Chapters Transcript Video Living Kidney Donation Thank you for taking the time to consider becoming a living kidney donor. Your willingness to explore this option means a great deal and could potentially make a life-changing difference for someone in need. Throughout this presentation, we will review the benefits of living donation, the different types of donation, the evaluation process, our multidisciplinary committee. Surgery, post- donation complications, post donation follow-up, and our SRTR. Every step of the evaluation is done to ensure that it is safe for you to donate a kidney. The Centera Kidney Pancreas Transplant Center is in Centera Norfolk General Hospital, which is located in Norfolk, Virginia. Living kidney donation is a completely voluntary process, and you can decide not to move forward at any time. At our center, we have two different teams, a team for the donor and a team for the recipient. Donor information is only discussed with the donor, and likewise recipient information is only discussed with the recipient. There are no medical benefits of the living kidney donor. However, there is an emotional benefit from helping someone in need. There is also the possibility that during your evaluation, our team identifies a health problem that you were unaware of prior to evaluation. For the recipient, receiving a kidney from a living donor has the potential for shorter wait times for a transplant, better outcomes, and the potential for a shorter recovery time. Expenses related to the living donor evaluation are covered by the transplant center. Expenses related to the living donor surgery are billed through the recipient's insurance. If the living donor receives a bill for testing ordered during their evaluation, they should notify our office as soon as possible so our financial coordinators can work to get this resolved. We ask that the living donor keep us updated with any statements they may receive, as some bills can take up to 6 months to be fully resolved. Donating a kidney could impact your ability to find employment, health insurance, disability, and life insurance. It's important that you talk with your own insurance carrier before making a decision about being a living donor, as your premiums could increase. If you do not have health insurance, serving as a donor could be considered as a pre-existing condition if you apply for insurance later. There are alternatives to living kidney donation for the recipient. These include waiting for a deceased donor kidney transplant or remaining on dialysis. If you choose not to proceed with your living donor evaluation, the potential recipient will continue to receive the same care they would have if you had not shown interest in donating. There is a possibility that the recipient may receive a deceased donor kidney transplant before you are able to complete your evaluation. It's also possible that the donor kidney could fail and the recipient may need to be placed back on the wait list for another kidney or returned to dialysis. Candidates not suitable for kidney donation include people under the age of 18 or over the age of 70. Candidates are not suitable if they are deemed psychologically unstable, or unable to give informed consent. The candidate is suspected to be under inducement, coercion, or other undue pressure. The candidate is suspected to be knowingly and unlawfully acquiring, receiving, or otherwise transferring anything of value in exchange for their kidney. are HIV positive, have an incurable malignancy, or an incompletely treated malignancy that requires treatment other than surveillance or has more than a minimal risk of transmission. If they're type 1 or type 2 diabetic, if they're currently taking more than one blood pressure medication, have uncontrolled high blood pressure, or have a history of high blood pressure with evidence of end organ damage, have any current or recreational drug use with the exception of marijuana, have a body mass index or BMI greater than 35, or have a low GFR cystatin C calculation on two occasions. Now we'll go through the evaluation process. Here you can see the average pathway for the evaluation of a living kidney donor. A nurse from the living donor team will reach out to the potential living donor to review their screening form that was completed online and send them a link to our educational video. After speaking with a living donor nurse, the potential donor is scheduled to meet with our social worker and advocate. Once these visits have been completed, the potential donor will need to sign the acknowledgement of Education form to officially start the evaluation process. They will then be scheduled for a visit with a living donor nurse and their first round testing, which will be covered in a few slides. The next step will be completing imaging of their abdomen called a CTA scan and collection of a 24 hour urine study. This is typically done the same day the potential donor meets with one of our nephrologists or kidney doctors to review testing. A dietitian and pharmacist will review donor charts for clearance to move forward. With the final step, the Living donor Multidisciplinary Committee reviews the potential donors evaluation as a group for the final decision on candidacy to donate. Completing an evaluation does not guarantee eligibility to donate. The transplant center can stop an evaluation at any time if a potential donor is deemed not a candidate. The potential donor also has the right to pursue a evaluation at another center. There is a possibility that a psychological clearance by a clinical psychologist or psychiatrist may be required if recommended by the living donor team. Genetic testing may also be a requirement depending on potential donor history. The potential donor will be scheduled to meet with one of our social workers to review their social history and confirm their support plan for time of donation before they can start their evaluation. Our social worker will follow them throughout the evaluation and donation process and is available to them at any time. After the living donor has met with our social worker, they will meet with one of our independent living donor advocates, or ILDA. The ILDA's role is to be a neutral person for the living donor to utilize if they have questions or concerns regarding donation and to advocate for their rights and wishes by ensuring they