Transplant Center: Receiving a Kidney
Recipient medical evaluation
A comprehensive evaluation must be conducted before determining whether you are a candidate for a kidney transplant. To facilitate that, be prepared to provide the transplant team with records of your medical history.
Once you arrive for your evaluation, you can expect a few things:
- Transplant nurse coordinator will educate you about transplantation if not completed already
- Transplant social worker will have one-on-one psychosocial interview with you
- Transplant doctor will perform physical exam and discuss medical history with you
- Dietician may see you
Based on our selection criteria, patients must have:
- Advanced kidney disease
- Adequate urinary tract
- Acceptable cardiovascular function
- Acceptable vascular system
- Acceptable lung function
- Acceptable liver function
- BMI < 45
- Cancer screening
- Capacity to perform daily activities without assistance
- Financial coverage
- No active significant fungal or bacterial infection
- Psychosocial health in good standing
- Appropriate support persons
As for the aforementioned physical exam, there are a few tests you can anticipate:
- Cardiac tests such as an echocardiogram (an ultrasound of your heart) and/or other tests
- Chest x-ray
- Abdominal cat scan
Once your entire evaluation is complete, the results will be reviewed by the transplant team. You will be notified by letter when you have been accepted for transplant at UF Health and are placed on the national transplant waiting list.
Sources of donor kidneys
Living organ donors and non-living donors are the two sources of donors. Here’s a look at the different types of donors that fall within both categories.
Transplanting a kidney from a healthy living individual into a person with kidney failure is called a living donation. Kidneys can come from living donors who may either be a living related donor (LRD), living unrelated donor (LURD) or a non-directed donor (not related to or known by the recipient). Live donor organs are usually better suited in terms of health, function and longevity in comparison to a non-living donor organ.
Non-living donors are people who have suffered brain death or cardiac death and there is consent to donate their organs. A potential transplant recipient can wait several years for a non-living kidney donor.
Surgery and what to expect afterward
When a patient receives a kidney transplant, the kidney will be placed in the lower abdomen. It may be placed on either side. The donor kidney's blood vessels will be connected to the recipient’s blood vessels. The donor ureter (the tube that carries urine from the kidney to the bladder) will be connected to the recipient’s bladder. A small plastic catheter called a urinary stent will be placed across the connection to provide support. The incision will be closed with staples or sutures. The surgery takes 3-4 hours in most patients and an additional 90 minutes for anesthesia to prepare for the surgery after the patient is asleep.
When the recipient wakes up after the surgery, he/she will have IVs in the neck and/or arm. The IV allows for enough fluids to keep up with the large amounts of urine usually made by the new kidney. Blood may be found in urine from the surgical connection in the bladder. Medication for pain will be given to the patient for comfort.
During the first two days after surgery, the nurse will be checking blood pressure, temperature, pulse IV fluids and urine outputs. The patient will be taught to use a lung exerciser that encourage deep breathing and help open up areas in the lungs. This helps prevents pneumonia and speed up recovery. The patient will be out of bed the day after surgery and should walk as often as possible. Each morning, the patient’s blood will be drawn and they will be weighed.
The patient will be in the hospital for about 5-7 days. Before the patient goes home, they will need to show our staff that they are able to:
- Learn to take medicines correctly
- Make changes in their medication record accurately
- Monitor fluid intake and urine output
- Weigh themselves
- State signs and symptoms of rejection and infection
- Know how to call their transplant nurse coordinator for any questions or problems
- Attend a class with their support person to learn about their new organ and follow-up care
After surgery, medicines called immunosuppressants will be administered to the recipient to keep his/her body from rejecting the new kidney. Recipients will have to take these every day for as long as they have the transplant. Even if the transplant were to fail, we recommend for the recipient to remain taking small doses of the medication to prevent antibody formation. This may help with a second transplant in the future.
There are several different immunosuppressants, and although a patient will not be taking all of these, they might be on a combination of them. Most patients go home on three of these medications.
- PROGRAF TACROLIMUS – is taken twice a day. The side effects of this drug can include headache, hand tremors, nausea, diarrhea, high blood pressure, increased blood sugar, increased potassium and decreased magnesium. Tacrolimus can also harm your kidneys over time, especially if the levels are too high. You must take care to dose it 12 hours apart and have your blood tests done just before your morning dose.
