To become a live kidney donor a person must aquire a lot of research and knowledge.  There are several things to consider and guidelines for follow.  The decision to participate in kidney transplantation should not be taken lightly.

Before we get into the nitty gritty of transplantation, perhaps we should briefly go over the basics of what kidnes are and what the do.First off, there are 2 kidneys which are located on either side of the spine at the bottom of the ribcage. The kidney performs several functions to keep us alive.  These functions are:

-Cleaning waste from the blood

-Control the making of red blood cells

-keep water and chemical balance

-help keep bones healthy

-remove extra water from the body

-release hormones that control blood pressure

They filter about 50 gallons of fluid every day to clean the blood, most of which is reabsorbed by the body.  What isn’t reabsorbed is mixed with filtered waste and makes urine.

Urine passes from the kidneys through tubes called ureters that connect the kidneys to the bladder where it is stored.  When the bladder is full, the urine is carried out of the body through the urethra during urination.

 
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Now tha we have gone over what kidneys are and how important they are for survival, do we know what happens when they fail?  There is a build-up of waste products which will make a person very ill and ultimately die.  The build up may cause shortness of breath, weakess, confusion and lethargy.  Though, in the beginning of kidney failure, there may be no sumptons at all.  Blood tests to measure creatine, BUN and Glomerular filtration rate are needed to diagnose failure.  Failure can occur from a number of conditions such as acute situations or chronic problems.   Kidney function that is lost rapidly is known as acute renal failure.  It canoccure from a variety of causes.  The causes are categorized on where the injury occurred.  When failure occurs, there are a couple of treatment options.  One is dialusis where a surgeon will make a fistula using the patients own blood vessels to connect an artery directly to a vein, usually in the forearm.  This will be connected to a machine that ceans the blood as it is circulated through and then returned to the body.  Treatments are usually a few hours long 3 times a week.  Dialysis is a treatment but not a cure.  It will prolong life by cleaning out the toxins from the blood, but can not produce the hormones needed to sustain life.  To truly have a chance to return to a healthy life, a new kidney is needed through transplantation.  For a transplant, there are 2 kinds of donors: living donors, as the name implies, is still alive and healthy.  Transplant is scheduled n advance for a time that is convenient for both donor and recipient and while all people involved are in good health.  Non-living donors are people who have died but had working kidneys. 

Who is eligible to make the decision?  Depending on their health, donors must be beteween the ages of 20-70, must be in good pusical and emotional health with normal kidney function, and must have a minimal risk of any financial difficultiesfrom being out of work for recuperation and healing.  Health insurance is highly recommended, though, the recipeints health insurance will be billed.  More on the financial responsibility later.  A strong support system is alsonneccessarey.  Some things that would disqualify aerson from becoming a donor are:

-diabetes or testing positive on a Glucose Tolerance Test

-active hepatitis B, hepatitis C or hepatitis C antibody positive

-a body mass greater than 35

-HIV

-less that 20 years of age

-coronary and /or Peripheral Vascular Disease

-psychologically or socially maladjusted or incapable of maiong decisions

-polycustic kidney disease * fi there is a family history, a person may still donateif under 30 years old and no cysts on the kidney

-cancer or pre-cancerous lesions

-payment or coercion in any form

Of course, these are just some of the possible examples, there may be other circumstances not mentioned that may prevent a person from becoming a donor.

 
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Let’s talk about the reason for this paper, the decision to become a live donor.  First and foremost, the decision must be voluntary and free from any kinds of pressure, family or otherwise.  The decision must be fully informed, educated and not taken lightly.  At first there will probably be a lot of mixed feelings and what if’s   That’s completely normal and good.  It shows that there is thought put into the decision.  If after talking with the donor coordinator about risks and benfits and facts, an individual deciedes to become a donor, its for a good reason.  It will potentially extend and improve the quality of the recipients life.  One thing to keep in mint though, transplantationis an elective surgery as a treatment for kidney disease, not a cure.  Most transplant patients do well, but some are not successful. Donation should not significantly change the donor’s  life.  I shoutl not shorten the length of itorincresase the chances of getting kidney disease the reamiaing kidney.  A donor advocateisassigned to all living donors as a representative for them.  Their primary responsibilithes are to advise the donor. Prtect and promote the donor’s interests, and to ensure that the decision to donate is informed and free from coesrion.  He donor advocate will be available throughout the entire donation process.  The donor may decideto not donate at any time, the trean;lant team will fully support the decision and notify the recipient but will not tell the reasons for the decision.

