The Kidney Transplant Operation
There are risks with any surgery, and general anesthesia in particular. But with advances in surgical technique, pharmaceutical breakthroughs, and the growing numbers of living donors, transplanted kidneys are lasting longer and functioning better. Transplantation success improves overall patient survival rates and enriches the quality of life. Some of our patients at BIDMC have had their transplanted kidney for more than 30 years.
Transplanting a kidney generally takes 2 to 3 hours to complete. The surgeon begins by making a hockey-stick shaped incision 8 to 10 inches long in the lower abdomen, on either the right or left side. If you still have one or both original kidneys, the surgeon does not remove them during this operation. Under certain circumstances (for example, if this is your third kidney transplant), the surgeon may remove a previously transplanted kidney at this time.
Next the surgeon will attach the artery and vein of your new kidney. The artery to the kidney is sewn into the side of the artery that supplies blood to your leg and lower abdomen, and the vein to the kidney is sewn into the side of the vein that drains blood from your leg and lower abdomen. The surgeon will also connect the donor kidney's ureter - the tube that carries urine - to your bladder. The surgeon may also place a stent (tube) in the ureter to hold it open and protect it until it has healed. There is absolutely no discomfort associated with a stent. A urologist will remove the stent during an office visit four or five weeks after surgery.
The team will close your incision with staples or sutures and cover the area with a gauze dressing. With the operation complete, you will go to the post anesthesia care unit (PACU), and from there, to the Farr 10 transplant unit. The surgeon will let your family members know how you are doing.
The Post Anesthesia Care Unit (PACU)
Following the operation, you initially go to the post anesthesia care unit (PACU) where doctors and nurses monitor you very closely. (Some patients, who may need more intense observation, go to the surgical intensive care unit (SICU), although this is very unusual.) Here's some of what you can expect when you wake up:
- You may hear unfamiliar sounds, such as machinery to monitor your heartbeat, blood pressure and breathing.
- If you have a breathing tube in place, which is very unlikely, you will not be able to talk.
- Some medications may make you very sensitive to the noises around you.
- You might feel nauseated from the anesthesia. Your nurse will give you medication for relief.
- Medication can also help relieve any pain or discomfort you feel from the surgery.
- Nurses will check the dressing on your incision frequently and change it as needed. It is not unusual for fluids to drain from your incision for some time after your operation.
- Doctors and nurses in the PACU will continuously monitor how well your new organ is functioning by taking blood tests, measuring and testing the fluids your body produces, and using other testing methods such as X-rays when necessary.
- Typically patients are in the PACU for 4 to 12 hours. When you are stable, we will move you to Farr 10, our transplant unit, for the rest of your hospital stay.
More Information about Tubes, Drains, and Monitoring Devices
Many of the tubes, intravenous lines, monitoring devices and drains that the team put in while you were under anesthesia will still be in place after the surgery. Here is a little more information about some of them.
The Breathing Tube
Called an endotracheal or "ET" tube, this tube is in your throat and attached to the respirator to help you breathe during surgery. It is usually removed in the operating room as you are waking up; you usually will not remember it being taken out because of the anesthetic medications. In some cases, however, it might be necessary to leave the tube in to help you breathe as you are waking up. If it is still in place when you wake up, the nurses will give you pain medications and sedation to help keep you comfortable.
While the tube is in place, a suction device will remove fluid from your mouth and the tube frequently. You will not be able to speak with this tube in place, but your nurse can help you communicate. You can also "talk" with loved ones by blinking your eyes once for "yes" and twice for "no." Try to relax and let the respirator do the work for you. That way you will conserve energy and feel more comfortable. Remember the tube is temporary and necessary for your recovery.
Your caregivers will remove the tube when the anesthesia has worn off completely and your lungs can function on their own - usually within 8 to 24 hours after surgery. We determine when you are ready to breathe on your own by taking a chest X-ray, by measuring oxygen levels in your blood, and by measuring your breathing strength.
After we remove the tube, you may have a mild sore throat, which goes away in a day or two. Your nurses will encourage you frequently to cough and breathe deeply to keep your lungs clear of fluids and to keep oxygen flowing freely. You will learn how to support your incision with your hand or a pillow, to make coughing more comfortable. Respiratory therapists and your nurses will help you keep your lungs clear with chest therapy (that is, gently tapping your chest and back) and with an incentive spirometer, a device to help you breathe deeply. We take all of these precautions to prevent fluid and secretions from collecting in your lungs, which can cause lung infection or pneumonia.
Intravenous Lines (IV)
The IV lines may remain in place for most of your hospital stay. They allow us to draw blood for tests, administer any medications that you may need during recovery, and provide you with fluids to promote blood circulation. They also help assess heart and lung function.
You may have a drain placed in your abdomen that lies close to the kidney. This allows any fluid that collects around the kidney after the transplant to be removed. The drain is usually removed before you are discharged but occasionally will remain in place longer.
The Bladder Catheter
Also called a Foley catheter, this will be placed in your bladder during surgery to drain your urine, and will be in place when you awaken. Your nurse will remove it a few days after the surgery.
The Foley catheter allows staff to monitor your urine output every hour to determine how well your new kidney is working and how much intravenous fluid you need. It also helps keep the bladder from becoming too full, which promotes healing at the suture site, where the donor ureter is attached to your bladder.
