The prospect of a long wait on the transplant list often leads patients, their family and friends to think about the possibility of a transplant from a living donor. There are many issues to think through. Most patients are hesitant about asking a family member or friend to consider donating a kidney. Family members and friends may be concerned about the risks involved. However the thought that a successful transplant may be possible is often a strong incentive for many to consider making a kidney donation. In 1999 14 patients received a single kidney, in Christchurch hospital, from a relative, partner or friend.
The Department of Nephrology co-ordinates the assessments of potential living donors for potential recipients who live in Canterbury, Otago or Southland and for patients who will be transplanted in other hospitals, both within New Zealand and overseas.
The first step for any potential donor is to have his or her ABO blood group identified and to send a paper lab copy of the result to the renal unit that cares for the potential recipient so that the unit staff can check that the potential donor and the potential recipient are ABO compatible.
In Christchurch we have an information booklet for potential donors to read:
What it means to be a living donor
A kidney transplant is one of the treatment options for most patients with end stage kidney failure. Healthy kidneys for transplantation come from either a previously well person who has suffered severe and irreversible brain damage (a deceased donor) or from a healthy living donor. The transplanted kidney can then perform the function of the diseased kidneys.
Every year there are many more people waiting for a transplant than there will be kidneys available. Most patients can expect to wait for many months, even years, before a kidney becomes available for them.
The prospect of such a long wait often leads patients and their relatives to think about the possibility of a living donor transplant. Most patients are hesitant about asking a family member or friend to consider donating a kidney. Family members and friends may be concerned about the risks involved. However, a successful transplant will mean the end of dependence on dialysis and the return to a more normal and healthier lifestyle and this is a strong incentive for many to consider making a kidney donation.
If you are thinking about giving one of your kidneys, you should take all the time you to need to think over the information that you will be given, before you make up your mind. The decision to donate a kidney is an important one.
Some people make the decision instantly with few worries or concerns. Others go through some soul-searching before deciding.
Remember the only "right" decision is the one that makes you, the potential donor feel comfortable.
There are several people with whom you could discuss donation including:
- the transplant coordinator
- the counsellor for potential living donors
- a Nephrologist
- the social worker
- the surgeon who operates on kidney donors
- someone who has donated a kidney
Who can be a living donor?
The prospective donor must be over 18 years of age (or over 21 years of age for a non-directed* donor) and be a fit and healthy person with two normal kidneys. In general donors must not have high blood pressure, cancer, diabetes, kidney, liver or heart disease.
There is no strict upper age limit but as there is less chance that an older person will pass the medical examination necessary before donation is judged to be safe, a potential donor must be under the age of 65 to start an assessment.
People considering donation, who are over-weight, will be asked to consider weight reduction before tests and assessments are started. A height and weight ratio determines a person's body mass index (BMI). Donors must have a BMI of 30 or less. Your practise nurse, GP or transplant coordinator can calculate your BMI for you. If you are motivated to lose weight and would like some professional assistance the transplant coordinator can refer you to a hospital dietitian.
It is necessary for any prospective donor to have an ABO blood group compatible with the potential recipient.
Inherited factors, called HLA antigens, are important in transplantation. Identifying these antigens, which are located on the surface of white blood cells, is called "tissue-typing". A close blood relative, usually a parent, brother or sister, may be the most suitable donor. Children inherit a half set of HLA antigens from each parent, which means that a parent and child will have at least a half set in common. Brothers and sisters may be a perfect match, a half match, or have no HLA antigens in common. Aunts, uncles, cousins or other relatives may wish to be considered but may have no HLA antigens in common with the potential recipient.
Where there is no blood (genetic) relationship between the prospective donor and the potential recipient there are unlikely to be any HLA antigens in common.
However it is possible for adoptive parents, husbands, wives, partners or even close friends to consider having tests to see if they may be suitable donors.
It is also possible for someone to consider altruistic donation. In such cases the kidney would be allocated to the best tissue-matched and low-risk recipient.
A prospective donor must be able to make up his or her own mind about kidney donation. There should be no pressure from others nor any financial incentive offered to encourage donation.
What are advantages of a living donor transplant?
For the recipient this means that a planned transplant:
Could take place before dialysis is needed
Could reduce the time on dialysis (this is especially important for children)
Allows for planning the time of the operation
Usually provides a good tissue match
Is likely to have a higher success rate - the transplanted kidney usually works straight away and lasts longer
What are the steps in the potential living donor's assessment?
