In order to undergo kidney transplantation, a number of steps and procedures must be followed to ensure a successful transplant process. These steps include:
The Transplant Process
Patients are usually referred to us by their nephrologist or their dialysis center social worker. We do accept self-referrals!
Patients referred are either already on or are approaching dialysis. For patients not yet on dialysis but with established, moderate-to-severe renal insufficiency, our goal is to fast-track listing to avoid initiation of dialysis.
Patients are encouraged to seek transplant evaluation as soon as diagnosed with moderate renal insufficiency. This is to establish records and plan on possible preemptive transplant if a live donor is available. In case of no potential live donor, we can assist in evaluation for listing in deceased donor kidney list.
The Work up Process
After successfully completing your initial pre-transplant evaluation, your transplant coordinator will begin scheduling appointments for testing and procedures needed prior to transplant. Some of these tests or procedures will need to be updated annually. Your transplant coordinator will notify you when a test or procedure needs to be updated. It is important to keep up with your tests and procedures so that you can be transplanted when you get the call.
- Simple blood tests including blood typing
- Chest x-ray
- Dental exam
- Abdominal Ultrasound
- Coronary Angiogram (for all patients over 45, diabetic, or risk factors/history of heart disease)
- Cardiology consult (if you have risk factors, are diabetic or over age 45)
- Colonoscopy (for all patients over the age of 50)
- Mammogram and Pap smear for all women over the age of 40
- Recent Prostate Specific Antigen (PSA) for all men over the age of 40
All patients will be presented at the Patient Selection Committee Meeting (PSC) after they have completed all their testing and have been seen by the multidisciplinary transplant team.
The purpose of the PSC is to review the results of testing, discuss visits with the multidisciplinary team, and to determine if they qualify for placement on the transplant wait list.
The results of the PSC discussion will be conveyed to the patient and referring physician within 10 days.
If you are approved and cleared by the multidisciplinary team in PSC, you will be added to the National Waiting List for pancreas transplant. You will be placed on the waiting list based on your blood type and antibody test.
The national organ waiting list is managed by an organization called the United Network for Organ Sharing (UNOS), a private, nonprofit agency that works with the federal government. UNOS keeps track of all the people in the United States who need pancreas transplants, and matches them with donors.
If you are not approved for listing at the time of PSC, your transplant coordinator will explain any additional testing or requirements to get you listed for transplant. On some occasions, you may not qualify for transplant. Your coordinator will explain in detail as well as send a letter to your primary doctor explaining the reasons you cannot be transplanted at this time.
When a suitable donor is found, the surgeon and coordinator will first review donor history and testing results. If the offer is suitable for you, the surgeon will give the OK to admit you for your transplant. In some cases, the surgeon or transplant coordinator may call and discuss the organ offer with you.
Getting the Call
Once you have received a call from the coordinator and you have accepted the organ offer, you will then be instructed to arrive at St Vincent as soon as possible. Please drive to St Vincent with as many important members of your family as necessary.
Your coordinator will ask you the following questions:
- What time did you last eat or drink anything?
- When was your last dialysis session?
- Have you had any recent admissions to the hospital or new health problems?
- Have there been any changes to your life situation (ie, support, financial, or emotional states that may impact your post-transplant care
Once these questions have been answered, you coordinator will instruct you not to eat or drink anything and come to the hospital. If you are diabetic, please inform the coordinators so that instruction about medication dosing can be given. You should bring all current medications and a bag with a set of clothes and other essentials for hospital admission.
Arrival to the Hospital
We strive to proceed with transplant ASAP, however we realize there may be need for further evaluation and or need for dialysis . You will be directed to Admissions and then the floor for nursing assessment, have some additional testing done including blood work, EKG, and chest xray, and any other testing that needs to be updated since your last clinic visit. You may require dialysis prior to your transplant. The transplant surgeon will order dialysis if needed.
On arrival to the hospital, you will be greeted by your surgeon. He will prefer to speak to you and your family members about the details of the process, including risks and benefits.
The Transplant Operation
When everything is ready, you will be taken down to the operating room. By this time your surgeon has already prepared the organ for transplant. (Please note: on rare occasions- an imported kidney once evaluated by your surgeon may not qualify as suitable for you and thus a last minute cancellation and discharge home for a better transplant is possible. But don’t be discouraged if this happens–the intent is to assure you receive the best organ possible!)
