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The Gift

At this stage, you've passed the donor evaluation, and it's time to donate. A date for the surgery is scheduled. Note that the date will depend in part on the health of the recipient since he or she must be able to withstand surgery, too. You will be put on eating and drinking restrictions and may be instructed to take a laxative the day before.

Here are some tips for preparing for and recovering from surgery in the hospital: Surgery Tips. And here are suggested questions a prospective living organ donor might ask of medical professionals: Questions.

You and the recipient will be admitted to the hospital the day before or the morning of the surgery. On the day of the surgery, you'll be "prepped," which may involve inserting an IV, dressing in a hospital gown, even taking a mild sedative. You'll be wheeled into the operating room. The surgeon greets you and the nurses get you situated for the surgery. The anesthetist starts the anesthesia through the IV, you count backwards, and "away we go."

While you're unconscious, the surgeon will follow one of two procedures:

• Open nephrectomy. This procedure, which is the older form of surgery, involves making an incision of several inches—as long as 10 inches—from the left side (assuming the left kidney is taken) along the bottom of the lower rib to the midriff. That's right—it's not along the back, it's on your stomach.

  There is an alternative open nephrectomy procedure that begins the incision further on the back along the side to the front (a flank incision), but a portion of the rib may have to be removed. You may be offered a choice between these alternatives.

  Regardless of the alternative, the incision requires cutting through three layers of muscle. Once access to the kidney is gained, the arteries and ureter are clamped off. The kidney is removed, flushed, and placed in a cold preservative solution. You may receive a blood transfusion during the operation, but such transfusions are rare.

• Laparoscopic nephrectomy. This procedure uses a laparoscope—a device inserted into the abdomen allowing the surgeon to see and operate. This technique involves making several small (a couple of inches each) incisions in your abdomen, called "ports," to allow insertion of a laparoscope and other instruments. The camera and instruments are used to cut the kidney away from surrounding tissue after clamping off the arteries and ureter. The kidney is removed through an incision below your belly button. Then you're closed up. (Note that donation of the right kidney is more complicated because the liver is in the way, therefore an incision may be made in a different area of your abdomen.)

Medical studies have compared the effect of open and laparoscopic procedures on donors and have generally found that the laparoscopic procedure results in less pain, shorter hospital stays, and faster recovery and return to normal activities. Here are the results of a study (Waller, at al., 2002) comparing the recovery times for 20 "laparoscopic" donors to 34 "open" donors in the United Kingdom:

Results favoring the laparoscopic procedure were also found in a Johns Hopkins study (Ratner, et al., 1999) comparing 25 laparoscopic donors to 37 open donors:

This study also found no significant differences in the results for the recipient. Surgical complications, rejection rates, need for dialysis, and hospital stays where comparable for an organ donated by the open or laparoscopic method.

There are data showing a slightly higher incidence of complications to donors arising from laparoscopy, but the difference is very small. (See the summary of medical studies below.)

Laparoscopic nephrectomy is now the more common form of surgical procedure. There are also variations, such as "hand-assisted laparoscopic" and "mini-open" nephrectomy that incorporate features of both laparoscopic and open nephrectomy. In a very limited number of situations, the surgical team will shift from a laparoscopic procedure to open nephrectomy if complications arise during the laparoscopic procedure. The incidence of switching from the laparoscopic to open procedure was 2.1% in a study of 381 procedures at Johns Hopkins over a six-year period from 1995 to 2001 (Su, et al., 2004).

Surgery takes about three to four hours. (Surgery under the laparoscopic method may be at the high end of that range.) After surgery, you are moved to a recovery room for several hours. Once you regain consciousness, you will be wheeled into your hospital room. Your ability to go home is a function of your ability to deal with the pain and your recovery from the general anesthesia.

You are helped in dealing with the pain with medication, such as a morphine drip. (Don't worry about addiction; the dosages are tightly controlled.) The other "pain" you'll deal with is those nicely nagging nurses who will aid with your recovery. They'll insert and maintain an IV for nourishment since your gastrointestinal tract is "sleepy" from the anesthesia. A catheter is inserted to remove fluid from your bladder. (The output is measured to ensure your remaining kidney is functioning adequately.) Special socks will be put on your legs to aid circulation and prevent clotting. And you'll be asked to inhale deeply, using a special device, to reduce the risk of pneumonia. You'll be encouraged to get up and walk as soon as you're able. Besides you'll be bored out of your mind and will welcome the diversion of a scamper around the nurses' station with your IV in tow and your gown giving a show!

Once your GI tract is operational (you can defecate and urinate on your own), you are mobile, and you can manage any pain, you can go home. Generally, recovery—from the time of surgery to the time of your discharge—is three to four days. You will likely be unable to perform any work, especially heavy lifting, for about six weeks.

Regardless of the procedure, there are risks to the donor during surgery. These risks are small and manageable, but in the interest of full disclosure, here are the possible complications and consequences:

• Pain. This is a certainty. Pain is managed through medication after surgery.

• Infection. The wound(s) from the incisions could become infected, delaying the healing process, causing scarring or herniation. Antibiotics are used to treat any infections.