The Nephrology Department will coordinate the tests and assessments, which will take six to nine months. A date for surgery will not be available until all the tests have been completed.
1. A simple blood test can show whether you have a blood group compatible with that of your prospective kidney recipient.
If this test shows that you are not compatible there will be no further testing because a transplant cannot occur.
The ABO blood group of potential altruistic donors will still be identified at this stage.
2. If the blood groups are compatible you will be asked to meet with the counsellor for living donors to learn more about the implications of donating a kidney.
3. Potential donors, who are not closely related to a particular recipient, will be asked to meet with a clinical psychologist.
4. After you have had time to think over the information you have been given, and you wish to continue with the assessments, more blood tests will be arranged.
If the recipient is known to you a "cross match" test is done where the potential donor's white blood cells are mixed with the potential recipient's serum. A donation is only possible if there is no reaction between the serum and the cells. If the donor cells are damaged, in this test, it means that the immune system of the recipient would reject your kidney.
If the cells remain alive, the donor is said to be white blood cell compatible with the recipient i.e. the donor is 'cross match compatible' with the recipient. The potential donor tissue type will be identified at this stage.
If there is more than one family member considering donation, tissue typing may reveal that one relative is a closer tissue match with the potential recipient.
5. Once the tests show that you and the potential recipient are cross-match compatible, the coordinator will meet with you to outline the blood and urine tests that are required. These tests will ensure that your kidney function and blood counts are normal. Your blood will also be screened for HIV, Hepatitis B and C and other viruses which could be passed on through the transplanted kidney.
You will be asked to have a chest x-ray, and might have an ECG assessment of your heart, to make sure there are no underlying heart or lung problems. An ultrasound scan (soft tissue imaging) of your kidneys and bladder makes sure that you have two normal kidneys.
If you have asthma or smoke you will be asked to have breathing tests. Also, if you have a close relative with diabetes, extra blood tests may be requested.
6. An appointment will be made with a nephrologist who will ask you about your medical history and your family's medical history. The nephrologist will discuss the results of your tests with you and you will have a routine physical examination to make sure you are fit and healthy. Further tests may be requested at this appointment.
If the nephrologist considers that you are medically fit to donate, a CT scan of your kidneys and urinary tract will be requested. This test is done as a one-hour out-patient appointment at the Radiology Department, Christchurch Hospital. During the procedure x-ray contrast fluid is injected into a vein.
The purpose of these x-rays and kidney function tests is to make sure that your kidneys, arteries, veins and urinary tract are in good working order and that it will be possible to remove your kidney and transplant it into the potential recipient. Occasionally people have extra blood vessels, which are normal for them, but may make transplantation technically impossible.
7. After the results of the tests done so far are reviewed, you will be asked to meet with the urologist, who is the surgeon who would remove your kidney. The urologist will ask you a few questions about your medical history and examine you. He will discuss the operation in detail and mention possible complications. He will explain how pain around the operation site will be relieved.
The urologist will discuss with you the implications of living with only one kidney. You will be given the opportunity to ask any question or raise any concerns that you might have.
8. Once the urologist is satisfied that you are able to be a donor, and you agree to have the operation to remove your kidney, called a nephrectomy, he will discuss the arrangements for the operation with the nephrologist and the surgeon who will do the transplant. The urologist will be responsible for your care.
9. You will be asked to provide blood samples for your tissue type to be identified (if it has not been necessary to do this earlier in the assessment).
At some stage in your assessment you will meet with the Nephrology social worker, who will help prepare you for the emotional aspects related to donation and also discuss practical matters such as arrangements after donation.
What are the issues for the prospective donor?
This is an operation that will be performed on someone who is in good health and does not need a surgical procedure for his or her own health.
It means you will have tests and procedures done that otherwise would not be necessary. There is the possibility that these tests may show up an abnormality that could have remained undetected. The results of these investigations sometimes show that you cannot donate a kidney.
You will also need to take time off from work to attend appointments and several weeks off work after the operation.
If you are able to donate one of your kidneys, the remaining kidney should be sufficient for your body's needs.
While most donor operations are straightforward, complications sometimes arise. The surgeon will discuss these with you before you decide to proceed.
Specific complications that may arise include:
a blood transfusion may be required during the operation
a minor degree of lung collapse
blood clots may develop in the legs and lungs
pneumonia
wound infection
urinary tract infection
If you smoke, you should consider stopping to reduce the risks of chest complications, thrombosis (clots) etc.
