The donor operation: before, during and after
What processes do you have to go through to be a living kidney donor?
The decision to donate a kidney is just the first step on a journey that may eventually lead to a kidney transplant operation. A potential donor has to go through a series of tests and examinations.
These checks are designed to ensure that the donor is healthy enough to give a kidney, has sufficient kidney function to live with a single kidney and is physically and emotionally prepared for the donation. The process of assessment can take three to six months (sometimes longer if further tests are required) to complete all the checks, which include medical, surgical and psychological assessments.
In England, Wales and Northern Ireland, no minimum age limit is specified under the Human Tissue Act 2004, but most donors will be over the age of 18 years. In Scotland, the law specifies that the donor has to be over 16. There is no upper age limit, and there have been donors in their 70s.
Throughout the process, anonymity and confidentiality are maintained, and most altruistic donors never meet the person who receives their donated kidney. It is, however, possible for both parties to contact each other after the transplantation, if both parties are willing.
Tests and examinations before the operation
Each transplant centre has its own protocol for potential donors, which are based on nationally agreed guidelines. The information given below is general information, but different tests may be done, depending on individual circumstances and where the transplantation takes place.
General physical health
A potential donor must be in good physical and mental health, and the initial tests are designed to confirm this. A full medical history is taken by a doctor or nurse, and weight, height and body mass index (BMI) are checked. The doctor will also need to perform a full medical examination.
Donation of a kidney can affect people in different ways. A psychologist or counsellor will routinely see altruistic kidney donors to ascertain their motivation for donation and the potential psychological impact.
The donor’s urine is tested to look for any sign of infection or other abnormalities, such as blood, protein or glucose in the urine. These tests can be done on an ordinary urine sample, which is tested with a simple dipstick and also sent to the laboratory.
Although the order of the tests may vary around the country, a simple blood test to ascertain a person’s blood group will usually be carried out at an early stage. The donor will also have a number of blood tests to check that they are not carrying any potentially harmful viruses, such as hepatitis or HIV, and other infections that could be passed on to a potential recipient.
Blood testing will also enable assessment of the function of the donor’s kidneys, liver and other organs as well as making sure that the donor has enough blood and that the blood clots properly.
Glucose tolerance test
A glucose tolerance test (a test for diabetes) may be carried out if you have a strong family history of diabetes or your blood sugar level is found to be high on initial testing. This test involves a series of two blood tests taken over a period of two hours. At the beginning of the series the donor is asked to come to the hospital in the morning and have a blood test before eating anything. The donor is then asked to drink a very sweet drink containing glucose and the blood test is repeated after two hours. The test measures how well the body copes with a high dose of sugar. People with diabetes or impaired glucose handling will not be able to donate a kidney.
Blood pressure monitoring
A donor will have to have their blood pressure checked several times to ensure that it is normal. People with high blood pressure may not be suitable donors, because kidneys are sometimes damaged by high blood pressure (hypertension), and removing a kidney may increase the risk of damage to the remaining one.
It is vitally important that a donor has two kidneys that are both functioning well. About one in 1000 people are born with only one kidney, and if a potential donor is found to have only one kidney they cannot be a kidney donor.
An ultrasound scan of the kidneys may be performed to check that a donor has two kidneys and that they appear to be of normal size and shape. The ultrasound is not able to determine if the kidneys are functioning normally.
Further tests are needed to check that both kidneys are working well. These may be blood tests, urine tests or other scans.
One blood test looks at a blood chemical called creatinine. This is a substance that the body produces naturally and that is normally removed from the bloodstream by the kidneys. The level of creatinine in the blood and the amount being excreted in the urine are measured as a way of seeing how well the kidneys are working.
Another way of testing kidney function is to look at a person’s glomerular filtration rate (GFR). This usually involves an injection of a chemical into a vein in the arm, followed by a series of blood samples. The test takes several hours. It measures the ability of the kidney to clear the blood of the substance that has been injected.
A donor may be offered a special X-ray of the kidneys called an IVU or IVP (intravenous urogram or pyelogram). This involves injecting a dye into the bloodstream, which can then be seen on a series of X-rays as the dye passes through the kidneys.
Most donors will have an MRI (magnetic resonance imaging) or CT (computed tomography) scan to assess the size, shape, position and blood vessels of each kidney. These scans will vary from hospital to hospital and will give a three-dimensional picture of the kidneys and their blood vessels.
Most donors will also undergo a scan to look at the relative function of the two kidneys and whether there are any scars on the kidneys. This is called a DMSA scan and involves the injection of a radionuclear dye that lights up functioning kidney tissue and allows the doctors to see the function of each kidney.
Once the function of each of the potential donor’s kidneys is determined, a decision can be made about which kidney is most suitable for donation. If one of a donor’s two kidneys works better than the other, the weaker kidney is usually used for donation. But if one of the kidneys is much weaker than the other, the donor may not be able to proceed with the operation.
An ECG test, usually carried out in a hospital’s cardiology department, is done to ensure that a person’s heart is healthy and functioning properly. Several small electrosensitive pads are attached to a person’s chest, arms and legs for a few minutes (a completely painless procedure) to monitor the electrical activity of the heart. Sometimes, extra tests will be done, such as an exercise (treadmill) ECG test or an ultrasound of the heart (echocardiogram).
All donors will have an X-ray of their chest to make sure their heart and lungs appear healthy.
As well as making sure that the donor is healthy to give a kidney, the doctors will have to make sure that there is no risk to the recipient from receiving a donated kidney. Female donors will be asked to make sure they are up to date with cervical smears and, if over 50 years old, with mammogram screening. Male donors will have a blood test for their prostate and may need to undergo a further examination.