If the organ is suitable, you will be escorted into the preoperative waiting suite. There, the anesthesiologist will greet and evaluate you. Once complete, you are transferred to the operating room. The process of anesthesia and IV line placement can be 1-2 hours depending on your general health condition and ease at establishment of IV access. Surgery commences upon incision and is terminated upon closure of skin. Surgery time is in general 2-3 hours.
A 6-8 inch incision is made in your lower, front abdomen, and this is where your new kidney is transplanted. The new kidney comes with blood vessels that are connected to the blood vessels that supply and drain blood in your legs. The ureter is a long tube portion of the kidney that drains urine. This tube is connected to your bladder. After sewing the ureter to your bladder, we leave a plastic tube or stent, 4 inches in diameter, and thinner than a spaghetti noodle in place. This tube assists in the healing of your bladder and is removed within 4-6 weeks of your transplant at the office under a simple office bladder camera procedure. This procedure is fairly painless and takes no more than 3 minutes.
We do not remove your own kidneys unless there are indications to remove them. Indications for removal of your own kidneys (one or both) include: kidneys that have growths suspicious for cancer, kidneys that contain infected stones, kidneys with many cysts that frequently bleed or lead to urinary tract infections or kidneys that are too large to allow room for implantation of another kidney.
After successfully receiving a transplant, our job is not done. A transplanted organ requires periodic maintenance and follow-up care to make sure both the organ and the patient continue to thrive!
Once surgery is complete, you are then awakened and transported to the recovery room or directly to the Intensive Care Unit , which is located on the 4th floor.
Your surgeon will have spoken to your family and they should be able to visit you within 1-2 hours of arriving at the ICU, Once your doctors consider your condition stable they will then transfer you to the 5th or 7th floor.
In general by now you will be free from most IV lines and allowed to eat and ambulate. During surgery a catheter will be placed into your bladder to drain urine. This catheter is removed on post op day 3-4. On rare occasion depending on your condition- the catheter may stay longer or you may even be sent home with a catheter to have a voiding trial later at the clinic.
By post-op day 4-5 you are ready for discharge. Instructions include:
- Avoiding excess water intake.
- Avoiding any food products with high potassium.
- Resuming diabetic diet and care if diabetic.
- Appropriate precautions for infection control.
Possible complications following kidney/pancreas transplant include:
- Clot in the kidney: Usually noted within the first 24-48 hours post-op, and can present with sudden abdominal pain and an acute rise in your blood sugars. The treatment for this condition is unfortunately removal of the pancreas or kidney, and we are not able to salvage an organ under these circumstances. You may in the future qualify for a second transplant.
- Delayed Graft function: Sometimes the transplanted kidney may not function immediately, and occurs in approximately 30-50 percent of deceased donor kidneys and less than 10% of live related or non-related kidneys. During this delay, the kidney is either making little urine or no urine at all, and you may need dialysis. Sometimes you may be discharged home on dialysis as we monitor improvement in your kidney function over time.
- Post-op pain
- Post-op bleeding requiring blood transfusion
- Infections that may include large abscesses which require wash out procedures and placement of drains.
- Urine leakage from the bladder suture line, for which you will be taken back to surgery for an attempt at correction.
- Hernia formation requiring surgical intervention.
Discharge from Hospital
Going Home from Transplant
During your admission to the hospital for pancreas transplant, the transplant coordinator will meet with you and your designated caregivers to discuss and educate you about how to take care of your new organ. A log book and manual will be given during your first teaching session.
You will be taught to monitor for:
- Signs and symptoms of rejection or infection
- How to record your weight, urine output, blood pressure, heart rate, and temperature
- The education sessions take place immediately after transplant, throughout your hospital stay, and upon discharge.
A transplant Pharmacist will review all of your new life-long medications to prevent rejection. All other medications you are taking will also be reviewed with you before discharge.
If you are diabetic or require insulin injections after transplant, a diabetes educator will review your insulin regimen with you and teach you how to inject insulin if needed.
24-Hour Nursing Care
A nurse is available 24 hours a day, 7 days per week including weekends and holidays. They can be reached at (213) 484-5551. The nurse can answer any questions you have related to transplant and call your doctors with any urgent needs.
The first 90 days
After leaving the hospital, you will follow up in the transplant clinic closely, as frequently as daily until you are stabilized. Labs are done every clinic visit in the morning before you take your medications. The transplant team will monitor your lab results, urinary output, vital signs, and incision closely to assure no complications arise.
