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Before the transplant

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The kidney transplantation candidate is visited by the transplant medical team: nephrologist, urologist, and anaesthetist. The living donor will be separately visited by a psychologist and by a transplant coordination medical professional too.

Once the viability of the donor and the recipient is confirmed, and their case has been assessed in a multidisciplinary session and by the ethics committee, the donor application is sent to court to obtain their final consent. The surgery is subsequently scheduled as an elective intervention.

Candidates for deceased donor transplantation, are included on a waiting list based on their blood type, after first having obtained approval by the appropriate medical and surgical professionals.

The day of the transplant

For living donor transplants, both the patient and the donor are admitted the day before the surgery to different hospitalisation rooms. Both the donor and the recipient enter the operating room simultaneously and the intervention is performed in adjoining operating rooms.

In the case of a deceased donor, the candidate recipient for the kidney receives a call from the medical professional on duty telling them to go to the hospital as soon as possible to be able to perform the compatibility test (cross matching) and then potentially proceed to the intervention.

Kidney transplant

During the surgery, the surgeon places the new kidney in the lower abdomen (usually on the right side), through an incision shaped like a golf club. Next, the kidney artery and vein are connected to the iliac vessels, artery (carrying oxygenated blood), and vein (blood coming from the legs to the heart) of the recipient. The connection of the ureter (tube that carries urine) to the urinary bladder is subsequently performed.

The transplanted kidney often starts producing urine immediately, but sometimes it can take a few weeks to start working, and the patient may even still require a few dialysis sessions. This condition is called delayed graft function.

Robot-assisted kidney transplantation can also now be performed. In this case, small plastic tubes (trocars) must be placed through the abdominal wall. The organ is inserted through a small incision in the lower abdomen. The vascular sutures and reimplantation are performed within the recipient’s body, thereby achieving the same functional results, and reducing the number of incisions and other health problems that can result from surgery.

After the transplant

Once the intervention is finished, the recipient is transferred to the resuscitation room or the intensive care unit for a few hours or days. The patient is then sent to a conventional hospital room. The patient usually remains hospitalised for a week, although on occasions and depending on the type of donor and recipient, the admission may be extended. The recipient leaves the operating room with a catheter and drain that are removed after a few days.

24–48 hours after transplantation, renal ultrasound and scintigraphy are performed to assess the viability of the organ. Likewise, daily tests are carried out to monitor the function of the kidney and to adjust medications.

Postoperative

The following complications can occur in the immediate postoperative period:

Infection. After the transplant, the patient’s defences will be exceptionally low meaning that there is a greater risk of having an infection. The most frequent infections are of the surgical wound and urinary infections. As the kidney stabilises, this risk decreases.

Haemorrhage. Sometimes there is blood loss due to surgery. If the patient was previously anaemic, they may require a transfusion during the intervention or in the days following the operation. This complication usually resolves on its own but will occasionally require surgical revision.

Haematuria. Sometimes there may be a slight loss of blood through the urine because of the recent surgical union of the donor ureter and the bladder. In general, this complication resolves spontaneously with washes through the tube.

Urinary fistula. This complication is rare. It means that urine is leaking through the ureter or bladder wall. Depending on the severity of the leak, a urinary tube or catheter is placed in the ureter for a few weeks to allow the bladder to rest and close spontaneously. In some cases, surgery must be done to repair the leak.

Productive drainage. After transplantation, a large amount of fluid can sometimes be produced by the drain. This is lymphatic fluid produced by small vessels surrounding the blood vessels, which remain open after surgery.

This excess fluid is generally self-regulating and leaving the drainage in place for more days is usually sufficient. If the drain is removed too quickly, a lymphocele (cyst containing lymph, a thin, clear fluid that circulates through the lymphatic system) can form. If a lymphocele forms, surgical treatment may be needed to resolve it.

Rejection. Rejection occurs when the immune system, a natural mechanism in the body designed to fight against infection, is activated. In this case, the immune system recognises the new kidney as something foreign to the patient’s body and tries to destroy it. This is the reason why transplant recipients must take immunosuppressive medications.

Hospital discharge

After the transplant and hospital discharge, the patient will be followed up at the hospital by their nephrologist. At the beginning these visits are more frequent (once a week during the first month) and they become progressively spaced further apart according to the evolution of the transplant.

During the visits, a series of tests are carried out including recording the patient’s blood pressure (BP), heart rate (HR), and weight. The surgical wound is also checked. It is useful for the patients to take blood pressure measurements at home as reference values because anxiety on the day of the hospital visit can alter the results. On the day of the visit, the patient should show these reference values (measured the day before or the same day as the visit, first thing in the morning) to their doctor who will review them alongside the treatment regimen.

These visits are also a good time to ask any questions related to the transplant. Additional tests such as ultrasounds may also be indicated to obtain more information about the kidney. In turn, the nursing team can resolve any doubts about the wound if it is not completely healed or if the patient still has staples.

Surgical wound

Surgical wound healing in kidney transplant patients is usually slower because of their immunosuppression treatment (transplant-specific medication). Staples are usually removed within three weeks by the outpatient nursing team.

The surgical wound must be kept clean. After completing a daily hygiene routine (shower), the wound must be dried well with gauze and povidone-iodine must be applied with another gauze. If the wound is dry, it can be left uncovered, without a dressing. Post-transplant, the use of cotton underwear is recommended, over which a tubular girdle should be placed. The hospital nursing staff will provide personalised recommendations for the wound. If the wound is not yet closed, it must be cared for following their directions.

During the surgery, a prophylactic dose of an antibiotic is administered to prevent infection of the wound. Despite this, in some cases the wound can still become infected, in which case a staple must be removed to facilitate wound cleaning and to allow the liquid to drain. In this case, healing will be slower, and we must wait for the new tissue to grow from the bottom up because this area cannot be sewn again. It is particularly important to keep the wound clean by re-dressing it daily. False closure of the wound surface must be avoided. These treatments can be carried out at home with the help of a family member or at a health centre, depending on their complexity.