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Nursing Practice

Review
Organ donation

Keywords: Live organ donation/Renal


failure/Kidney care
This

article has been double-blind


peer reviewed

A kidney donor describes and reflects on her experience, from her partner's
diagnosis with kidney failure, through assessment to transplantation and recovery

Live kidney transplant


from an unrelated donor
In this article...
S
 igns and symptoms of renal failure
A
 ssessments for both donor and recipient
P
 rocess and follow-up care for transplant patients
I
 mpact of live donation
Author Sharon Smith is principal lecturer;
Vimala Sinniah is senior lecturer; both in
pre-qualifying nursing at Buckinghamshire
New University.
Abstract Smith S, Sinniah V (2013) Live
kidney transplant from an unrelated donor.
Nursing Times; 109: 27, 12-15.
This article provides an insight into the
experience of live donation from the
donor and recipient perspectives from
diagnosis until 18 months after
transplantation. The lead author details the
diagnosis of end-stage renal failure in her
partner and their decision for her to
donate a kidney.

oward is 58 years old and, in


common with many men, is
keen to have as little as possible
to do with healthcare providers. In April 2011, I had become concerned about a small wound on his nose
caused by ill-fitting glasses; the wound did
not appear to be healing as expected and I
persuaded him to visit our GP. During this
visit the GP measured his blood pressure,
which was 161/96 and, in accordance with
National Institute for Health and Clinical
Excellence (2011) guidelines for stage 1
hypertension, blood tests were requested
(Table 1).
The blood results strongly indicated
that Howard was suffering from renal
insufficiency. He was immediately
admitted to hospital, initially for the treatment of his hyperkalaemia (raised serum
potassium levels in the blood) and for further investigation to establish the reason
for his abnormal blood results.
Reducing the potassium level was a

primary concern at this time, as untreated


hyperkalaemia can lead to cardiac arrhythmias and arrest (Hudak et al, 1998). This
was treated with salbutamol via a nebuliser, which was supplemented with intravenous infusion of glucose and insulin.
The insulin promotes movement of potassium from the extracellular space back
into the cells (Gross and Pistrosch, 2004).
Salbutamol may not lower potassium
in all patients, and some studies show
that up to 40% of those who have a degree
of kidney failure requiring renal replacement therapy (those who are dialysis
dependent) are resistant to salbutamol
(Gross and Pistrosch, 2004). Although
Howards full blood picture indicated
that he was likely to require dialysis,
this treatment succeeded in reducing his
blood serum potassium level from
6.2mmol/L to 4.9mmol/L (Table 1). He
started on a low potassium diet in the first
few days following diagnosis.
The kidneys filter waste and excess fluid
from the blood, which are excreted as
urine, thereby regulating the levels of
potassium, urea and creatinine.
An ultrasound scan showed bilateral
polycystic kidney disease (PKD), which is a
genetic disorder causing the growth of
numerous cysts in the kidneys (Jacob,
2012). These cysts fill with fluid and can
profoundly enlarge the kidneys and
replace much of the normal structure,
resulting in reduced kidney function and
leading to renal failure.
Howard was diagnosed with end-stage
renal failure (ESRF) secondary to PKD.
Without a transplant, he would need three
five-hour haemodialysis sessions a week.

12 Nursing Times 10.07.13 / Vol 109 No 27 / www.nursingtimes.net

5 key
points

Live donation
addresses the
problem that there
are too few kidneys
available for
deceased donors
Without a
kidney
transplant people
with end-stage
renal failure need
haemodialysis
Research
suggests that
survival rates of
transplanted
kidneys is greater
than those of
cadaveric organs
Polycystic
kidney disease
can profoundly
enlarge the
kidneys, replacing
much of the normal
structure and
reducing kidney
function
Around half of
patients with
the most common
type of PKD will
progress to
end-stage renal
failure

2
3

Nursing is fantastically
rewarding if you get it right
Susan Stewart

p24

Table 1. Howards blood results compared with normal values


Test

On diagnosis,
13 May 2011

During haemodialysis,
9 July 2011

After transplant,
15 December 2011

Normal values

Creatinine (mol/L)