• Pneumonia. You will be asked to cough and breath deeply following surgery to combat the risk of pneumonia as a consequence of the anesthesia. You may be given a device to encourage deep breathing—inhaling deeply to suspend some balls in chambers of the device—and told to use it several times a day while in the hospital.

• Blood clotting. As with any surgery, blood clots in the legs can be a problem. To prevent clotting and related complications, circulation in the legs is aided at first by special stockings you wear while in bed. The stockings are hooked up to a machine which inflates the stockings periodically, applying pressure to your legs and improving circulation. Once you are able, you will be encouraged to walk around, which also stimulates circulation.

• Allergic reaction to anesthesia. Part of the screening process includes identifying allergies you may have. In the event of an allergic reaction to anesthesia, the anesthetist will take immediate corrective action.

• Death. It happens. Fortunately, it is exceedingly rare. The generally accepted rate of mortality risk is 0.03% (that's three deaths for every 10,000 procedures.)
  

Research shows that the risk of death exists and is very small. The risk of any complication ranges from 2% to 16%, depending on how complications are defined. Major complications occur at a rate of about 2% - 6%. Below are summaries of medical research studies covering the risks and complications from living kidney donation. If you need help understanding the terminology,  click here to open Google, then type "definition [word]" (without the quotation marks) in the search box, where "word" is the word or words you'd like to have defined.

• Matas, A.J., et al., 2003. This extensive study surveyed 171 transplant centers asking about morbidity and mortality after living kidney donations from 1999 through 2001. The results cover 10,828 living donor nephrectomies. Generally, the study found the risk of mortality at 0.03% and the risk of complications, mostly minor, in less than 10% of donors. Here are more details on the findings:

• Death: two donors (0.02%)

• Persistent vegetative state: one donor (less than 0.01%)

• Re-operation: 66 donors (0.61%). Causes for re-operation included hernia, bleeding, bowel obstruction, and bowel injury.
  

• Complications not requiring re-operation: 65 donors (0.60%). These complications included bleeding, rhabdomyolysis, deep vein thrombosis/pulmonary embolus, pneumothorax, and prolonged ileus.
  

• Readmission rate: 2.2%. Reasons for readmission included nausea and vomiting, constipation, diarrhea, and wound infection.

• Su, Li-Ming, et al., 2004. This study evaluated trends in morbidity among 381 laparoscopic nephrectomies at Johns Hopkins between 1995 and 2001. Note that the study looked only at laparoscopic procedures. The total complication rate was 16.5%, with about half of those complications being major and half being minor. Researchers also noted that the laparoscopic procedure was switched to the open method in 2.1% of the cases. Here are more statistics from the study:

• Re-operation rate: 1.8%

• Transfusion rate: 3.4%

• Major complications: 7.6%. These complications included renovascular injuries, bowel injuries, and hematoma.

• Minor complications: 8.9%. These complications included wound infection, transient neuromuscular injury, epididymitis/urinary tract infection, orchalgia (chronic pain of the testicles and scrotum), retroperitoneal hematoma, and splenic capsular laceration.

• Siebels, Michael, et al., 2003. Researchers in Germany evaluated the risks and complication of living kidney donation based on the experience of almost 160 nephrectomies.  The donations were made between 1994 and 2001. There were no deaths and 41 (25.6%) complications, with 35 (21.9%) minor and six (3.8%) major.
  
  Minor complications included urinary tract infection (10%), unknown fever (4.4%), splenic hemorrhages (3.1%), blood transfusion (3.1%), and pneumonia (2.5%). Major complications included one case each of splenectomy, liver bleeding, incarcerated umbilical hernia, infected pancreatic pseudocyst, pneumothorax, and acute renal failure.

• Shaffer, David, et al., 1998. This older study reviewed the morbidity (but not mortality) of 201 living-donor kidney transplants between 1988 and 1997:

• Major complications: bleeding (0.5%),  pneumothorax requiring a chest tube (1%), wound infection (1%), and pneumonia (1%).

• Minor complications: asymptomatic pneumothrorax resolving itself spontaneously (10%), urinary retention (6%), and urinary tract infection (0.5%).

• Friedman, Amy, et al., 2006. The final study looks at a specific form of complication in living kidney donation--hemorrhaging. The study is based in 213 surveys of transplant surgeons. The respondents reported 105 incidences, of which 66 were arterial and 39 were venous . Of the arterial episodes, two resulted in donor death, two resulted in renal failure, and 19 required transfusions. Conversion from laparoscopic nephrectomy to open nephrectomy or late re-operations for hemorrhage were reported in 29 cases.

  
  Hemorrhagic complications were found to occur in both open and laparoscopic procedures, with the use of locking and standard clips applied to the renal artery being associated with the greatest risks.

Our hope is that research on perioperative and post-operative complications will continue, with more extensive participation and deeper analysis. We believe this kind of information is necessary for potential living donor to be sufficient informed for "informed consent." LDO will keep a watch out for additional medical research on this subject as it becomes available.

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