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Receiving a Kidney

What to expect after surgery

When the recipient wakes up after the surgery, he/she will have IVs in the neck and/or arm. The IV allows for enough fluids to keep up with the large amounts of urine usually made by the new kidney. Blood may be found in urine from the surgical connection in the bladder. If a clot were to form and block the catheter tube, the nurse will need to flush it. Medication for pain will be given to the patient for comfort.

During the first two days after surgery, the nurse will be checking blood pressure, temperature, pulse IV fluids and urine outputs. The patient will be taught to use a lung exerciser that will measure how deeply the patient is breathing and will help open up areas in the lungs. This helps prevents pneumonia and speed up recovery. The patient will be out of bed the day after surgery and should walk as often as possible. Each morning the patient’s blood will be drawn and they will be weighed.

The patient will be in the hospital for about seven to 10 days. Before the patient goes home, they will need to show our staff that they are able to:

  • Learn to take your medicines correctly
  • Make changes in your medication record accurately
  • Monitor fluid intake and urine output
  • Weigh yourself
  • State signs and symptoms of rejection and infection
  • Pass a basic transplant test
  • Know how to call your transplant nurse coordinator for any questions or problems

The UF Health Shands Transplant Center is open from 8 a.m. to 4:30 p.m. Monday through Friday. If an urgent problem occurs, your transplant coordinator is available outside of business hours. After the first six months following your transplant, you should consider calling your primary care doctor or local nephrologist with any medical problems. The transplant nephrologists and surgeons are available 24 hours a day to consult with any physician caring for you. These physicians can be contacted through
the hospital operator at 352.265.0111.

Medications

After surgery the recipient will be receiving medicines called immunosupressants to keep their body from rejecting the new kidney. Recipients will have to take these every day for as long as they have the transplant. Even if the transplant were to fail, we recommend for the recipient to remain taking small doses of the medication to prevent antibody formation. This may help with a second transplant in the future.

There are several different immunosuppressants and although a patient will not be taking all of these, they might be on a combination of them. Most patients go home on three of these medications.

  • PROGRAF (TACROLIMUS) – is taken twice a day. The side effects of this drug include headache, hand tremors, nausea, diarrhea, high blood pressure, increased blood sugar, increased potassium and decreased magnesium. Tacrolimus can also harm your kidneys over time, especially if the levels are too high. The dosing of this drug is based on the amount of drug in your blood. You must take care to dose it 12 hours apart and have your blood tests done just before your morning dose. This type of drug is called a calcineurin inhibitor. (do you want to add the extended release tacrolimus drugs here and just say it is the same tacrolimus mediation, but in a special capsule so it is released more slowly throughout a full day, so it is taken once a day. Envarsus and Advagraf)
  • CYCLOSPORINE (NEORAL, GENGRAF) – is taken twice a day. The side effects of this drug include high blood pressure, mild hand tremors, headache and increased growth of hair. Cyclosporine can also harm your kidneys over time. You must take care to dose it 12 hours apart and have your blood tests done just before your morning dose. Cyclosporine is closely related to tacrolimus, so you will not take both of these medications at the same time.
  • RAPAMUNE (SIROLIMUS) – is taken once a day in the morning. The side effects of this drug are ankle swelling, abdominal pain, nausea, diarrhea or constipation, joint aches, fever, headache, high blood pressure, anemia and high cholesterol and triglyceride levels. Blood levels are also measured for this medicine so blood test should be done before your morning dose. This type of drug is called a mTOR inhibitor.
  • EVEROLIMUS (CERTICAN) – is taken two times a day. It is related to Rapamune in how it works and its side effects.
  • CELLCEPT (MYCOPHENOLATE MOFETIL) – is taken two times a day. The side effects of this drug are diarrhea, nausea, vomiting, rash and low white blood cell count with increased risk for infection.
  • MYFORTIC (MYCOPHENOLATE SODIUM) – is taken twice a day and is very similar to Cellcept.
  • PREDNISONE – is a steroid and is often taken for the life of the transplant and is taken once a day. Some patients will suffer from difficulty sleeping or may feel “hyper” when taking larger doses early after the transplant. These feelings will pass in a few days and will decreasing the amount you take. The major side effects of long-term prednisone are increased appetite, stomach ulcers, osteoporosis, diabetes, cataracts, mood swings and Cushing’s syndrome. Cushing’s syndrome includes round cheeks, protruding abdomen, fat deposits over the upper back, acne, and increased growth of facial and body hair. Most patients are not on high enough doses to suffer from these side effects, and these side effects will decrease or disappear as the dose is decreased. After a few weeks, you are only taking about twice as much prednisone as your body makes naturally.