815mol/L

690

124

60-120

Urea

30.1mmol/L

13.8

5.1

2.5-6.7

Potassium

6.2mmol/L

3.6

4.3

3.5-5.0

Haemoglobin

11.3g/dL

10.3

14.1

12-14

Estimated glomerular
filtration rate

6ml/min

52 ml/min

>90ml/min

Source: Peate and Dutton (2012)

Signs and symptoms

Patients with ESRF often experience


uraemia. Typically, these patients will have
raised blood urea and creatinine (Huether
and McCance, 2004), both of which were
elevated in Howards case.
Uraemia is an increase in blood urea
nitrogen, which delays wound healing by
preventing the granulation of new tissue
(Kindlen, 2003). This may explain why the
wound on Howards nose had failed to
heal, the only outward sign that he was
seriously ill.
Huether and McCance (2004) suggest
that patients with ESRF normally have
problems with fatigue, anorexia, nausea
and vomiting. Howard did not complain of
any of these symptoms. However, in retrospect his appetite was perhaps reduced
and I had been aware of a malodour, which
I later recognised as uraemia.
Howard was discharged from hospital
once his blood chemistry was within a
safe range.

Treatment

Approximately 50% of patients with the


most common type of PKD will progress to
end-stage renal failure (ESRF) (Table 2). At
the point of diagnosis, Howard was found
to already be in ESRF (also termed chronic
kidney disease stage 5). Patients experiencing renal failure as a result of PKD may
require dialysis or transplantation.
The optimum treatment for PKD is a
pre-emptive transplant before dialysis is
required (Papalois et al, 2000). However,
according to Kalble et al (2010), there is
little significant difference to the longterm outcome when the patient has been
on dialysis for less than six months.
Our first meeting with the renal specialist was 48 hours after Howard had been
discharged and it was at this meeting
that the decision was made to start dialysis. Dialysis is required when the estimated glomerular filtration rate (eGFR) is
below 10 (NICE, 2008) and Howards had

deteriorated below this level at diagnosis


(Table 1).
The implications of the pre-transplant
assessment for both Howard and I were
discussed. We were fortunate to be able to
attend one of the regular patient seminars
delivered by the renal transplant coordinator and the transplant team within a few
days. This seminar reaffirmed that a live
transplant would provide the optimum
outcome for Howard in terms of quality
oflife.
To gain access for dialysis, Howard had
a dialysis catheter inserted in early June.
The haemodialysis catheter has two
lumens, which are inserted into the venous
system and positioned with the tips in the
right atrium and the superior vena cava,
facilitating connection to the dialysis
machine. The catheter was used instead of
forming a fistula because Howard needed
to start haemodialysis three times a week
as soon as possible. His haemoglobin continued to fall while on dialysis and did not
start to return to a normal level until after
the transplant (Table1).
Before any assessment was made, we
were told there was a better than 50%

chance that I would be able to donate a


kidney to Howard. Kalble et al (2010) have
suggested the survival rates of grafts (kidneys) from living donors are higher than
those of cadaveric grafts. We were also
aware that, if I was able to donate a kidney,
the transplant could take place significantly sooner than if we had to wait for a
cadaveric transplant.

Assessment

The overall aims of the pre-transplant


assessment protocol within guidelines for
live kidney transplantation are to ensure
both donor and recipient are fit for transplant and that the potential for graft survival is good (British Transplant Association and Renal Association, 2011). In
addition, pre-assessment has to establish
that the donor will continue to have satisfactory kidney function after donation
(Table3).
The first area of investigation looked at
our potential tissue compatibility, which
involved blood tests to look at blood
groups and antibody levels. These tests
confirmed our compatibility; however,
some non-compatibility issues can be

Table 2. stages of renal failure


Stage

Glomerular filtration
rate (ml/min)

Description

90+

Normal kidney function but urine analysis


or structural abnormalities of the kidneys
or genetic trait point to kidney disease

60-89

Mildly reduced kidney function, and other


findings (as for stage1) point to kidney
disease

3B

45-59

3B

30-44

Moderately reduced kidney function with


or without evidence of kidney damage

15-29

Severely reduced kidney function

Less than 15 or
dependent on dialysis

Very severe or end-stage renal failure

Source NICE (2008)

www.nursingtimes.net / Vol 109 No 27 / Nursing Times 10.07.13 13

Nursing Practice
Review
Table 3. Summary of the investigations in preparation for transplant
Recipient (Howard)

