coordinator can help with explanations and information as well as coordination with a living donor(s)’ primary care physician(s).
Once the candidate has been placed on the transplant list, he/she begins a period of waiting to be matched with a donor. The waiting period can be quite long—ranging from several months to several years. There really is no way to predict how long your patient’s wait will be. For statistical averages of waiting times for each type of organ, visit www.unos.org.
There is no such thing as “the top of the list.” The order of the list changes with every kidney that becomes available and is dependent on blood type waiting time, tissue type and crossmatching results. The length of time a candidate may wait will depend on your blood type and crossmatch reactivity to individual donors.
Whether the donor kidney comes from a living donor or from a cadaveric donor, the basic transplant surgery (on the recipient’s end) is the same.
When your patient is admitted for a deceased transplant, he/she will have blood tests, an EKG, chest X-ray, physical exam and a final crossmatch before going to the operating room. If your patient is receiving a living donor kidney, both the recipient and the donor will be admitted to the hospital the morning of the scheduled procedure. All pre-operative testing will have been completed.
It’s important to note that the transplant could be cancelled if:
- The recipient (or the live donor) shows any signs of infection.
- The donor kidney has any problems.
- A new medical problem exists.
- The final crossmatch is positive (if the recipient has antibodies against the particular donor kidney).
There could also be “false alarms.” For example, when the surgeon evaluates the donor organ, it may be determined it is not a good match for the recipient, based on many factors such as the condition of the organ or the levels of antibodies in the recipient’s bloodstream making it more likely that the recipient will reject the organ. The Kidney Transplant Team is dedicated to obtaining the best possible organ for each candidate, but organs are fragile, and their condition can degrade significantly in just hours. We would rather wait for the best possible kidney for your patient’s transplant. Of course, we will do our best to avoid these situations, and in the case of a “false alarm,” your patient’s place on the national waiting list will remain the same.
The transplant surgery itself takes from 3 to 6 hours. An incision of about 6-8 inches long is made, and the donor kidney is placed in lower abdomen on either the right or left side just above the hip. The surgeon then attaches the donor kidney to the necessary blood supply and to the bladder for urine drainage.
Generally, the native kidneys are left in place; however, exceptions to this may be made in the event of infection, the potential for infection, the presence of cancer, and in some cases, if a patient has very large kidneys as seen with patients who have polycystic kidney disease. Because the operation does not involve the abdominal cavity itself, the degree of post-operative pain is usually described as moderate.
Recovery From Surgery
After the transplant surgery, the recipient will wake up in Recovery Room of Crozer’s Operating Room and will then be transferred to the Step Down Unit. Recipients will be closely monitored while in the Step Down Unit. The average stay in the unit varies but averages a few days, individualized according to the patient’s needs. Families allowed to visit in the Step Down Unit.
When the recipient comes back from the operating room, he/she will have a breathing tube in place. It will be removed as soon as the patient can breathe on his/her own. Patients will have some mild discomfort, but will receive medication to relieve any pain.
A catheter will be in place in the bladder to help the patient pass urine. In the case of a kidney from a living donor, the transplanted kidney generally makes urine right away. It may even make large amounts of urine the first day. In the case of a deceased kidney transplant, the kidney may not make urine initially. Sometimes it takes days or weeks to function well. In some situations, some patients require dialysis for a short time if the donor kidney does not work right away.
Infection is a serious concern. Precautions to prevent infection and rejection will be started as soon as the recipient is moved to the Step Down Unit. Medications and fluid will be given through an IV for the first few days after transplant.
The average time in the hospital after an uncomplicated kidney transplant is six to seven days.
Potential Risks for Transplant Recipients
Kidney transplant surgery is major surgery, and as such, carries a risk of significant complications, including:
- Blood clots
- Leaking from or blockage of the tube (ureter) that links the kidney to the bladder
- Failure of the donated kidney
- Rejection of the donated kidney
- Increased risk of high blood pressure, diabetes, cataracts, stomach ulcers and infection
Post Operative Care
Infection and organ rejection are serious concerns with any organ transplant. Organ rejection and infection are the most common causes of transplant failure, particularly in the first year after surgery.
