Kidney Transplant Options

The Nebraska Medical Center Kidney Transplantation Program offers several types of transplant options for adults, adolescents and pediatrics. Those options include:

• Living Donor Kidney Transplants
• Deceased (Cadaver/Cadaveric) Donor Kidney Transplants
• Kidney/pancreas transplants

Living Donor Kidney Transplants

For the first time ever, in 2001, living donor transplants exceeded deceased (cadaver) kidney transplants nationally. Living donor kidney transplants are accomplished when a healthy individual with two functioning kidneys agrees to have one of their healthy kidneys removed and “donates” it to someone who is on dialysis or will need dialysis in the very near future. Individuals who need dialysis have been determined by their physician/nephrologists to have end stage renal disease (ESRD) and thus, are potential candidates for a transplant.

Each year, the number of patients needing kidney transplantation increases while the number of cadaver donors has remained about the same. Recent studies show that patients who receive a kidney transplant not only have an improved quality of life but also live longer as a result of transplantation. Studies also show that patients transplanted before the initiation of dialysis or within the first six months of dialysis actually have improved outcomes.

Living donation has been successful because the risk of death and the risk of disease (to the donor) are very low. Donor selection is very important to ensure minimal risk to the donor. It is important for the transplant team to evaluate a donor’s overall health to determine that if it is satisfactory and to provide a safe surgical procedure.

Types of Living Donor Transplants
Living Related Donors - Individuals who are blood relation to the transplant recipient such as a parent, aunt, uncle, brother, sister, nephew, niece, etc.

Living Unrelated Donors - Individuals who are not a blood relation to the transplant recipient and may include a spouse, friend, neighbor, co-worker, brother-in-law, sister-in-law, etc.

Anonymous Donors - Individuals who offer to donate a kidney to an individual who is listed on the waiting list that they do not know. Their donation is made “out of the goodness of their heart” and with no financial gain. Anonymous Donors can further be defined as follows:

• Altruistic/Good Samaritan – an individual who wishes to donate to the general pool with no specific recipient in mind.
• 3rd Party Donor – a relative or friend who wishes to donate but is unable to due to incompatible blood type or cross match. Instead, this individual can donate to the general pool, which in turn gives their friend or relative extra points on the list to improve their chances for a transplant (with a cadaver donor).
• Paired Exchange – an individual wishes to donate to a relative or friend but cannot because of incompatible blood types or cross match. If another pair is found in the same circumstance, an exchange may be possible between the two pairs.

Surgical Approaches for Living Donors

Traditional Kidney Transplant
A kidney transplant is performed by placing the kidney on the right or left side of the lower abdomen. An incision is made to implant the new kidney, attach it to the necessary blood supply and to the bladder for urine drainage. Generally, the native kidneys are left in place, however, exceptions to this may be made in the event of infection, the potential for infection, the presence of cancer, and in some cases, if a patient has very large kidneys as seen with patients who have polycystic kidney disease.

Open Donor Nephrectomy
An “open” donor nephrectomy is done through a flank incision either on the left or the right side of the abdomen, just above or just below the twelfth rib. This type of donor nephrectomy is considered the standard or traditional method of removing a kidney and can be fairly painful. Average length of stay in the hospital is four to five days and return to work after discharge can be four to six weeks, especially if the job involves heavy lifting.

Laparoscopic Donor Nephrectomy
Laparoscopic donor nephrectomy is a procedure in which the kidney is removed from the donor through several small (approximately one-inch) incisions. The operation is performed with the aid of a camera, which is inserted through one of the small incisions. Pencil-thin instruments are inserted through the other incisions. At the end of the procedure, the kidney is removed through a five- to seven-inch incision that extends slightly above and slightly below the belly button.

The potential benefits of removing the kidney laparoscopically (instead of the traditional “open” procedure) include less post-operative pain, a shorter hospital stay and overall quicker recovery time. The average length of stay after laparoscopic donor nephrectomy is about three days and most donors are ready to return to work in three to four weeks. A donor whose work involves heavy lifting is still required to recover for six weeks before returning to full duty. However, many times employers will allow the donors to return to “light duty” until their six-week recovery is completed.

Individuals interested in being considered as potential living donors should contact the Transplant Office at The Nebraska Medical Center and ask to speak to the Donor Coordinator. The Donor Coordinator will complete a short questionnaire and answer your questions. A packet is then mailed to you that includes educational material for the donor as well as questionnaires that need to be completed and returned to the Transplant Center. After questionnaires have been reviewed, the donor will be contacted to start the evaluation process.

Deceased (Cadaver/Cadaveric) Donor Kidney Transplants

Deceased (Cadaver/Cadaveric) Donor Kidney Transplants are done when a patient on life support has been determined to be brain-dead and the decision is made by the family to donate the kidneys to someone on the waiting list.

Kidneys are distributed to patients on the waiting list through the United Network of Organ Sharing (UNOS). Kidneys are distributed by a point system which is calculated by the length of time a recipient has been on the waiting list, how well the donor matches the recipient, emergent status of the recipient as well as whether the patient is a pediatric patient.

Kidney/Pancreas Transplantation (Simultaneous Kidney/Pancreas)

This dual transplant is considered when an individual with Type I diabetes mellitus has developed kidney failure as a result of diabetes and has completed a transplant evaluation and found to be an acceptable candidate for the combined transplant. The patient is placed on the deceased (cadaveric) donor list and receives a kidney and pancreas from the same donor.

Types of Kidney/Pancreas Transplants

Living donor kidney transplant followed by pancreas after kidney transplant:
Many times the waiting time for a transplant is very long (up to two to three years) for the combined kidney/pancreas transplant. If a patient has an acceptable kidney donor we can proceed with living donor kidney. When the patient recovers from this surgery, they are placed on the waiting list for a pancreas (after kidney) transplant.

Deceased (cadaver) donor transplant followed by pancreas after kidney transplant:
Patients who do not have a living kidney donor possibility and who may be anxious to obtain a kidney transplant have the option of being listed for a kidney or kidney/pancreas, whichever comes first. In the event that they receive a deceased (cadaver) donor kidney transplant, they can be reactivated on the waiting list for pancreas (after kidney) when they have recovered from the kidney transplant.

Steroid-Free Protocol

The Nebraska Medical Center Kidney and Pancreas Transplant Program instituted Steroid-Free Protocol in 2001, which eliminates the use of steroids during the transplantation process. Most patients are candidates for this process. Steroids are responsible for many long-term side effects including: weight gain, moon face, acne, osteoporosis, deterioration of the joints, elevated blood sugars, development of diabetes, cataracts, gastric ulcers, and increased cardiac risk, among others. Eliminating steroid use by using newer, equally effective immunosuppression agents can provide tremendous benefits to the patient without the increased risk of rejection.

Steroids (corticosteroids, prednisone, deltasone, medrol) have been used in organ transplantation for many years and have served as a critical agent to prevent rejection, making transplantation possible. New immunosuppression (anti-rejection) agents have lowered the risk of rejection and furthered the success of transplantation. With the lowered risk of rejection, emphasis has been placed on improving the long-term wellness in transplant recipients.