Before the donor evaluation process even begins, it is vital that the potential donor provides all medical health information.  The information that may be required are:

-a physical within the past 12 month which includes height, weight and blood pressure blood work showing the results of chemistry panal, fasting blood sugar, fasting lopidpanal , CBC, PSA for all males under 50 years old if deemed necessary.

-a recent pap smear for all woman

-a recent mammogram for all women over 40

-a colonoscopy of over 50 or younger is needed

-a cardiac stress test

If the donor meets the critiera for donation, the next step is to see if they are a match.  A blood test called tissue typing is required to check compatability.   It is used to identify  the donor’s blood type and measure cell marker called antigens that exist on the surface of white blood cells.  Checking antigens can tell if the donor kidney is compatible for transplant for the recipient.  Half of a person’s antigens are from their mom, the other half from dad, everyone has a unique pattern where siblings have a 1 in 4 chance of an identical match.  The closer that the donor’s antigens match with the recipient’s, the lower the chances the donated kidney will be rejected. Though, all is not lost if the antigens don’t match due to andvances in immunosuppressive medications.  The most important thing  is the next step, the cross match.  In cross matching, blood cells from the repient is mixed with blood cells from the potential donor to see if the recipient has developed antibodies against the donor’s cells.  If there is a positive cross match, the donation can not move forward because the kidney will be rejected by the recipients body.

 
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So, the blood tests prove a match.  What happens next?  The living donor evaluation process begins once the recipient is accepted into the program.  The donor evaluation is very thorough and done for the purpose of checking the donor’s physical, emotional, and financial capacity to be a donor.  It is important to check for risk factors that may cause kidney disease later in the donor’s life.  The donor will be asked about their financial situation as well as their emotional and physical help support which will be needed through out the entire donation process.  And of course, all personal information is confidential.  The donation evaluation process has 3 phases.  Phase 1 is where the potential donor goes over all the information that’s in the donor Information Packet and they complete the required forms and return them to transplant center.  Once the forms are received, a phone interview with the donor coordinator is scheduled.  While waiting for the initial interview, the potential donor should get all their health records up to date .  Phase 2 is where the interview is completed and all mandatory health records are received.   The remainder of the evaluation will not begin until all records are reviewed.     Tissue typing to check for compatibility is also performed.  Phase 3 includes the following items:

-fasting and non-fasting blood tests.  One of which includes a screening for transmissible diseases.

-CT angiogram of the abdomen so the surgeons and physicians can see the kidneys and surrounding blood vessel supply.  They will also determine which kidney will be the one used for the donation

-urine tests to evaluate kidney function

-chest rays and ekg to screen for heart and lung diseases

-evaluations where the donor will meet with each transplant team member such as: the independent living donor advocate, living donor coordinator, nephrologists, social worker, dietician, financial coordinator, psychologist, and surgeon.

After all testing is complete and results received, the evaluation is sent to a multidisciplinary team for review.  When they approve it, surgery is scheduled. 

Now that surgery is scheduled all there is left to do is wait, right?  Not even close.  There are certain events that take place before the big day.  One is a pre-operative history and physical is performed with the transplant surgeons.  They will review past medical history and describe the method of surgery that will be used.  They will also discuss which kidney will be removed.  The risks of the surgery will be discussed and a consent form authorizing the surgeon to perform the surgery must be signed withing 30 days of the scheduled surgery.  Another is an appointment with the donor coordinator for pre-operative instruction that will explain bowel prepatartion for surgery, where to go for surgery, what to expect the morning of and during the hospital stay.  Also, the follow up appointment will be scheduled.  A final cross match needs to be performed within 5 days before surgery to be sure of compatibility, in rare occations the recipient may develop the antibodies against the donor. 