All the immunosuppressant drugs listed above work to prevent the patient’s immune system from rejecting the transplanted organ. These medications also make it more difficult for the immune system to fight bacteria, viruses and cancer cells, which puts you at higher risk for infection and cancer. The recipient will have to take antibiotics and antivirals for the first three to six months after transplant to help prevent infection and also have regular physicals with a primary care doctor for cancer screening, including screening for skin cancer, which is the most common post-transplant cancer.

In addition to the immunosuppressants and antibiotics/antivirals, the patient may also need to take other medicines to treat high blood pressure, diabetes or other conditions. Patients may be sent home with up to 12 medications after their surgery and must be committed to taking all of the assigned medicines. After a few months, most patients are on less medication after transplant than they were on dialysis.

Potential risks

With any procedure, there are possible complications. The following are potential risks related to the donor transplant graft, immunosuppression medications required to try to prevent rejection of the graft and possible complications if you require a blood transfusion.

  • Risk of rejection of the transplanted organ (this is not related to the surgery itself but with your immune system attacking the kidney)
  • Increased risk of infection due to the immunosuppressant medications
  • Any of the side effects of the immunosuppressant medications as previously discussed.
  • Very small risk for acquiring HIV/AIDS, Hepatitis B, Hepatitis C, other viruses or a cancer from the donor organ. Non-living organ donors are screened very carefully for these diseases by the organ procurement organizations, however, on rare occasion, the infections or cancers are not detectable and may be passed to the recipient.
  • Potential for a blood transfusion due to blood loss in the operating room and related risk for the transmission of infectious diseases from a blood donor. Blood donors are screened very carefully, but there may be a rare case when a disease may be undetectable and may be passed to the recipient. Few transplant recipients require a blood transfusion if they come into the operation with a good blood count, that is, that they do not have anemia.

It is usually not possible for transplant candidates to donate their own blood ahead of time, because we never know when the transplant will occur for patients on the wait list. Anemia is a common problem with kidney disease, which prevents donation.

Note: If you do not accept blood products due to your religion, your red blood cell count (hematocrit) must be greater than 36 at the time of transplant admission. Our surgeons feel that this requirement protects your safety and well being.

The following are potential complications due to any general anesthesia (going to sleep with a breathing tube in your throat during the surgery):

  • Chipped teeth, a sore throat or an injured vocal cord from the insertion of the breathing tube
  • Allergic reaction to medications used to put you to sleep
  • Risk of infection from the insertion of IV lines
  • Risk of a pneumothorax (collapse of the lung) from the insertion of a large IV line (used for giving fluids) that may require a tube placed next to your lung to allow this to heal
  • The possibility of requiring mechanical ventilation (a breathing machine or respirator) after surgery
  • Risk of death due to problems with the heart (such as heart attack or abnormal heart beats) or lungs (especially from a blood clot traveling to your lungs during or after surgery)

The following are complications that may occur in the operating room or after surgery and related to the surgical procedure itself:

  • Wound infection and/or hernia that could require another surgery to repair the hernia or clean the infection.
  • All surgical wounds have pain afterwards, which usually resolves over a couple of weeks. Occasionally, a local nerve may heal abnormally and give you persistent pain. These nerves can sometimes be injected directly by pain specialists several weeks after you recover from the transplant procedure. All surgical incisions have some numbness around them from cutting the skin nerves.
  • All surgeries will have some bleeding. Occasionally, you could require a blood transfusion as you will fill up the new kidney graft with your blood, and you will bleed some. Most patients therefore have a blood count decrease equivalent to donating one unit of blood and do not require a blood transfusion unless they have a low red blood cell count before surgery, or if they are on a blood thinner (such as coumadin, Plavix or others), or if they have significant hardening of the arteries and have a difficult blood vessel connection. You can also require return to the operating room to wash out blood clots and/or check for ongoing bleeding, especially when you have been on blood thinners or have diseased blood vessels.
  • Rarely, you can have a significant blood vessel problem during or after surgery. This is most commonly due to severe hardening of the arteries (atherosclerosis). In surgery, the surgeons need to clamp your blood vessels to temporarily stop the blood flow to the leg. Very diseased blood vessels may not open up normally and may not allow blood to flow normally after removing the clamps. This may rarely result in not enough blood flow to your leg and urgent surgery to restore blood flow to your leg. This is very uncommon and occurs less than once a year at large transplant centers. This may also result in loss of the kidney graft due to clotting.
  • The kidney graft may clot and be lost. This is uncommon overall, less than 5 out of 100 surgeries, but can happen more often when you have blood vessel disease, or when the kidney has more than one artery or a vein injury from the donor operation. When a kidney has more than one artery, the multiple arteries are smaller in size and more difficult to connect to your artery. Rarely, the vein allowing blood to leave the kidney may clot also. This is most often due to an anatomy issue from the donor.
  • For most patients, we make the incision from just above the bladder to just inside the hip in the lower abdomen, and we are usually able to stay around the outside of the intestines (outside the peritoneal membrane), and therefore have little to no chance of direct bowel injury. For some patients, we may need to enter into the middle of the abdomen and have a greater chance of injuring the bowel. This is especially true in patients who have previous transplants or prior blood vessel surgery.
  • Some patients may have pain or numbness on the thigh below the incision from irritation of a nerve that runs close to the blood vessels used to connect the kidney. This usually improves over several weeks.
  • If the kidney fails early, it may be removed with another surgery if your transplant physicians feel this is necessary, usually due to bleeding, infection or pain.
  • A kidney graft may not work at all after surgery. This occurs less than 5 out of 100 times, but it does happen to about four to five out of 100 patients in the United States. Most kidneys do work within a day or two after surgery, and more than 80 of 100 patients will leave the hospital in a week or less with the kidney working well enough to not require dialysis. Of the less than 20 of 100 patients leaving the hospital requiring dialysis, about 15 of these 20 patients will have the kidney wake up and work enough to get them off dialysis. The national OPTN/UNOS kidney allocation system will allow the four or five of 100 patients who do not have kidney function to get back in line on the waiting list where they were before this kidney transplant. That is, they will get their waiting time back. (If you lose your kidney graft due to rejection after the kidney was originally working, you may not get your waiting time back).