have been afforded and given informed consent. The ILDA is available to the living donor throughout the entire consenting and donation process and serves as support should they have any hesitation about proceeding. Once the donor has completed their visits with their social worker and ILDA and completed the acknowledgement of Education form, they will then be scheduled for testing. We follow the recommendations from the American Cancer Society regarding cancer screenings. All females are required to have a current Pap smear or pelvic exam. All females over age 40 or above are required to have a current mammogram. There are some instances where this may be required prior to age 40. All patients age 45 or older will be required to have a current colonoscopy. In some cases, you may be required to have a colonoscopy earlier than age 45. For example, if you have a family history of colon cancer, it may be recommended that you have a colonoscopy earlier. Patients over the age of 50 with a current or previous smoking history may be required to have lung imaging via chest CT scan to be ordered by their primary care physician or PCP. If you are not up to date on your cancer screenings, please reach out to your PCP to get these set up. If you have already completed your cancer screenings, please have your results sent to our office to help expedite your evaluation. You are responsible for scheduling your cancer screenings. Remember, these tests are billed through your insurance and not covered by the transplant center. On this screen, you can see our evaluation testing. The first round testing of the donor evaluation includes a chest X-ray to look at your heart and lungs, an EKG to look at your heart rhythm, check your blood type and blood counts, check a comprehensive metabolic panel, which tells us your kidney function, liver function, and electrolyte levels. We check hepatitis labs, we'll check your urine for blood or protein. We check for HIV and syphilis. We check a drug screen on all donors. We order a cystatin C, which gives us more information on your kidney function. We check to see if you have ever been exposed to two different viruses cytomegalovirus or CMV and Epstein-Barre virus or EBV, which are important when choosing which medications to use for the recipient after transplant. We check for tuberculosis. We will check a hemoglobin A1C, which tells us how well controlled your blood sugar has been over a 3 month period. Depending on donor history, we may check a glucose 2-hour tolerance test. For this test, you come in fasting with nothing to eat or drink at least 8 hours before and have your blood sugar checked. You then drink a sugary drink, and 2 hours later, you get your blood sugar rechecked to see how well your body is able to tolerate the extra sugar. Females of childbearing ages will have a pregnancy test. Males 45 and older will have a PSA level. Between May and November, we check donors for the West Nile virus. Some donors may require endemic area screening, which is 1 to 2 extra blood tests, if they have ever traveled to Africa, Asia, or the Gulf Coast in their lifetime. The second round testing is done at the end of the evaluation. It involves completing imaging of the abdomen called a CTA scan, completing a 24 hour urine collection, and checking compatibility with the intended recipient if applicable. These tests are usually completed the same day you meet with our kidney doctor and surgeon. If you have any abnormal results during your evaluation, you may be required to have further testing or to see a specialist for clearance. Our center will cover your initial visit with a specialist. However, if that specialist orders additional testing or follow-up, it will then be billed through your insurance as it will then be considered medical management. Please contact us if you receive any bills for any testing we order for you, or if you are not sure if you are responsible for the bill. The living donor evaluation is our primary focus. Once you are close to being cleared, we will check compatibility with your intended recipient if you have one in mind. Compatibility results typically take 1 to 2 weeks to come back. Our team will reach out to you to discuss our donation recommendations once we have these results. There are several different routes for kidney donation. There's the directed donation. This donor directly donates to their intended recipient. The donor must be compatible with the recipient to donate this route, which we'll discuss on the next slide. Kidney pair donation allows for you to still help your recipient receive a living donor kidney transplant if you are not directly compatible or a good match to your recipient. Donors are entered into your registry to either find another incompatible pair to swap donors with or donate in advance to give the recipient a voucher to redeem at a later time for a returned living kidney donor. This option has the added benefit of helping more than one person, the person your kidney goes to, and your intended recipient. The last route for donation is non-directed donation, which occurs when the donor does not have an intended recipient. In order to directly donate to a recipient, the donor must be blood type compatible and tissue type compatible. Our lab will perform a cross match between you and your recipient to ensure there is no reaction between the donor and recipient blood. If there is a reaction, that means that the recipient has antibodies to the donor's blood, which tells us there would be high likelihood of organ rejection after transplant. Compatibility can change over time due to several different factors, including pregnancy, blood transfusion, and previous organ transplants. There are some instances where recipients are able to receive an organ from a living donor with low level of antibodies. These cases are reviewed with the physicians at the transplant center. As mentioned earlier, kidney pair donation is an option that allows you to still help your intended recipient if we find that you are incompatible to directly donate to your recipient, or it could be suggested if our team feels that you are not a good match to the recipient. This could be due to compatibility or the difference in size or age. If you look at the picture to the right of the screen, you can see an example of a paired exchange or swap where you can see that the