 
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Here it is, the big day.  Upon the donor’s arrival to the hospital where they can expect to stay for about 3 days, they will begin the admission process.  An IV will be placed along with other preparations for the surgery.  When the time comes, the donor is put to sleep using anesthesia and a catheter is placed in the bladder for the medical staff to monitor urine output for 24 to 48 hours after surgery.  The surgeon will use a technique called Hand Assisted Laaroscopic  Donor Nephrectomy which is less invasive and has a much faster recovery time.  He will make 3 incisions, a 7 centimeter incision around the naval where the kidney removed from and 2 ½ inch incisions on the left side of the abdomen where the instruments and a video camera are put through. Carbon dioxide is pumped into the abdomen to make space so the surgeon has room to work.  Surgery is rarely done with an open incision nowadays, but if difficulties do arise, the incision around the belly button may need to be enlarged.  The procedure will take roughly 3 to 4 hours, recovery will be anywhere from 1 to 4 hours, and then back to the hospital room where the donor will be greeted by a specialized transplant nurse and patient care aide.

During the hospital stay, several things must be done for recovery to go smoothly.Walking soon after surgery is very important, it helps the bowel function to return to normal, aids breathing and improves circulation.  The donor will be encouraged to get out of bed and walk a bit as early as that evening or the next morning.  Coughing and deep breathing using a breathing machine called an incentive spirometer will promote full lung use and prevent respiratory problems.  And while laying in bed, a devise called a pneumatic antiembolism stockings will be put on the lower legs.  They help with circulation by giving intermittent compressions to prevent blood clots from forming.  Pain control will be provided to help speed up recovery.  Nobody feels like doing much when they are in pain.   Diet will be clear liquid until bowels return to normal usually about 2 days after then the donor can eat normally.  Fatigue is a common side affect and will get better with plenty of rest, eating well, and lots of fluids.

Yay!  It’s time to go home!  No driving though, until the physician in the post transplant clinic gives the go ahead, usually about 10 to 14 days post op.  Walking and climbing stairs shouldn’t be too much of a problem.  In fact, it is encouraged for faster recovery.  No lifting more than 10 pounds or strenuous activities for at least 6 weeks.  A normal diet can be followed as long as it doesn’t cause constipation and drinking at least 80 ounces of water is imperative.  Always call the transplant physician if there are any complications, things to watch out for are:

-nausea lasting more than 12 hours or vomitting

-burning or difficultly passing urine, decreased urine flow or blood in the urine

-fever over 101

-no bowel movement after 5 days despite using a laxative

-chills, cough, or feeling weak

-severe pain that does not respond to pain medication

-incision becomes open, swollen, red, warm, has increased drainage, or has a rash

The donor must also keep all follow up appointments.   The first will be 10 to 14 days after the surgery, then 1, 3, 6, 12, and 24 months after.  They are necessary to monitor health and collect data for research.  The data will be sent to UNOS.

So, who pays for all of this?  The recipients health insurance pays for the evaluation and surgery.  Routine maintenance is the donor’s and their insurance’s responsibility.  It is strongly recommended the donor have health insurance, in fact, not having it may disqualify the donor from being eligible.  The donor will NOT be paid for the kidney.  It is illegal to knowingly receive any human organ for valuable consideration for use in transplantion.  Though, recipients are allowed to reimburse the donor for expenses incurred that includes travel, food, lost wages, or housing.  There is also federal assistance through the National Living Dnor Assistance Center available for donors who meet the requirements.

As you can see, being a live kidney donor requires extensive knowledge and research.  The decision to become a donor is a big one, but is highly rewarding.

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