Session #1: Introduction to Kidney Transplantation and Live Donation

Johns Hopkins Comprehensive Transplant Center

Presented by: Elizabeth A. King, M.D.

Program Mission

• Motivation– Patients hesitant to ask– Don’t know enough about live donation– Don’t know how to start the conversation– Don’t know who to ask– Family and friends eager to help

• Goals– Decrease burden felt by transplant candidate– Increase awareness of renal failure and benefits of

living donation– Identify potential living donors

Program Schedule

• Introduction to Kidney Transplantation and Live Donation

• Initiating a Conversation with Potential Live Donor Candidates

• Who Should I Speak To? Identifying a Social Network• Success Stories: Live Donor and Recipient Panel• Surgeon and Nephrologist Q&A• Program Recap

Program Requirements

• Six educational meetings• Baseline knowledge assessment• Pre and post surveys• Post program knowledge assessment

Renal Failure

• Kidney filters waste and excess water

• Keeps bone tissue healthy

• Controls blood pressure• Failure leads to build-up

of waste and fluid• Many causes of failure

– High blood pressure– Diabetes

Renal Failure

• Anemia• High blood pressure• Difficulty breathing• Dietary changes

– Potassium– Salt– Fluid

• Treatment– Dialysis

• Peritoneal dialysis: daily

• Hemodialysis: three times per week

– Transplant

Kidney Transplantation

• >600,000 people in the U.S. in need

• Average wait-time 3-5 years

• Each year 8% of patients die while waiting

Living Donation - Basics

• 1 in 4 Americans would donate if they knew someone in need

• 4 types– Direct– Paired Exchange– Altruistic– Incompatible

• You don’t need to be a “match” to donate

Living Donation - Benefits

• Immediate decrease in wait-time• Off dialysis, reverses adverse effects• Double life expectancy• Live donor kidneys work better and last longer • Surgery is scheduled• Shortens wait-time for others • If donor develops ESRD they go to the top of the

wait-list

Living Donation - Eligibility

• At least 18 years old• Medically and psychologically healthy• Ineligible

– Diabetes– Cancer– Kidney disease– HIV/AIDS– Hepatitis

Living Donation - Eligibility

• Hypertension– Certain people with high blood pressure are able

to donate a kidney– Eligible to donate:

• Caucasian and > 50 years old• Risk of developing ESRD higher for

– Hypertension + race other than Caucasian– Hypertension + <50 years old

• Allow the transplant team to decide if a donor is eligible

Living Donation - Evaluation

Evaluation ProcessStep 1 Blood type confirmation

Step 2 24 hr urine collection, urinalysis, stool test, TB testCollection of medical records (routine labs, pap smear, mammogram if >40, colonoscopy if > 50, exercise stress test if >50)

Step 3 Appointment with Nephrologist, Surgeon, Psychologist, Social Worker, Transplant Coordinator3D CT scan, EKG, CXR

Step 4 Transplant team clears candidate for donation

Step 5 Final blood draw (must be within 30 days of planned surgery)

Step 6 Pre-Operative visit with Anesthesia

Step 7 Cross match (must be within 7 days of planned surgery)

Step 8 Surgery

Step 9 Recovery

Living Donation - Surgery

• Open surgery– Rare

• Laparoscopic surgery– Routine approach– First done at Hopkins in 1990– Faster recovery– Shorter hospital stay– Less pain– Smaller incisions

Donor Nephrectomy

Living Donation - Recovery

• 2 days in hospital– Walking in hospital

• 4-6 weeks for full recovery– Return to work in as little as 2 weeks

• Will require temporary pain medications• No dietary restrictions following donation

– Recommend a healthy, balanced diet

Living Donation- Risks

• Extensive evaluation to ensure low risk• Life expectancy

– Donors live longer than average adults• Surgical Complications

– Bleeding– Surgical infection– Urinary tract infection– Pneumonia– Blood clot

Living Donation - Risks

• Death– 0.03%

• Long term health– Slightly increased risk of developing high blood

pressure– Quality of life is equal if not better than average

adults

Living Donation - Cost

• A live donor’s medical expenses are paid by the recipients insurance or by Medicare

What the average person knows about live donation…

Living Donation - Myths

Myth #1: A kidney donor will have to take medications for the rest of their life

Myth #2: A kidney donor will have debilitating pain for an extended period of time.

Myth #3: A kidney donor will be on bed rest following surgery.

Myth #4: A kidney donor will be in the hospital for an extended period of time after surgery.

Myth #5: A kidney donor can no longer participate in sports or exercise.

Living Donation - Myths

Myth #6: A kidney donor will have to follow a new diet plan following donation.

Myth #7: A kidney donor can no longer consume alcohol following donation.

Myth #8: A female kidney donor should not get pregnant after donation.

Myth #9: A kidney donor's sex life will be negatively affected by donation.

Living Donation Facts

Fact #1: A kidney donor will be given prescriptions for pain medication and stool softeners at discharge from the hospital. These are only for the immediate post-operative period, after that time, a donor does not have to take medication.

Fact #2: A kidney donor will have some pain after surgery from both the incisions and related to gas and bloating. This pain will diminish in the days following surgery and can be controlled with pain medication if necessary.

Fact #3: A kidney donor will be out of bed and walking independently before discharge from the hospital.

Fact #4: A kidney donor will be hospitalized for two nights (i.e. if surgery is on a Tuesday, the donor will typically be discharged on Thursday).

Living Donation Facts

Fact #5: A kidney donor should be able to return to regular activities and exercise at approximately 4-6 weeks following surgery.

Fact #6: A kidney donor should eat a healthy, well balanced diet. There are no dietary restrictions following donation.

Fact #7: While excessive alcohol use is always dangerous, a kidney donor can consume alcohol in moderation.

Fact #8: A female kidney donor should wait 3-6 months' time after donation to become pregnant. The body requires time to recover from the surgery and to adjust to living with one kidney prior to pregnancy.

Fact #9: A kidney donor may engage in sexual activity when they feel well enough to do so.

Matching

• Immune system fights off foreign invaders– Antigens = invaders– Antibodies = fighters

• Immune system mistakes the kidney for a foreign invader

• Leads to rejection– Immediate or gradual

Blood type

Tissue type

• 88 possible types• Everyone has a unique

set of 6 • 2A, 2B, 2DR• Cross match tests for

recipient antibodies to donor tissue

AB

DR

Panel Reactive Antibody

• Referred to as PRA• Tests recipient antibodies against most common

tissue types • Ranges from 0 to 100• 0 = no antibodies, less likely to reject• 100 = many antibodies, very likely to reject

Paired Donation

• Donor/recipient pairs that are poor match

• Exchange organs with another donor/recipient pair to make a better match

• Usually two pairs but can be three or more

Incompatible Donation

• Blood type or tissue mismatch• Plasmapheresis

– Before and/or after transplant– Similar to dialysis– Removes antibodies

Questions

Other Resources

• www.hopkinsmedicine.org/transplant• www.kidney.org/transplantation/livingdonors

Homework

• Speak to 5 people• Brainstorm what materials you need to share with

others• Contact us with questions

– 443-287-0134– livedonorchampion@lists.johnshopkins.edu

Post Survey

• Take 10 minutes to fill out the post survey

• Next Month’s Session

“Initiating a Conversation with Potential Live Donor Candidates”