mother is incompatible with her son and the husband is incompatible with his wife. By entering a pair exchange, the mother is able to donate to the wife and the husband is able to donate to the son. While the donors were unable to donate directly to their intended recipient, they were the key that helped to facilitate the recipient receiving the living donor kidney transplant. Without their donation, their intended recipient would not have been able to receive a kidney from a living donor. Paired or swapped donation is not prioritized in the National Kidney registry and can take several years for donors and recipients to find a match. Voucher donation allows for you to have more control over your donation time. Once you have donated, your intended recipient will receive a voucher similar to a coupon that they can redeem after you have donated. This may be a good option if you plan to be a recipient support person or vice versa, or if your recipient isn't quite ready for transplant. An added bonus to these types of donation is that you are helping more than one person get transplanted. As we just mentioned, voucher donation gives donors more control over their donation day versus pair exchange. Donors are asked to provide a 3-week window to the National Kidney registry, and surgery will be planned within that time. There are 2 different types of voucher donations, the standard voucher program and the family voucher program. With the standard voucher program, you are donating on behalf of someone who is in imminent need of a kidney transplant. This means that it's likely that your intended recipient will need a transplant in the next year. You may also list up to 9 other family members or friends in the event your intended recipient is unable to redeem the voucher. This type of voucher donation is often utilized when donors are not a good match to their intended recipients. The family voucher program is available for donors who want to donate but do not know anyone in imminent need of a transplant. This program allows you to list up to 10 family members or friends to receive a voucher in the event they ever need a transplant in the future. Only one of the people you list on your voucher are able to redeem the voucher. The National Kidney Registry, or NKR has a donor assistance program available that offers several different perks. These include the ability to apply for lost wage reimbursement for up to $2000 per week for up to 12 weeks, up to $6000 for travel and lodging expenses for both the donor and the donor's caregiver. They offer kidney prioritization in the unlikely event that the donor ever finds themselves needing a kidney in the future. They allow voucher donation, which we discussed earlier in the presentation. They assist with remote donation to help avoid air travel for the donor evaluation and surgery. They can link you up with another person who has donated in the past, so you can talk to them about their experience. They help maximize the impact of your donation by finding the best match possible for your kidney. They have legal support available if needed for termination and or discrimination, and they help with reimbursement if there are any complication costs. In order to qualify for DonorShield, the donor must donate through the NKR via remote donation, paired exchange, or voucher donation. The last type of donor is the altruistic donor, also known as the non-directed or good Samaritan donor. This is a donor that does not have an intended recipient. These types of donors are entered into the National Kidney registry to find a match for their kidney and are given the opportunity to complete a family voucher as mentioned earlier. These types of donors are often used as a way to start donation chains that have the potential to impact multiple people. Another assistance program available to donors is the National Living Donor Assistance Center, or NAWLDAC. This program can help cover travel expenses, lost wages, and dependent care expenses. For directed donors, eligibility is determined based on the recipient's household income. For non-directed donors, recipient income is not a factor in determining eligibility. Our financial coordinators and social workers can provide assistance in applying for this program if you are interested. All donors can apply to this assistance program. Now, we'll talk about the donation surgery. Our program follows the enhanced recovery after surgery or ERAS care plan. This care plan was designed to help reduce the stress of surgery on your body by helping you heal quickly and return to your normal routine as soon as possible. One thing that you can do prior to surgery to help with this is start exercising. If you do not routinely exercise, start a walking program. Start off with a 10 to 15 minute daily walk at a comfortable pace, leading up to a more intense walk, increasing your distance and speed. A good goal may be working up to a 30 minute brisk walk. Exercise will prepare your body to heal faster. You can also optimize your nutrition. Focus on a diet high in vitamins and protein, which will include whole grains, fruits, vegetables, and lean protein. Improving your nutrition will help with wound healing. You can also avoid drinking alcohol leading up to surgery. Stop smoking if you smoke. Consider calling your primary care doctor for help in quitting smoking. Studies show that stopping smoking as early as possible before surgery helps reduce the risk of wound complications, helps with healing, and reduces pulmonary complications. On the bottom right of your screen, there are additional resources if you need help to stop smoking. With the kidney donation procedure, we removed your kidney, a portion of the main artery and vein through which the blood flows into and out of the kidney, and the ureter, the tube through which urine passes from the kidney to the bladder. The surgeon will make 4 small incisions in your abdomen. A small camera or scope is inserted to help your doctor perform the surgery. Our center utilizes the left kidney from the donor as the vein and artery are longer on that side, giving our surgeons more room to perform the surgery. There are 2 different surgical approaches we use at our center, the hand-assisted laparoscopic living kidney donor nephrectomy and the robotic assisted living kidney donor nephrectomy. With the hand assisted procedure, your