Precautions to prevent infection and rejection will be started as soon as the patient arrives in the ICU, and although kidney transplants are performed on a routine basis, it is important that your kidney transplant patient get very meticulous care—in and out of the hospital—after the surgery.
In order to prevent rejection, we prescribe a rigorous course of immunosuppressive medications. Patients will have to take these immunosuppressive medications for the rest of their lives, although the dosage will decrease with time.
The same immunosuppressive medications will also make the body's defense system weaker. Therefore, after transplant, especially early on, a patient will be more susceptible to infections. As part of the post-transplant therapy, we also prescribe medications to fight infections.
Medications After Transplant Surgery
Transplant patients will take a complex regimen of medications when they leave the hospital and for the rest of their lives. Patients may take many different drugs several times a day, including powerful immunosuppressants and steroids, which can have significant side effects. They will also take several drugs to alleviate these side effects. It is critical that patients learn about the medications and develop a system to take them exactly as prescribed. Taking these medications is the single most important thing to do in order to prevent rejection, and they must be taken as directed. Not taking the medications immediately or missing doses will cause damage to, and eventual loss of, the transplanted kidney.
The medications fall into nine main categories:
Immunosuppressants (or “anti-rejection” medications): These medications are designed to suppress (or lower) the immune system and lessen the chance of kidney rejection.
Steroids (the first line of defense for rejection): These medications are also designed to lessen the chance of kidney rejection and will quickly be reduced to low doses.
Antivirals/antibacterials: These medications help the body prevent viral, bacterial and fungal infections.
Antihypertensive: These medications, although used to treat high blood pressure, will improve blood flow to the transplanted kidney.
Cholesterol lowering agents: These medications are designed to lower and manage Cholesterol.
Diuretics: Also known as “water pills,” these medications help control fluid buildup.
- Various medications to help prevent stomach ulcers.
- Various medications to counter side effects of the immunosuppressants.
- Vitamins and minerals
Dialysis After Transplant
There is a possibility of a patient needing dialysis after the transplant operation. There are two reasons for this. One reason is that the kidney may develop acute temporary changes between the time it is removed from the donor and transplanted into the recipient. This may be characterized as the kidney’s going into a state of "hibernation" and may require up to several weeks to resolve before the kidney "opens up" and begins to function. This condition is called acute tubular necrosis or ATN. If a patient has ATN, he/she will not receive some of the routine immunosuppressive medicines until the kidney begins to work well. Instead, he/she will receive ATG. The other reason for dialysis is that during an episode of rejection, dialysis may be necessary to provide support while the kidney is not working. Dialysis is stopped once the kidney is working.
In spite of careful observation and treatment, some kidneys do not ever function well. The reason for careful monitoring of kidney function and the early recognition and treatment of acute rejection is to promote kidney function and to have the best possible transplant outcome. However, treatment of acute rejection is not continued to a point at which treatment is making patient sicker than the rejection itself.
If the transplant is rejected, after a period of time for recovery, another transplant is usually possible. It is not necessary to remove a rejected transplanted kidney unless it is making the patient ill.
Post-operatively, for the first month after surgery, patients will visit the Kidney Transplant Center for post-operative appointments twice-weekly, every Monday and Friday. For the second month after surgery, patients will visit the Kidney Transplant Center for post-operative appointments once a week (either Monday or Friday); and for the third month after surgery, patients will visit the Kidney Transplant Center for post-operative appointments every other week. After the first 12 weeks, patients will still visit the Kidney Transplant Center for post-operative appointments, but the visits will be less frequent.
If the patient lives a great distance from Crozer-Keystone, making travel to the Kidney Transplant Center for post-operative appointments inconvenient, many of the follow-up visits can be performed by you as their primary care provider.
As part of the transplant process, the Kidney Transplant Team will work closely with you to set up post-operative care and will provide you with support resources and assistance throughout the care continuum.
The Crozer-Keystone Kidney Transplant Team will work closely with you to co-manage patient care and provide you with support resources and assistance throughout the care continuum.
Consults are always available for both pre- and post-transplant patients, as well as for living donor candidates. To make a referral or to request a consult—or even just to ask a question—call The Kidney Transplant Team at 610-619-8420 or email email@example.com. You will receive a prompt reply.