- CYCLOSPORINE (NEORAL, GENGRAF) – is taken twice a day. The side effects of this drug can include high blood pressure, mild hand tremors, headache and increased growth of hair. Cyclosporine can also harm your kidneys over time. You must take care to dose it 12 hours apart and have your blood tests done just before your morning dose. Cyclosporine is closely related to tacrolimus, so you will not take both of these medications at the same time.
- ENVARSUS XR (Tacrolimos Extended Release) - take once a day. Evarsus works the same as Prograf as listed above, with similar potential side effects as well.
- SIROLIMUS (RAPAMUNE) – is taken once a day in the morning. The side effects of this drug can be ankle swelling, abdominal pain, nausea, diarrhea or constipation, joint aches, fever, headache, high blood pressure, anemia and high cholesterol and triglyceride levels. Blood levels are also measured for this medicine so a blood test should be done before your morning dose.
- CELLCEPT (MYCOPHENOLATE MOFETIL) – is taken two times a day. The side effects of this drug are diarrhea, nausea, vomiting, rash and low white blood cell count with increased risk for infection.
- MYFORTIC (MYCOPHENOLATE SODIUM) – is taken twice a day and is very similar to Cellcept.
- PREDNISONE – is a steroid and is often taken for the life of the transplant and is taken once a day. Some patients will suffer from difficulty sleeping or may feel “hyper” when taking larger doses early after the transplant. These feelings will pass in a few days, and the amount you take will decrease. The major side effects of long-term prednisone are increased appetite, stomach ulcers, osteoporosis, diabetes, cataracts, mood swings and Cushing’s syndrome. Cushing’s syndrome includes round cheeks, protruding abdomen, fat deposits over the upper back, acne and increased growth of facial and body hair. Most patients are not on high enough doses to suffer from these side effects, and these side effects will decrease or disappear as the dose is decreased.
All the immunosuppressant drugs listed above work to prevent the patient’s immune system from rejecting the transplanted organ. These medications also make it more difficult for the immune system to fight bacteria, viruses and cancer cells, which puts you at higher risk for infection and cancer. The recipient will have to take antibiotics and antivirals for the first 3-6 months after transplant to help prevent infection.
In addition to the immunosuppressants and antibiotics/antivirals, the patient may also need to take other medicines to treat high blood pressure, diabetes or other conditions. Patients may be sent home with 10 or more medications and must be committed to taking all of the assigned medicines. After a few months, many patients are on less medication after transplant than they were on dialysis.
With any procedure, there are possible complications. The following are potential risks related to the donor transplant graft, immunosuppression medications required to try to prevent rejection of the graft and possible complications if you require a blood transfusion.
- Risk of rejection of the transplanted organ (this is not related to the surgery itself but with your immune system attacking the kidney)
- Increased risk of infection due to the immunosuppressant medications
- Any of the side effects of the immunosuppressant medications as previously discussed
- Very small risk for acquiring HIV/AIDS, hepatitis B, hepatitis C, other viruses or a cancer from the donor organ. Non-living organ donors are screened very carefully for these diseases by the organ procurement organizations. However, on rare occasion, the infections or cancers are not detectable and may be passed to the recipient.
- Potential for a blood transfusion due to blood loss in the operating room. Few transplant recipients require a blood transfusion if they come into the operation with a good blood count, that is, that they do not have anemia.
It is usually not possible for transplant candidates to donate their own blood ahead of time, because we never know when the transplant will occur for patients on the wait list. Anemia is a common problem with kidney disease, which prevents donation.
Note: If you do not accept blood products due to your religion, your red blood cell count (hematocrit or hemaglobin) must be at an acceptable level at the time of transplant admission. If the level is low, the surgery may need to be cancelled. Our surgeons feel that this requirement protects your safety and well-being.
The following are potential complications due to any general anesthesia (going to sleep with a breathing tube in your throat during the surgery):
- Chipped teeth, a sore throat or an injured vocal cord from the insertion of the breathing tube
- Allergic reaction to medications used to put you to sleep
- Risk of infection from the insertion of IV lines
- Risk of a pneumothorax (collapse of the lung) from the insertion of a large IV line (used for giving fluids) that may require a tube placed next to your lung to allow this to heal
- The possibility of requiring mechanical ventilation (a breathing machine or respirator) after surgery
- Risk of death due to problems with the heart (such as heart attack or abnormal heart beats) or lungs (especially from a blood clot traveling to your lungs during or after surgery)
The following are complications that may occur in the operating room or after surgery and related to the surgical procedure itself:
- Wound infection and/or hernia that could require another surgery to repair the hernia or clean the infection.