What to bring to your clinic visit
- Your log book (tracks urine output, vital signs, and blood sugar if necessary)
- Medication list
- All your medication bottles
- Snacks, comfort items (pillow, blanket, books, etc) while you are waiting
At the end of your clinic visit, your transplant coordinator will review any medication changes and provide a new medication list, prescriptions and lab orders for the next visit. It may be necessary to call you at home with lab results. Keep your medication list with you and be prepared to write down any changes to your medications.
The First 5 years
Once you are more stable, you will be seen less frequently in the transplant clinic. You will need to follow up with your primary doctor 90 days after transplant and regularly after that. Your primary doctor will manage any related health issues such as high blood pressure and diabetes, and your regular annual health exam and cancer screenings. You will also need to follow up with any specialist physicians regularly such as Endocrinology and Cardiology.
What to bring to clinic
- Medication list
- Any new medications or changes prescribed by another doctor
- Any requests or orders from your primary or other doctor(s)
Five years and Beyond
Your transplant doctors will continue to watch for any signs of problems with your kidney. These can include:
1.Chronic Rejection: this occurs when your transplanted kidney slowly stops working. Usually, this type of damage may be caused by your immune system attacking the organ. Sometimes, other issues such as high blood pressure, diabetes, high cholesterol, or high levels of immunosuppressants, or the original cause of your kidney disease, may also slowly damage your new kidney.
2.Some of the most common symptoms of rejection include:
- Decreasing urine output
- Tenderness over the kidney
- Elevated blood creatinine level
- High blood pressure
3.Coronary heart disease
4.Cancers, including skin, breast, vulvar, cervical and colon cancer
A needle biopsy may be needed to find the reasons for ongoing problems with the pancreas transplant. Possible treatments for chronic rejection include different types of immunosuppression, steroids, or other medications.
Understanding Your Kidneys
The kidneys are 2 bean shaped organs located at either side of the spine below the rib cage. They are considered to be in the abdominal region of your body. The kidneys filter blood to produce urine, composed of wastes and extra fluid. They allow us to excrete waste.
The kidneys have 2 main functions:
Problems With Your Pancreas
Diseases of the pancreas can present with a variety of symptoms including abdominal pain, diarrhea, diabetes, or jaundice (yellowing of the eyes and skin).
Pancreatitis occurs when the pancreas becomes inflamed, which can be due to a variety of sources including alcohol use, gallstones, or medications.
What is pancreatitis?
Pancreatitis is inflammation of your pancreas which can cause leakage of pancreatic fluid into other parts of the pancreas or surrounding areas.
What are the signs and symptoms of pancreatitis?
Pancreatitis often presents with sudden severe pain in your upper belly. You may also experience nausea, vomiting, fevers, chills and upper back pain.
Why do I get pancreatitis?
The most common causes of pancreatitis are gallstones and alcohol. Other, less common reasons are certain medications and diseases that run in your family. If you have one sudden attack, you have acute pancreatitis. Multiple attacks are called chronic pancreatitis, and lead to permanent damage of your pancreas and its function.
How is pancreatitis diagnosed?
If you have symptoms of pancreatitis, your doctor may order blood tests or scans of your abdomen. Sometimes you may also need a procedure.
- Your doctor may check blood tests to look for an infection and check he function of your liver and pancreas.
- Abdominal Ultrasound to look for gallstones in your gallbladder.
- CT or MRI scan of your belly (or of the abdomen and pelvis) to look for gallstones and inflammation of the pancreas.
- An Endoscopic Retrograde Cholangiopancreatography (ERCP) can remove gallstones that cause pancreatitis. Your doctor can perform and ultrasound at the same time called EUS, which can look at your pancreas.
How is pancreatitis treated?
- Hospital admission and supportive care
- Surgery for Pancreatitis
Some patients with pancreatitis have to be admitted to the hospital. You will receive intravenous fluids and pain medications until your pain has gone away.
Some patients have more severe episodes of pancreatitis and might spend some time in the intensive care unit. Sometimes the treatment involves not eating which may require a feeding tube through your nose into your intestines until you get better.
Surgery for Pancreatitis
If you have gallstones, your gallbladder will be removed with an operation called a laparoscopic cholecystectomy after you have recovered from pancreatitis.