Women on oral contraceptives should consider using an alternative method of birth control for three months before the operation.
Any operation involves some pain, but this is managed by modern pain-relieving techniques. You will be given detailed information on these by the anaesthetist.
Death from kidney donation is extremely rare. Overall the risk of dying from a donor nephrectomy is 0.03%. To put this into perspective the risk can be related to the risk of dying in a motor vehicle accident which is present each and every year. In three years the risk of dying in a car accident on the open road is about 0.05%.
There is a potential risk that a kidney donor may subsequently develop kidney failure and require dialysis and/or a transplant. The risk of this occurring is 0.11% - which is actually lower than the expected incidence for the general population.
What type of operation will I have?
There are two types of operations to remove a kidney:
- an open nephrectomy
- a laparoscopic nephrectomy
For an open nephrectomy, the surgeon makes an incision about 25cm long horizontally below the ribs, and cuts through the abdominal muscles. Please note: At Christchurch Hospital, the procedure to remove a kidney does not involve the breaking or removal of ribs.
During the laparoscopic procedure, the surgeon makes 3 or 4 small incisions in the abdomen to allow the insertion of surgical instruments and a small (8-10cm) incision just above the pubic bone to allow the removal of the kidney.
The laparoscopic procedure should be less painful and donors recover more quickly.
However it will not be possible to tell you whether you can consider a laparoscopic procedure until the surgeon has reviewed the CT scan and assessed you.
Even if a laparoscopic procedure is planned the surgeon will ask you to consent to the operating being changed to the open procedure if this should become necessary during the course of the operation. Generally laparoscopic surgery is very safe but like open nephrectomy, deaths have been reported following this surgery as well. As mentioned before the risk of a donor dying is about 1 chance in 3000.
When will the operation date be advised?
When the date is finalised you will receive a letter from the transplant coordinator confirming that the operation is being planned for a specific date. The coordinator will also send you a blood test form for a specific date to enable the lab to again perform the white blood cross-match test. The Urology Department will send you the date and time for your admission to hospital.
What will be the timetable for the operation?
You will be admitted the day before the operation. You can expect to be in hospital for 5 to 7 days after an open nephrectomy and 2 to 3 days for a laparoscopic nephrectomy. You will be discharged when the surgeon considers that it is safe for you to go home. You will be asked to come back for the urology outpatient clinic about six weeks after the operation. You will be offered long-term follow up.
What restrictions are there after the operation?
Most kidney donors recover quickly after the surgery and are able to go back to work and other activities within a few weeks. The length of time off work depends on the type of work you do and the type of operation you have had. You should avoid heavy lifting, digging, and playing golf for about 6 weeks and aim to be back doing everything you normally do by 3 months after the operation.
Are there any long-term effects of donating a kidney?
As mentioned before, one healthy kidney is enough to provide for normal health. Having one kidney does not change life expectancy or increase the risk of getting kidney disease. Of course, other problems might arise in the remaining kidney, for example, infection or a kidney stone, but the chances of this happening are quite small. Living with one kidney does not interfere with a woman's ability to have children.
Will this kidney transplant work?
We know that a year after a transplant operation about 9 out of 10 kidneys transplanted from a living donor will be working well. Most of these continue to work well for 8 to 10 years. Some people have a transplant that is still working well after 20 years.
What we cannot tell you is whether your recipient will be the one person out of 10 whose kidney is not going to work. Unfortunately some kidneys are lost through rejection, infection, or blood supply problems.
Before donating a kidney it is important that you consider what your feelings would be if the transplant should not be successful.
Are there any financial costs involved?
The costs of the tests and the surgery will be met by the hospital. Travel costs will be covered if you live outside Christchurch. Financial matters are best discussed with the social worker who works with the Nephrology Department.
There may be assistance with any loss of income or extra childcare costs you have because of the operation. (Refer to Work and Income Leaflet entitled "Financial assistance for live organ donors"). In general, medical insurance companies do not deny cover for subsequent unrelated conditions to people who have previously donated a kidney. If you have any concerns about future entitlement to private health insurance, you should discuss these with your insurance company.
Points to note
You have the right, to decide against making a kidney donation.
It is important to remember that you can stop the assessment process at any stage.
The counsellor, the nephrologist, the social worker and the urologist are always willing to answer your questions.
Living with one kidney should not interfere with everyday activity.