How Is It Done?

A slightly belated welcome to the last week of National Donate Life Month to you. I have learned so much about kidney donation via my research for the blog this month, and hope you have, too. What makes more sense than to take a look at the donation process this week? 

Ready? I suppose the physical donation is the first part of the process so let’s look at that first. This is what Jefferson Heath, the home of Home of Sidney Kimmel Medical College, had to say about deceased donors: 

“It isn’t necessary to match the donor and recipient for age, sex or race. All donors are screened for hepatitis viruses and the HIV virus. What’s more, all deceased donor organs are tested extensively to help ensure that they don’t pose a health threat to the recipient. Also, many studies – such as ABO blood type and HLA matching – are performed to ensure that the organs are functioning properly. 

As soon as a deceased donor is declared brain-dead, the kidneys are removed and placed in sterile fluid similar to fluid in body cells. They are then stored in the refrigerator. The harvested kidneys need to be transplanted within 24 hours of recovery – which is why recipients are often called to the hospital in the middle of the night or at short notice.” 

I wondered if the process were different for a living donation. The Mayo Clinic tells us: 

“Both you and your living kidney donor will be evaluated to determine if the donor’s organ is a good match for you. In general, your blood and tissue types need to be compatible with the donor. 

However, even if your donor isn’t a match, in some cases a successful transplant may still be possible with additional medical treatment before and after transplant to desensitize your immune system and reduce the risk of rejection.” 

Now to the actual process. Johns Hopkins offered this very clear explanation of the process: 

“Generally, a kidney transplant follows this process: 

You will remove your clothing and put on a hospital gown. 

An intravenous (IV) line will be started in your arm or hand. More catheters may be put in your neck and wrist to monitor the status of your heart and blood pressure, and to take blood samples. Other sites for catheters include under the collarbone area and the groin blood vessels. 

If there is too much hair at the surgical site, it may be shaved off. 

A urinary catheter will be inserted into your bladder. 

You will be positioned on the operating table, lying on your back. 

Kidney transplant surgery will be done while you are asleep under general anesthesia. A tube will be inserted through your mouth into your lungs. The tube will be attached to a ventilator that will breathe for you during the procedure. 

The anesthesiologist will closely watch your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. 

The skin over the surgical site will be cleansed with an antiseptic solution. 

The healthcare provider will make a long incision into the lower abdomen on one side. The healthcare provider will visually inspect the donor kidney before implanting it. 

The donor kidney will be placed into the belly. A left donor kidney will be implanted on your right side; a right donor kidney will be implanted on your left side. This allows the ureter to be accessed easily for connection to your bladder. 

The renal artery and vein of the donor kidney will be sewn to the external iliac artery and vein. 

After the artery and vein are attached, the blood flow through these vessels will be checked for bleeding at the suture lines. 

The donor ureter (the tube that drains urine from the kidney) will be connected to your bladder. 

The incision will be closed with stitches or surgical staples. 

A drain may be placed in the incision site to reduce swelling. 

A sterile bandage or dressing will be applied.” 

I wanted to know if there might be side effects or something else I should worry about as a kidney transplant recipient. The United Kingdom’s National Health Service was detailed in their response: 

Short-term complications 

Infection 

Blood clots 

Narrowing of an artery 

Arterial stenosis can cause a rise in blood pressure.  

Blocked ureter 

Urine leakage 

Acute rejection 

Long-term complications 

Immunosuppressant side effects: 

an increased risk of infections 

an increased risk of diabetes 

high blood pressure 

weight gain 

abdominal pain 

diarrhoea 

extra hair growth or hair loss 

swollen gums 

bruising or bleeding more easily 

thinning of the bones 

acne 

mood swings 

an increased risk of certain types of cancer, particularly skin cancer” 

Not everyone experiences these complications, nor are they insurmountable as far as I can tell. 

But what about the donor? Could he experience any ill effects? According to the trusted and respected National Kidney Foundation

“You will also have a scar from the donor operation- the size and location of the scar will depend on the type of operation you have. 

Some donors have reported long-term problems with pain, nerve damage, hernia or intestinal obstruction. These risks seem to be rare, but there are currently no national statistics on the frequency of these problems. 

In addition, people with one kidney may be at a greater risk of: 

high blood pressure 

Proteinuria 

Reduced kidney function” 

Naturally, as a donor, you’ll also be concerned about the financial aspects of donating. UNOS has information about this: 

Medical bills 

The transplant patients’ health insurance, Medicaid, or Medicare may cover these costs: 

Testing 

Surgery 

Hospital stay 

Follow-up care related to donation 

Personal bills 

Paid vacation and sick leave… 

Tax deductions and credits… 

Time off… 

Tax deductions or credits for travel costs and time away from work… 

Short-term disability insurance… 

FMLA (Family and Medical Leave Act) … 

NLDAC (National Living Donor Assistance Center) … 

AST (American Society of Transplantation) … 

Other 

Your private insurance or a charity may also cover costs you get during donation related to: 

Travel 

Housing 

Childcare” 

Not everyone is entitled to these financial aids. It depends on your employer, your length of time at that job, your state, and previous financial standing. 

You’ve probably noticed how little Gail there is in today’s blog and how much research there is. Remember, I knew extraordinarily little about transplant before writing this month’s blogs. 

Until next week, 

Keep living your life! 

Sunny Transplants?

A few years ago, when I wrote only about Chronic Kidney Disease, the representative of a transplant group asked me to write about transplantees and skin cancer. I respectfully declined. As you may have noticed, my topics have become more wide ranging this year, from PKD to the Chronic Disease Coalition and all things in between. This week, I’m going to add skin cancer and transplantees to that list.