Donor (myself)

Coronory investigation: ECG and percutaneous coronary


intervention
Routine chest X-ray
Ultrasound scan of the kidneys
Blood test
Blood group (ABO)
Full blood count, urea and electrolytes, renal profile, liver
screen, bone screen, glucose
Human leucocyte antigen (HLA)
Virology (hepatitis, CMV)
MRSA swabs
Brain magnetic resonance imaging (because PKD diagnosis
would make Howard prone to cerebral haemorrhage)
Colonoscopy (family history of bowel cancer)

Ultrasound of kidneys
Magnetic resonance angiogram (MRA)
Nuclear medicine test for glomerular filtration rate total
function and nuclear medicine test for GFR each kidney
Exercise ECG test
Chest X-ray
Routine blood tests
ABO blood group and HLA compatibility
24-hour urine collection
MRSA swabs

overcome by medical intervention before


transplant. Where the donor and recipient
have different blood groups for example
one has group A and the other group B
plasma exchange can be used to remove
conflicting antibodies. These are known as
ABO-incompatible kidney transplants. If
the level of antibody incompatibility
cannot be overcome, willing donors can
have the option of being entered into a
scheme where they donate a kidney to a
compatible stranger so that their loved one
can receive a kidney from a stranger.
I underwent MRI and ultrasound scans
to look at the anatomy of my kidneys, as
this varies from one person to another. The
donors left kidney is the preferred one to
use, because the left renal vein is usually
longer than the right one, and is therefore
easier to join to the recipients vein.
Nuclear medicine tests were required to
look at the glomerular filtration rate (GFR)
of each of my kidneys as my left one was
significantly larger than the right. This test
demonstrated that my overall kidney function was split 50/50 between each kidney,
despite the difference in size. Had there
been a 60/40 differential (or more) the
transplant would not have taken place as
the kidney with the lesser function would
not have been enough to sustain satisfactory renal function in either Howard or
myself. I also underwent tests to establish
my fitness for anaesthetic.
To ascertain Howards fitness for transplant, he underwent routine cardiac and
respiratory investigations, and a brain
scan to rule out cerebral haemorrhage,
which is one of the complications of PKD
(Jacob, 2012). As he has a close family history of bowel cancer, he also underwent a
colonoscopy. It was important to establish
if Howard had any pre-existing cancer as
the drugs he would need to take for the rest

of his life could exacerbate this condition.


Immunosuppressive drugs, such as tacrolimus, are given to suppress lymphocyte
production.
Once all these tests had established
Howards fitness for transplant and my
appropriateness as a donor, together with
my fitness for surgery, non-medical assessment was required. This involved us being
interviewed together by an independent
assessor, who then saw me on my own to
verify that I was not being coerced to
donate my kidney. This is in accordance
with UK Human Tissue Authority regulations (HTA, 2013).
I had made up my mind that I wanted to
be a donor before I understood all the
physical implications of having this surgery. The risks were explained to me and I
understood that my renal function would
not be compromised by having one kidney,
although I might experience some fatigue

Box 1. resources
A short article by the lead author on her
feelings about being a live donor
www.nursingtimes.net/livedonation
National Kidney Federation
www.kidney.org.uk
Kidney Patients Association
www.britishkidney-pa.co.uk
NHS Blood and Transplant (organ
donation) www.organdonation.nhs.uk
You can join the NHS Organ Donor
register by filling in a form online or
calling the NHS Donor Line on 0300 123
23 23. Lines are open 24 hours per day
all year. Calls are charged at your
contracted rate for local calls.

14 Nursing Times 10.07.13 / Vol 109 No 27 / www.nursingtimes.net

initially while the lone kidney adapted. I


very much wanted to be able to give
Howard a kidney and trusted the renal
team to not put me at any undue risk.
During the build-up to the transplant,
my anxiety was far more focused on
hoping we would be able to have the surgery than on its implications.