The EKG/Telemetry Leads
When you leave the PACU, a nurse may remove the EKG leads used to monitor your heart.
Your surgeon may have placed a stent (tube) in your ureter to hold it open during healing. If so, a urologist will remove the stent during an office visit about 4 to 5 weeks after surgery.
Your Stay on Farr 10
Although recovery times vary from patient to patient, and complications are unpredictable, you can anticipate being in the post anesthesia care unit (PACU) for 4 to 12 hours. Once you leave the PACU, or the intensive care unit, you will move to Farr 10, our inpatient transplant unit. You will learn how to care for yourself here so you will feel confident and comfortable when you are ready to go home.
Out of Bed
You will be out of bed and walking with assistance the day of, or the day after, your operation. We will give you fluids to drink 24 to 48 hours after the surgery, and you can begin to eat solid foods when you can tolerate them. You may need dialysis if your new kidney does not produce urine right away. While this can be disappointing, it does not mean the kidney will never work properly. Barring any complications, you could go home from the hospital within 4 to 7 days.
While in the hospital, staff will:
- Order blood tests to be drawn at least once a day
- Take your temperature and blood pressure several times a day
- Weigh you every day
- Check your incision several times a day and change the dressing as needed
- Empty the catheter and drain bags
- Adjust your intravenous lines
- Help you learn about your medications; symptoms to watch for at home; specific diet requirements; and any needed post-op care
- Help you prepare to go home or to another facility in numerous ways such as making sure you can bathe and walk by yourself, take your medications properly, change your dressing, and empty any drains
More about Your Daily Care
While you are on the transplant unit, you will continue coughing and deep breathing exercises to keep your lungs clear of fluid. Your nurses will also encourage you to get out of bed and walk around your room and down the hall at least three times a day. Walking increases your blood circulation, helps relieve gas pains, and helps maintain your muscle tone.
Some people have trouble sleeping while in the hospital, and some people experience strange dreams that seem very real. Many transplant recipients also report memory problems after the surgery. These problems are temporary. Talk with your doctor if this persists or troubles you. Your appetite and energy level will not be the same as it was before the surgery. In general these will return to baseline within a few weeks of the transplant.
For a detailed, day-to-day description of your care on Farr 10, click here to download "A Guide to Your Daily Care."
Our Nursing Staff
Our nurses at BIDMC are the heart and soul of patient care delivery. Nursing's dedication to compassionate care is one of the medical center's guiding strengths. Patients, peers and colleagues recognize our nurses for their valued expertise and proficiency.
Patient satisfaction surveys applaud nurses throughout the medical center, including those who are part of our Transplant Institute, for their exemplary efforts in meeting patient needs.
Transplant Center nurse coordinators and nurses on staff in PACU and Farr 10 have extensive experience with the post-transplant patient. They are often the best resource for patients and families when there are questions regarding your care.
The transplant nurse coordinator will follow you during your evaluation and after transplant to ensure continuity of care.
A physical therapist will visit you post-transplant, and may have seen you pre-transplant. Our therapists will help you regain your strength and teach you how to move about more comfortably.
Case Management Services
Case managers constantly monitor your progress. They help develop a discharge plan, including decisions about whether you should move to a facility for rehabilitation or arrange for homecare services. They work with you and your family to set up these and any additional services you might need.
Social Work Services
A social worker will also see you, and perhaps your family, to help with coping strategies, home arrangements, and any other issues surrounding your transplant.
Learning to Care for Yourself
You will have many things to remember when you leave the hospital. Taking an active role in your self-care and developing a daily routine while you are in the hospital will help you better care for yourself after you go home.
One of the most important things you will learn on Farr 10, under the guidance of our experienced nurses, doctors and other staff members, is how to take care of yourself safely.
Your role as a member and a partner of the transplant team becomes more important than ever at this point because your new kidney will need a lot of care, attention, and monitoring to do its job. Having a new kidney is a life-long commitment!
Learning about Your Meds
Your transplant team will decide what medications are right for you. You will have to take immunosuppressive medication to prevent the rejection of the transplanted kidney. You will take these medications for as long as you have a functioning kidney transplant.
In addition to the immunosuppressants, you will also have to take medications to prevent infection, although you will not have to take these medications for long. You may also need medications after your transplant to help control your blood pressure and cholesterol.
The team will adjust your meds in the hospital and will continue to monitor their effectiveness after discharge. We will teach you the names and basic effects of each drug you need to take. Remember, taking your medications is your responsibility. If you are unable to take your medications at home for some reason, you must call the Transplant Center.
These medications suppress the immune system enough to keep the transplanted kidney healthy. The three main categories of medication include induction immunosuppression, maintenance immunosuppression and rescue therapy for the treatment of rejection:
- Induction immunosuppression is the initial high dose medication, both intravenous and oral, that you take in the first 1 to 2 weeks after your transplant.
- Maintenance immunosuppressants are also started while you are in the hospital. You will continue on these medications in order to prevent your body from rejecting the kidney transplant over time.
- Rescue therapy for the treatment of rejection is typically given as an intravenous medication while in the hospital.
For more information about transplant medication, visit the American Society of Transplantation (AST) Web site:
www.a-s-t.org, under the patient education section.