Potential complications with new kidney

  • Delayed Graft Function – Typically the transplanted kidney will make urine right away. In some cases, the kidney may have a delayed function after surgery. This is called a Delayed Graft Function (DGF) and usually results from acute tubular necrosis (ATN). DGF can occur as a result of factors related to the donor such as low blood pressure before donation. DGF may also occur if the recipient has a low blood pressure and/or unexpected bleeding during surgery or a biopsy.Sometimes the patient may have to just wait patiently for the new kidney to start working and may require dialysis for a few weeks or months. DGF is suspected when the creatinine does not fall quickly after transplant. The creatinine may decrease slightly each day, but if it remains high, there is no way to tell for sure whether rejection is also happening. If this happens, a biopsy is usually done so that the doctors can treat any rejection quickly.
  • Primary Non-Function – Primary non-function is when the transplanted kidney never starts to work. This can happen, but is rare. If this were to happen, dialysis is usually required in the first 48 hours after surgery and will continue to be required on a regular basis. Patients with primary non-function usually have a renal biopsy that reveals irreversible damage. In some cases the transplanted kidney needs to be surgically removed. Primary non-function does not prevent you from having another transplant, and the Transplant Center can request reinstatement of your original wait time allowing re-transplant to happen sooner.
  • Infection – Infection is a constant risk to transplant recipients. The immunosuppressive medications that you take to prevent rejection cause you to be at increased risk for infections. You will take antibiotics to prevent infection for the first three to six months after your transplant.
  • Dehydration – Dialysis patients are trained to avoid extra fluid. When you have a functioning kidney, restricting fluid can lead to dehydration. During summer months it is especially important to drink plenty of fluids because the water loss from heat/perspiration can cause dehydration and your creatinine to rise. Most adults with good kidney function will be encouraged to drink at least 3 to 3 ½ quarts (or liters) per day.
  • Urine Leak – The ureter is a muscle tube that drains urine from your transplanted kidney to the bladder. An incision is made in the bladder so the ureter can be stitched to the bladder. If the bladder becomes too full before the incision in the bladder has healed, then the ureter can pull away from the bladder and urine can leak out. If a urine leak occurs, the urine draining from your catheter will stop. Usually this occurs abruptly. As the urine drains into the area around the kidney, you may develop pain. The only treatment for this problem is an operation to reconnect the ureter.One of the reasons that you will have a catheter is to keep the bladder from becoming too full. Once your catheter is removed, it is important for you to go to the bathroom frequently during the first few days to prevent the bladder from becoming very full. Most patients will feel the urge to go to the bathroom frequently because the bladder shrinks over time when your kidneys do not make urine. When the transplanted kidney produces large amounts of urine, you may feel like going to the bathroom often. After you leave the hospital, the end of the muscular ureter can scar down and close off blocking urine from leaving the kidney by what we call a stricture. If this narrowed area is very short in length, it can sometimes be stretched by a balloon placed across it by the radiologists going through the kidney. If the stricture is long or does not stretch with the balloon, it could require a surgery to correct it.
  • Donation after Cardiac Death – There will be some degree of oxygen deprivation from organs recovered from a donor after cardiac death and as a result, the kidneys may be slow to start and may have an increased risk of delayed graft function.
  • BK Virus – Most people get BK virus, or polyomavirus, in early childhood and see no symptoms. The virus stays present in the kidneys and can be detected by a kidney biopsy. Most illnesses caused by BK virus occur in those receiving immunosuppression after an organ transplant. Kidney injury develops late in the course of BK virus disease and reducing the amount of immunosuppressive medication can help decrease the virus.

Follow-up

After discharge, patients have lab tests every Monday and Thursday. On lab days, do not take Prograf, Cyclosporine or Rapamune before having blood drawn. The blood tests will be drawn right before your morning dose so we can measure the lowest level of these drugs in your blood. All other medication can be taken at your normal time.

  • Patients will visit our transplant clinic two times a week for the first month after surgery. During your first clinic visit after discharge, plan to be at the appointment for a couple of hours. Make sure to bring all of your medicines and your transplant diary.
  • Your lab tests and clinic visits arrangements will be made by one of the transplant coordinators when you are discharged. As time passes, the clinic visits and lab tests will be less frequent.
  • If you don’t live in the Gainesville area, we can make arrangements with a lab closer to you for blood tests. It’s important for you to be seen regularly by a transplant doctor the first couple of months after your transplant.
  • Patients should not drive for about three to four weeks after their transplant. All transplant patients need to have a primary care doctor and they must pay close attention to routine health maintenance.
  • A ureteral stent is placed during surgery and will stay in place for four to six weeks. It is a small, soft tube about six inches long that is placed in the ureter. The purpose of this is to hold the ureter open and maintain proper drainage of urine until the surgical connection between the transplanted ureter and the bladder heals. Your stent removal appointment will be scheduled prior to discharge and takes place at the UF Health urology clinic as an outpatient visit.
  • A biopsy of the transplanted kidney is ordered three to 12 months after transplant. A biopsy of the kidney tells our staff what is happening at the microscopic level of your kidney and it involves taking one or more tiny samples of you kidney to look at with microscopes. A biopsy can identify early scarring from chronic rejection, injury from medications or the silent rejection that can occur as creatinine goes up. This is performed with a needle that is placed through the skin and removes tiny pieces of kidney guided by ultrasound pictures. The procedure is done under local anesthesia and takes about half an hour. After the procedure, the patient rests for a few hours and is then able to return home. The patient will be contacted with the results one to two weeks after the biopsy.