surgeon uses a scope or camera and surgical instruments to manually detach the kidney and remove it through an incision in your abdomen. With a robotic assisted procedure, your surgeon uses a computer console to control the arms of a robotic device that detaches your kidney. A second doctor will then make an incision along your lower abdomen to remove the kidney. There are post-op risks associated with living kidney donation. Every donor will have some level of pain after surgery. Our center uses non-narcotic pain medications after donation. Tylenol will be given postoperatively to assist with pain control. We encourage you to refrain from requesting narcotics as much as possible, as they can delay your recovery and oftentimes are associated with multiple side effects. Other risks include fatigue, bleeding, infection including the surgical incision, damage to bowel, spleen, liver, stomach, kidney, or blood vessels in the abdomen, kidney failure, bowel obstruction or blockage, bloating, nausea, vomiting, hernia, testicular pain, inflammation of the pancreas, which is called pancreatitis, blood clots in the leg or lung, pneumonia, nerve injury, heart attack, or stroke. All donors are given stool softeners for 2 to 4 weeks after donation to help with bowel function, and are encouraged to walk at least 3 times a day. The average length of stay for living donors is between 1 and 3 days. Most donors are discharged the day after surgery, as long as their pain is well controlled, they are up walking around, they're able to urinate on their own and are eating and drinking without any difficulty. On average, living donors will have anywhere from a 25 to 35% permanent loss of kidney function after donation. The current practice today is to prioritize prior living kidney donors who become kidney transplant candidates themselves. For females, the risks of preeclampsia and gestational hypertension or high blood pressure are increased in pregnancies after donation. You may be considered high risk and be referred for closer monitoring during your pregnancy. There are some psychological effects after kidney donation. These include permanent scars on your body, which could lead to problems with body image, changes in lifestyle due to donation, you'll be unable to drive or lift anything heavy after surgery. There is a possibility to experience feelings of anxiety, guilt, depression, and post-traumatic stress disorder. The recipient may also not return to optimal health after transplant. This can be related to the transplant itself or other related illnesses. Please reach out to the living donor team if you experience any of these so we can provide assistance. While in the hospital, the living donor coordinator, independent living donor advocate, or ILDA, pharmacist, dietitian, and social worker will all see you. Our team is also available to speak with you at any time, both throughout your evaluation and after donation. Once you are discharged from the hospital, you may contact the living donor coordinator at any time with questions or concerns. We will be available to you 24/7. Restrictions after donation include no driving for 2 weeks after surgery, no lifting anything heavier than 20 pounds for 6 weeks, and no soaking in any form of water until your incisions are fully healed. Incisions are closed with skin glue and left open to air. There is no need to use creams or lotions to these incisions. Donors are typically out of work anywhere from 4 to 8 weeks post donation. If your job is physically demanding, expect to be out of work closer to the 8-week time frame. In the event of potential disease or malignancy transmission within the 1st 2 years after donation, we may be required to report to our local, state, or federal public health authorities, as well as your kidney recipients transplant center in the OPTN or organ procurement and Transplantation Network patient safety portal. After discharge, all donors should follow up with their primary care provider or PCP at least once a year for routine exams and lab tests for the rest of their life. After donation, donors should avoid all NSAIDs or non-steroidal anti-inflammatory drugs. Common NSAIDs include ibuprofen, Advil, Motrin, naproxen, Aleve, Excedrin, and BC or goodies powder. While these medications work well, they're filtered out of the body through the kidneys. Excessive use can cause damage to your remaining kidney, which could lead to kidney failure. If you currently take NSAIDs on a regular basis and are unable to stop, please reach out to our team to discuss if donation will be safe for you. After donation, acetaminophen or Tylenol should take place of these medications. After donation, we require all donors come back to see their surgeon between 2 and 4 weeks post donation. After this, we'll see you again around your 6 month, 1 year, and 2 year post donation anniversary. At these visits, we will check basic labs that will tell us your kidney function and check your urine for blood or protein. We will also be checking your weight and blood pressure at these visits. Don't forget, we want every donor to follow up with their PCP at least once a year. Every transplant center has SRTR data. This stands for the Scientific Registry for Transplant recipients. You can go online and see outcomes for both patient and organ survival rates for every center. We will also be providing you with a copy of our statistics. Please reach out to us if you have any questions or need help understanding this data. Here is a list of additional resources that contain great information regarding living kidney donation and transplantation. Please don't hesitate to reach out to our center with any questions. Now that you have completed watching this presentation, your next step is to meet with our social worker, and Independent living donor advocate, or ILDA. These visits should have already been scheduled for you. If they have not, please reach out to our team to schedule. After these visits have been completed, you will need to sign our acknowledgement of education form that will be emailed to you. A member from the living donor team will call you once we have received your signed forms and schedule your testing and next steps. Please don't hesitate to reach out to our team with any questions or concerns. Published January 22, 2025 Created by
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