Excellent outcomes can occur when a patient receives a kidney from a healthy living donor, regardless of whether or not the donor is a relative. In the past, relatives, such as siblings, parents or children, made up the vast majority of living donors, due to the importance of tissue matching. Improved medications to prevent kidney rejection have made tissue matching less important. Today, unrelated living donors, such as spouses and friends, represent a large segment of living donors.
A potential donor’s blood type will be determined first because kidney transplants can only occur between people with compatible blood types. Four blood types occur in humans: O, A, B or AB. The Rh factor (negative or positive) is important for blood transfusions but does not need to match between the kidney donor and the transplant recipient.
The following chart shows blood-type matching that permits organ donation:
|If the Recipient's Blood Type is:
||The Donor's Blood Type must be:
||A, O or B
||O or B
||O, A, B, or AB
Further Donor Evaluation
After the initial blood test shows a compatible blood type with the recipient, the potential donor will undergo more extensive pre-transplant testing. If risk factors for future kidney disease are found at any point in the pre-transplant evaluation, a donor will be declined. He or she may be directed to seek further medical care. Sadly, some highly motivated potential donors may not be acceptable candidates to donate a kidney.
The donor’s initial pre-transplant evaluation includes:
- A complete medical history and physical examination by a kidney specialist (nephrologist)
- Chest X-ray and EKG
- Blood tests to assess blood-cell counts, liver function and the presence of diabetes or infectious diseases, such as HIV and hepatitis.
- Assessment of kidney function, which will include two 24-hour urine collections
- A complete gynecological examination for all female donors and a mammogram for women 32 years and older
- Evaluation of the gastrointestinal system
- A preliminary crossmatch. This tests the interaction between the donor’s and the recipient’s blood cells. The blood serum of the recipient may contain antibodies that can react with the donor’s cells. If these antibodies are present (a positive crossmatch), the transplant cannot be performed. This test will be repeated just prior to the transplant surgery.
- Tissue typing of the donor cells. This is another blood test, which evaluates the match between six codes on the donor and recipient cells. While still required as part of the transplant process, lack of tissue matching is rarely a barrier to donation.
The transplant nurse coordinator arranges the donor evaluation through testing conducted at Swedish or, if more convenient, at an appropriate facility closer to the donor’s home.
Medical and Other Concerns
The concerns of most potential donors revolve around the risks of surgery and the consequences of living with only one kidney. The removal of a kidney (termed a nephrectomy) is a major surgical procedure. As such, some predictable medical risks are associated with it. In a healthy individual, these risks are typically small. All donors undergo an extensive evaluation to ensure their suitability for surgery. The transplant will only be scheduled if the transplant team feels confident that the health of a potential donor will not be jeopardized in any way.
Some conditions, such as smoking and severe obesity, add a significant risk factor to the donor’s surgery. It is required, therefore, that donors who smoke, stop smoking a minimum of three months prior to surgery. Some donors may be asked to participate in a weight-loss program. In addition, donors are screened carefully to determine if they are at increased risk of developing high blood pressure, diabetes or kidney disease in the months or years after surgery.
Only one kidney is necessary to provide good health and a normal life. Long-term medical consequences for kidney donors are very rare, and the donor can expect to live a normal life span with an excellent quality of life. Kidney donation does not impact a woman’s ability to have a normal pregnancy and childbirth. It is important, however, for the donor to avoid accidents that may damage the remaining kidney. Such accidents are usually the result of major trauma or severe sports injuries. Therefore, donors should avoid extreme contact sports and risky activities, such as boxing or tackle football.
Psychological and Emotional Considerations
Donation must be a voluntary act, with no monetary compensation or other forms of pressure or reward. The transplant team will have extensive discussions with the potential donor about his or her motivations and expectations. In particular, a donor must remember that success of the transplanted kidney cannot be guaranteed. A donor may feel regret or responsibility if the transplant does not turn out as well as anticipated.
Most donors believe that the emotional advantages of donating a kidney outweigh the disadvantages. Studies have shown that many donors experience an improved self-image and report a closer relationship with the recipient after the transplant.
The donor does not pay for his or her medical expenses, so it is not necessary that kidney donors have their own medical insurance at the time of transplant. The recipient’s insurance will be asked to pay for the costs of the donor evaluation, donor surgery, hospitalization and medications. In the small chance of immediate postoperative complications, the recipient’s insurance is also responsible for these costs. Most insurance plans pay for donor expenses in full.
Bills incurred by any potential kidney donor prior to transplant are sent to the Organ Transplant Department for payment; these costs are later forwarded to the recipient’s insurance at the time of the transplant. Charges for the surgery and costs after transplant are billed directly to the recipient’s insurance.
Although a donor does not pay for his or her medical expenses, he or she may be unable to work for as long as six weeks after the surgery. The donor must consider the financial impact of lost wages during the postoperative recovery period, as well as the possible additional costs for travel to Seattle, lodging and childcare. Occasionally, the recipient’s insurance plan will allocate funds for the donor’s lodging and travel expenses, but none give compensation for lost wages. A potential donor should check with his or her employer to see if short-term disability, annual leave or organ-donor leave benefits are available.
The Organ Transplant Program’s social workers will discuss these financial issues with the potential donor. They can assist in finding resources that may help pay for nonmedical expenses.
Donating a kidney is not financially possible for everyone. The transplant team understands and respects the need to decline based on financial or other reasons.