For me, that means going back to the basics since I was surprised that this was even an issue. The logical place to start was The Skin Cancer Foundation at https://www.skincancer.org/prevention/are-you-at-risk/transplants:

The most common skin cancers after transplant surgery are squamous cell carcinoma (SCC), basal cell carcinoma (BCC), melanoma and Merkel cell carcinoma (MCC), in that order. (See Table Below) The risk of SCCs, which develop in skin cells called keratinocytes, is about 100 times higher after a transplant compared with the general population’s risk.  These lesions usually begin to appear three to five years after transplantation…. While basal cell carcinoma is the most common skin cancer in the general population, it occurs less frequently than SCC in transplant patients. Even so, the risk of developing a BCC after transplantation is six times higher than in the general population….

Risks of Four Types of Skin Cancer After Transplantation

Risks of Four Types of Skin Cancer After Transplantation

You could have knocked me over with a feather. From this stunning information, I extrapolated that it looks like the anti-rejection drugs are the source of the skin cancer.

Let’s see what these drugs are. The National Kidney Foundation at https://www.kidney.org/atoz/content/immuno explains.

Immunosuppressants are drugs or medicines that lower the body’s ability to reject a transplanted organ. Another term for these drugs is anti-rejection drugs. There are 2 types of immunosuppressants:

  1. Induction drugs: Powerful antirejection medicine used at the time of transplant
  2. Maintenance drugs: Antirejection medications used for the long term.

Think of a real estate mortgage; the down payment is like the induction drug and the monthly payments are like maintenance drugs. If the down payment is good enough you can lower the monthly payments, the same as for immunosuppression.

There are usually 4 classes of maintenance drugs:

  • Calcineurin Inhibitors: Tacrolimus and Cyclosporine
  • Antiproliferative agents: Mycophenolate Mofetil, Mycophenolate Sodium and Azathioprine
  • mTOR inhibitor: Sirolimus
  • Steroids: Prednisone

Okay, got it. But I still don’t understand what that has to do with skin cancer. The Department of Dermatology at Oxford University Hospital of the National Health Service Trust (in the United Kingdom) at https://www.ouh.nhs.uk/patient-guide/leaflets/files/11710Pimmunosuppressants.pdf offers this information:

“These drugs work by reducing your immune (defence) system. However, these treatments also increase your risk of skin cancer….”

Now it makes sense. While saving your life via preventing the rejection of your new life giving organ by suppressing your immune system, other conditions like cancer are sneaking passed that suppressed immune system. So you need to take these drugs to keep your new kidney, but they could shorten your life by letting the cancer cells multiply.

PATIENT CHARACTERISTIC FREQUENCY OF
DERMATOLOGY EXAM
No history of skin cancer or Actinic Keratosis Every 1-2 years
History of Actinic Keratosis Every 6 months
History of 1 non-melanoma skin cancer Every 6 months
History of multiple non-melanoma skin cancer Every 3 to 4 months
History of high risk SCC or melanoma Every 2 to 3 months
History of metastatic SCC Every 1 to 2 months

Hmmm, but maybe not. There must be a way to at least help guard against this… and there is. Actually, there are several including avoiding the sun, using sun block, wearing the newish sun blocking clothing, and simply wearing clothing that blocks the sun. (The chart above comes from the same site as the quote below). As the University of California San Francisco Skin Transplant Network phrases it at http://skincancer.ucsf.edu/transplant-patients:

“Clothing is a simple and effective sun protection tool. It provides a physical block that doesn’t wash or wear off and can shade the skin from both UVA and UVB rays. Long-sleeved shirts and pants, hats with broad brims and sunglasses are all effective forms of sun protective clothing.”

There’s quite a bit of easily understood information about the different kinds of skin cancer that affect transplantees at the above URL. By the way, this request for patient participants also appears on their website:

We need transplant recipients to please help us by participating in our brief survey study about your skin.

Please click here to access our online consent form to learn more about the study.

After electronically signing the consent form, you will be directed to a short questionnaire about your health.
There will be no cost to you; your participation is entirely voluntary and will not influence your care or your relationship with your doctors.

Thanks so much for your help in skin cancer research!
UCSF IRB approved, #16-20894

Not only do you find the information you may be looking for about skin cancer and transplantees on this website, but you also have this opportunity to help with skin cancer research.

Whoops! I neglected to define UVA and UBV rays. Encarta Dictionary apprises us that UVA is “ultraviolet radiation, especially from the sun, with a relatively long wavelength,” while UBV is “ultraviolet radiation, especially from the sun, with a relatively short wavelength.” Not very helpful, is it?

Let’s try this another way. Many thanks to Cancer Research UK at https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/sun-uv-and-cancer/how-the-sun-and-uv-cause-cancer for clearing this up for us:

“There are 2 main types of UV rays that damage our skin. Both types can cause skin cancer: UVB is responsible for the majority of sunburns. UVA penetrates deeper into the skin. It ages the skin, but contributes much less towards sunburn.”

Another way to help yourself avoid skin cancer after having a transplant is to learn how to monitor your skin for cancer and then to do so on a regular basis. If you notice any abnormal spots or growths, get thee to thy dermatologist quickly. Apologies to Mr. Shakespeare for suborning his line.

You’ll probably be taught the ABCDE of Melanoma detection, too. The American Academy of Dermatology at www.aad.org is another good source of skin cancer information.

Here are some things I didn’t know about skin cancer that you may not know either. I picked them up at a local lecture on avoiding skin cancer:

Your lips need sunscreen, too.

The most common spot for men to develop skin cancer is the back; for women, it’s the legs.

Stage 3 and 4 Melanoma can get into your lymph nodes.

Effective sun screens contain both titanium and zinc.

Use SPF 50 on your face.

My transplanted friends always tell me transplant is “a treatment, not a cure.” Now I understand it’s a treatment with some possibly serious side effects.

Until next week,

Keep living your life!