Live kidney transplantation

The investigations caused a high degree of


anxiety for us both, but we finally made it
to the operating theatre on 15 September
2011. Fig 1 shows the position of a transplanted kidney. It is normal to not remove
the diseased kidneys unless they grow
excessively large (Jacob, 2012).
After surgery, we both spent two days in
the renal high dependency unit. My renal
function was closely monitored until it
reached satisfactory levels of a GFR over
70ml/min and creatinine below 120mol/L.
We were discharged home after two
weeks when Howards creatinine was
below 200mol/L, his wound appeared to
be healing and the pharmacist was satisfied that he understood his drug regimen.
Following discharge, Howard continued to be closely monitored by the renal
outpatients department. In the first couple
of weeks after discharge, this meant visits
three times a week, then twice weekly and
gradually reducing to once every six weeks.
On each visit, his creatinine level was
tested, as a significant rise could indicate
signs of rejection (Thomas, 2008). If picked
up early, this can be rectified by adjusting
the dose of anti-rejection drugs.
Howard also had a biopsy of the transplanted kidney at three months and again
one year after the transplant. This is
because this tissue can show signs of early
rejection before creatinine levels change
(Thomas, 2008).

Nursing
Times.net

For more information on live kidney donation,


go to nursingtimes.net/livedonation

fig 1. placement of transplanted kidney

others to grasp the opportunity of live


organ donation to enhance the quality of
live for those with ESRF. NT

Diseased kidneys
Inferior vena cava
Aorta
Ureters
Transplanted
kidney

Transplanted
ureter
Bladder

I returned to work after a three-month


recovery period. Since the transplant,
Howard has experienced only one occasion
when a raised creatinine level caused him
to be readmitted to hospital for 24 hours.
This was just after he had been discharged
home and the warm weather had caused
him to become dehydrated. He has had
to learn to increase his fluid level carefully
whenever the ambient temperature
increases.

The renal team is satisfied that Howard


fully understands the importance of correct fluid intake and of adhering to his
drug regimen, which means we can now
travel abroad.
Life for both of us has been good since
the transplant, culminating in us getting
married in August 2012. The transplant
journey was challenging but the positive
outcome made it worthwhile for us both.
We hope our experience will encourage

References
British Transplant Association and Renal
Association (2011) United Kingdom Guidelines for
Living Donor Kidney Transplantation. tinyurl.com/
TTS-living-donor
Gross P, Pistrosch F (2004) Hyperkalaemia again.
Nephrology Dialysis Transplant; 19, 2163-2166.
Hudak CM et al (1998) Critical Care Nursing: a
Holistic Approach. Philadelphia, PA: Lippincott.
Huether SE, McCance KL (2004) Understanding
Pathophysiology. St Louis, MO: Mosby.
Human Tissue Authority (2013) Code of Practice
2: Donation of Solid Organs for Transplantation.
tinyurl.com/HTA-transplant-code
Jacob E (2012) Polycystic Kidney Disease: a
Comprehensive Guide to Symptoms, Treatment,
Research and Support. Silver Spring, MD:
Medifocus.
Kalble T et al (2010) Guidelines on Renal
Transplantation and Kidney Donation. Arnhem,
the Netherlands: European Association of
Urology.
Kindlen S (2003) Physiology for Health Care and
Nursing. Edinburgh: Churchill Livingstone.
Mc Kay DB, Steinberg SM (eds) ( 2010) Kidney
Transplantation: a Guide to the Care of Kidney
Transplant Patient. Thousand Oaks, CA: Springer
Science
National Institute for Health and Clinical
Excellence (2011) Hypertension: Clinical
Management of Primary Hypertension in Adults.
London: NICE. www.nice.org.uk/CG127
National Institute of Health and Clinical
Excellence (2008) Chronic Kidney Disease: Early
Identification and Management in Chronic Kidney
Disease in Adults in Primary and Secondary Care.
London: NICE. www.nice.org.uk/CG73
Peate I, Dutton H (2012) Acute Nursing Care:
Recognising and Responding to Medical
Emergencies. London: Pearson Education Limited.
Papalois VE et al (2000) Pre-emptive transplants
for patients with renal failure: an argument against
waiting until dialysis. Transplantation; 70: 4,
625- 631.
Thomas N (ed) (2008) Renal Nursing. 3rd edition.
London: Baillire Tindall.

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