Advantages of a Living Donor Transplant
A kidney can be donated from one of two sources: either from a deceased donor (cadaveric) or from a living donor. Having a living donor provides these distinct advantages over deceased-donor transplant:
- A Shorter Wait for the Recipient
The supply of deceased donor organs is limited, and the waiting time for those in need can be lengthy. A patient can wait months or many years for a cadaveric transplant. While awaiting a cadaveric organ, a patient’s health can decline to the point where poor health affects the success of the transplant. In a small number of cases, the patient may no longer be well enough to undergo the operation.
- Living-Donor Transplants may Last Longer
The outcomes for both deceased and living-donor organ transplants are excellent over the first two years. There is growing evidence that organs donated by living donors may last longer than those from deceased donors.
- A Faster Recovery for the Recipient
In most cases, organs from living donors begin to function immediately after transplantation. This helps the recipient recover faster and shortens the length of the hospital stay. Recipients of living-donor transplants are generally released from the hospital on the fifth day after the transplant.
- A Shorter Wait for Kidney Recipients in General
When a person donates a kidney, in effect, he or she benefits two parties: the person to whom he or she donates, as well as other people on the waiting list with no possible living donor. By donating to one person on the list, donors can shorten the wait for others in need of a deceased kidney.
Preparing for the Transplant
After the donor has completed all pre-transplant testing, the donor’s case will be discussed at the Organ Transplant Program’s Living Donor Medical Review Board meeting. The nephrologists, nurse coordinators, social worker and surgeons of the Living Donor committee will review the medical, psychological, social and financial information about the donor during this meeting. If there are no medical or psychological contraindications to donation, the donor will be approved to proceed to the two final tests: evaluation of the kidney blood vessels and a final crossmatch.
Evaluation of the Blood Vessels
The kidney’s blood vessels are studied to view the anatomy of the kidneys and to rule out any unsuspected disease or abnormalities. Testing also identifies which of the two kidneys would be more suitable for the transplant. There are two methods used for studying the blood vessels. One method is computed tomography (CT) angiography. For this highly sophisticated X-ray, a specialized dye is injected through a small vein in the donor’s arm and a CT scan is taken of the kidneys. This procedure takes about one hour to complete and does not require an overnight stay. There are no activity restrictions after the scan.
The blood vessel study will take place at Swedish or in some cases, at a major medical center closer to the donor’s home.
Final Blood Testing and Preadmission Appointment
The final cross match is the last major blood test that needs to be completed. The donor’s blood cells and the recipient’s blood cells are combined and evaluated to make sure that the recipient has not created any antibodies that would attack the donated kidney. This test is performed during the final week before the transplant. A positive cross match means that the recipient has antibodies to the donor’s blood cells, which could lead to immediate failure of the transplant. A positive cross match will either rule out a specific donor or delay the possible transplant for further testing in the future. A negative cross match means that the transplant can proceed forward.
The final cross match is usually drawn during the donor’s preadmission appointment at Swedish. During this appointment, the donor will receive information about any surgical preparations needed and what to expect after surgery. The donor also undergoes additional blood and urine tests.
Surgery and Hospitalization
The surgery itself will be performed using one of two techniques. These techniques will be discussed with the donor in advance of the procedure so he or she will know what to expect.
Laparoscopic Donor Nephrectomy
Laparoscopic donor nephrectomy is the operative technique most often used to remove a kidney. The laparoscopic technique requires several short incisions in the donor’s abdomen, through which a specialized camera and other instruments are inserted. This allows the surgical team to free the kidney from its surrounding tissues. An additional incision is made in the lower abdomen, and the surgeon removes the kidney through this opening. Since the incisions are small, the surgeon is able to enter the abdomen without actually dividing muscles. The donor suffers less pain, and recovery is rapid. With laparoscopic nephrectomy, donors can generally expect to be in the hospital for three to four days.
The Open Technique
In approximately 20 percent of kidney donors the laproscopic donor nephrectomy procedure may not be appropriate. For these donors, using the open technique provides a safer alternative. This technique involves an incision in the side of the abdomen (flank) below the rib cage and the division of some muscles. The kidney is removed through this incision, and the muscles and the skin carefully closed. This technique is associated with more postoperative pain, but the pain can be effectively managed with medication. The donor can expect a hospitalization of approximately four to five days, slightly longer than for a donor having the laparoscopic procedure.
Following either type of surgery, the donor will be observed for a period in the recovery room and then be returned to his or her hospital room. Both the donor and the recipient will be on the nursing unit of the hospital that specializes in the care of patients with kidney disease, nephrectomies and transplants.
The donor is hospitalized after the kidney donation for about two to four days. The donor should not drive for 10 days after the procedure and should not lift anything weighing more than 10 pounds for the first two to three weeks after the surgery and nothing weighing more than 25 pounds for six weeks after the surgery. Within three to four weeks after surgery, the donor may return to work, depending on the physical requirements of the job.
The donor commonly experiences some bloating and constipation early on after the kidney donation procedure. They may experience some fatigue or loss of stamina for up to six weeks.
In all cases, the donor is required to spend seven to 14 days in the local area after the surgery. During this time, the donor will have at least one outpatient clinic appointment to check surgical healing and to assess kidney function.
Long-Term Follow-Up after Kidney Donation
A few weeks after surgery, the donor’s remaining kidney will have increased in size and will be doing the work of two kidneys. A kidney donor is expected to have a normal quality of life and life expectancy. Like all other healthy persons, a donor should have a yearly blood pressure check and periodic evaluation of kidney function (a urinalysis and blood tests) every year. These tests are part of any routine physical examination, and the donor’s regular physician can perform them.