- All surgical wounds have pain afterward, which usually resolves over a couple of weeks. Occasionally, a local nerve may heal abnormally and give you persistent pain. These nerves can sometimes be injected directly by pain specialists several weeks after you recover from the transplant procedure. All surgical incisions have some numbness around them from cutting the skin nerves.
- All surgeries will have some bleeding. Occasionally, a blood transfusion may be required.
- You can also require a return to the operating room to wash out blood clots and/or check for ongoing bleeding, especially when you have been on blood thinners or have diseased blood vessels.
- For most patients, we make the incision from just above the bladder to just inside the hip in the lower abdomen, and we are usually able to stay around the outside of the intestines (outside the peritoneal membrane), and therefore have little to no chance of direct bowel injury. For some patients, we may need to enter the middle of the abdomen and have a greater chance of injuring the bowel. This is especially true in patients who have previous transplants.
- Some patients may have pain or numbness on the thigh below the incision from irritation of a nerve that runs close to the blood vessels used to connect the kidney. This usually improves over several weeks.
- If the kidney fails early, it may be removed with another surgery if your transplant physicians feel this is necessary, usually due to bleeding, infection or pain.
- A kidney graft may not work after surgery. Dialysis may be required for a short time or potentially long term.
Potential complications with new kidney
- Delayed Graft Function– Typically, the transplanted kidney will make urine right away. In some cases, the kidney may have a delayed function after surgery. This is called a Delayed Graft Function (DGF). The patient may require dialysis for a few weeks or months. DGF is suspected when the creatinine does not fall quickly after transplant. The creatinine may decrease.
- Primary Non-Function – Primary non-function is when the transplanted kidney never starts to work. This can happen, but is rare. If this were to happen, dialysis is usually required after surgery and will continue to be required on a regular basis. Patients with primary non-function usually have a renal biopsy that reveals irreversible damage. In some cases, the transplanted kidney needs to be surgically removed. Primary non-function does not prevent you from having another transplant, and the Transplant Center can request reinstatement of your original wait time to allow re-transplant to happen sooner.
- Infection – Infection is a risk to transplant recipients. The immunosuppressive medications that you take to prevent rejection cause you to be at increased risk for infections. You will take antibiotics to prevent infection for the first 3-6 months after your transplant.
- Dehydration – Dialysis patients are trained to avoid extra fluid. When you have a functioning kidney, restricting fluid can lead to dehydration. During summer months, it is especially important to drink plenty of fluids because the water loss from heat/perspiration can cause dehydration and your creatinine to rise. Most adults with good kidney function will be encouraged to drink at least 3 to 3 ½ quarts (or liters) per day.
- Urine Leak– The ureter is a muscle tube that drains urine from your transplanted kidney to the bladder. An incision is made in the bladder so the ureter can be stitched to the bladder. If the bladder becomes too full before the incision in the bladder has healed, then the ureter can pull away from the bladder and urine can leak out. As the urine drains into the area around the kidney, you may develop pain. The only treatment for this problem is an operation to reconnect the ureter. One of the reasons that you will have a catheter is to keep the bladder from becoming too full.Once your catheter is removed, it is important for you to go to the bathroom frequently during the first few days to prevent the bladder from becoming very full. Most patients will feel the urge to go to the bathroom frequently because the bladder shrinks over time when your kidneys do not make urine. When the transplanted kidney produces large amounts of urine, you may feel like going to the bathroom often.
After discharge, patients have lab tests frequently to monitor kidney function, drug levels and more. A schedule of labs, clinic visits and procedures is provided.
- Patients will visit the transplant clinic on a regular basis after surgery. During your first clinic visit after discharge, plan to be at the appointment for a couple of hours. Make sure to bring all of your medicines and your transplant diary.
- Your lab tests and clinic visit arrangements will be made by one of the transplant coordinators when you are discharged. As time passes, the clinic visits and lab tests will be less frequent.
- If you don’t live in the Gainesville area, we help identify a lab closer to you for blood tests. It’s important for you to be seen regularly by a transplant doctor during the first couple of months after your transplant.
- Patients should not drive for about 2-4 weeks after their transplant.
- A ureteral stent is placed during surgery and will stay in place for 4-6 weeks. It is a small, soft tube about 6 inches long that is placed in the ureter. The purpose of this is to hold the ureter open and maintain proper drainage of urine until the surgical connection between the transplanted ureter and the bladder heals. Your stent removal procedure will be scheduled prior to discharge.
- Continue regular visits with your primary physician and other specialty doctors, including your nephrologist.