Finding out about test results
Potential donors are often frustrated by delays in getting the results of their tests. In order to avoid this problem, it is a good idea to ask the doctor or nurse who is arranging the test how and when you can find out the results. You may be able to phone the transplant co-ordinator after the test is done. In some cases you may need to wait until your next regular appointment.
What if the tests discover an unexpected abnormality?
It is not unusual for a blood test or scan to find something that needs further investigation. An “abnormal” result does not necessarily mean that something is seriously wrong. It is important to realise that test results are not always going to be perfectly normal, and in a small number of cases the tests will detect problems at an early stage and have not yet caused any symptoms. When this happens, you may be told that further tests are needed, or that you need to be referred to another specialist.
Meeting the transplant surgeon
If a potential donor successfully passes all these tests, they will be invited to meet with the consultant transplant surgeon to discuss the donation, details of the operation and possible dates. You will be asked to sign a consent form when you are happy that all your questions have been answered.
Once a potential donor passes all the initial health checks, blood tests are carried out to assess the donor’s tissue type and blood group. These tests are required to match up the donor with a potential recipient.
The tissue type of both donor and recipient is determined by testing for marker proteins on the surface of cells. When these proteins match up well, the kidney transplant is less likely to be rejected by the recipient’s immune system and more likely to be successful.
Once a potential recipient is chosen, blood will be taken from both the donor and the recipient to check that the recipient does not have antibodies that might react against the donated kidney. If there are antibodies to the donor kidney, another recipient may be chosen.
The independent assessor
The final stage involves seeing an independent assessor. These assessors are trained by the regulatory body, the Human Tissue Authority (HTA). The assessors want to find out if the person who is offering to donate a kidney completely understands the implications of the process. They must also be sure that the potential donor is not being either bribed or coerced into donating. Final approval for the transplantation must come from the Human Tissue Authority, and this may take a number of weeks.
In the week or fortnight before the operation a few of the blood tests may be repeated to check that nothing has changed. Some routine “pre-op” (before the operation) investigations may also be done during a pre-admission visit to the hospital.
The operation to remove a kidney is a major operation that requires a general anaesthetic. This means that the donor will be asleep during the operation, which usually takes about two to three hours.
Traditionally, surgeons used a technique called “open nephrectomy” to remove a kidney. This involves the surgeon making an incision (15–20 cm long) in the side of the abdomen to remove the kidney. This operation is still used by many surgeons.
A kidney can also be removed using “keyhole” or laparoscopic surgical techniques. This type of surgery is becoming more common. It involves a number of small incisions (1–3 cm each), through which instruments are inserted to remove the kidney. A larger incision is then made to take the kidney out. Keyhole surgery may take longer to perform than open nephrectomy, but the recovery time is quicker because the incisions are smaller.
Once the kidney is removed it is taken to the recipient, who will usually be in another hospital. After the operation is completed, the donor is taken to a recovery room where they will wake up from the anaesthetic. They will have several temporary tubes or lines inserted during the operation, which may include a tube inserted into the bladder (catheter) and a drainage tube from the wound. These tubes are usually removed within a few days. Drugs for pain relief will be given immediately, and these are gradually reduced as the person recovers from the operation.
The recovery and aftermath
Recovery from a kidney donation operation can take from two to 12 weeks depending on the operation (“open” or keyhole surgery) and a person’s individual progress.
Traditional open surgery
If the operation was an open nephrectomy, the donor may be in hospital for five to seven days, but they should be out of bed the day after the operation. Surgeons use either stitches or clips to close the incisions they made during the operation and these will be removed around 10 days after the procedure.
Before the donor leaves hospital, a follow-up clinic appointment will be made, usually for four to six weeks later. The scars from the operation may be sensitive or sore for several weeks, and some numbness around the scar is common. There will be a permanent scar. There may also be twinges or a drawing sensation around the scars for some months, but most people feel back to normal by about 12 weeks after the operation.
If the operation was keyhole surgery, recovery time is shorter and there is usually less pain afterwards. After this type of surgery a donor will normally need four to six weeks of recovery time at home before resuming their normal activities. Painkillers may be needed for a while, depending on an individual’s symptoms. The donor will be asked to come in for a follow-up appointment four to six weeks after the operation.
After donating a kidney, many people feel quite emotional. They can feel a sense of anticlimax, be sad or feel other unexpected emotions. They may be concerned about their own well-being or the well-being of the recipient. It is usually possible to find out how successful the transplantation has been, but the recipient may not want to reveal too much information about themselves. Transplant co-ordinators and other staff should be available to answer any questions.
Getting back to normal life
After donating a kidney a person may need up to 12 weeks off work to recuperate, although most donors are more or less back to normal within six weeks. If an employer does not provide enough paid sick leave, a person can claim legitimate expenses for loss of earnings and travel expenses, usually up to a maximum of £5000. This is at the discretion of primary care trusts or local healthcare authorities and boards and should be discussed with the transplant co-ordinator before the operation. Any claim will need to be supported by proof of loss of income.
There are no rules about how soon a person can start driving again, but usually it will be four to six weeks after the operation.
A person should return to exercise gradually and build up their exercise routine slowly.
Sexual relationships can resume as soon as a person feels comfortable to do so.
- For more information about living kidney donation, go to the NHS Blood and Transplant website at www.organdonation.nhs.uk
- Living Donor Kidney Transplantation : Your Questions Answered can be found at www.organdonation.nhs.uk
Other useful resources
- UK Guidelines for Living Donor Kidney Transplantation, 3rd edition (British Transplantation Society and Renal Association, 2011)