Transplant

Hello kidney warriors & knowledge seekers! Today, we continue from our previous article on all steps that kidney patients & kidney donors need to follow before getting admitted to the hospital for a Transplant surgery.

The article today explains the basic workflow involved for every kidney patient scheduled for a transplant & their donor starting from hospital admission until they finally get to go under the knife.

Contents

• When do you get admitted to the hospital?
•  What to bring to the hospital
•  Things to consider before going to the hospital if you live alone
•  Formalities at the billing/admissions section
•  Day before the surgery
•  Evening before the surgery in the hospital
•  Morning of the surgery in the hospital

1. WHEN DO YOU GET ADMITTED TO THE HOSPITAL FOR TRANSPLANT?

LIVING DONATION

For living donation, hospital admission is relatively relaxed. The date of hospital admission & surgery can be planned with mutual agreement between:

i. The medical team for available slots for surgery

ii. How stable, the health of the kidney patient is

iii. Comfort of the kidney donor

iv. Financial arrangements on the part of both patient & donor

It is less common, but sometimes, patients get admitted to the hospital the morning of the surgery even if they are getting a live donation. In such cases, make sure you arrive at least 4-6 hrs ahead of your scheduled surgery time.

DECEASED DONATION

In this case, hospital admission is necessary as soon as you “get the call” of having found a matched kidney from a brain-dead donor. The time frame here, is pretty short. So, patients need to be suitably prepared with necessary documents, finances and logistics ahead of time.

2. WHAT TO BRING TO THE HOSPITAL?

For convenience during your hospital stay, consider the following suggestions:

◾Bring your Identity documents (government approved ID) to be shown at the Admission counter.

◾Carry in your health insurance /financing documents for showing at the billing counter during admission.

◾Bring a current list/prescription of your medicines, including the dosages and the times you take them.

This makes it easy for your nursing team to plan your medication timing before & after surgery.

◾If you have a health care directive document (living will), bring a copy.

Also, inform your lawyer before your hospital admission.

◾Most hospitals provide you with a hygiene kit that contains toothbrush, toothpaste, soap, facewash, comb. If you prefer, you can bring your own personal care items as well.

◾If you wear glasses or contacts, bring storage containers for them. Put your name on each container.

◾If you wear hearing aids, bring a storage container and extra batteries. Put your name on the container.

◾If you want to wear your own gown or robe other than what the hospital supplies, bring your own.

◾Bring weather-appropriate clothing (and innerwear) to wear home after discharge. Don’t forget to include socks, shoes (supportive with nonslip soles).

◾Leave valuables at home/family/bank lockers. You may want to bring a little money for any miscellaneous expenses at the hospital (buying magazines / newspapers)

◾All rooms have a television and phone. But you may want to bring a book or magazines.

3. THINGS TO CONSIDER BEFORE GOING TO THE HOSPITAL IF YOU LIVE ALONE

For convenience, consider the following suggestions:

◾Find someone to do your yard work.

◾ Arrange to have your paper and mail delivered to your door rather than curb side, as needed/stop deliveries temporarily.

◾Arrange transportation to the grocery store, community events, family activities and doctor and clinic appointments.

◾ Find someone to help care for your pet, if needed.

◾ Prepare and freeze a few meals before your surgery. You can then thaw and eat them once you return without having to do all the cooking yourself.

This saves undue effort on your part as well as protects you from contracting any possible infection.

What happens is, after transplant, you will be on strong anti-rejection medication to dampen your immune system. This is to let your new kidney settle properly. But as a side effect, these could make you prone to catch infections easily. Food from outside is a potential source of infection. So it is best to avoid outside food for sometine after your transplant.

Your medical team will advise you on when it’s safe for you to be able to eat out again in follow-up appointments.

4. FORMALITIES AT THE BILLING/ADMISSIONS COUNTER AT THE HOSPITAL

◾ Once at the patient & the donor are at the hospital, they will meet their medical/transplant teams or the assigned liaison officer.

They need to collect all necessary administrative paperwork and hand them over to the accounts section for initial billing for admission.

◾ Along with medical documents, the person at the Admissions section will ask the patient/donor & caregiver to provide some form of Government-approved ID.

Acceptable forms of ID differ from country-to-country. Make sure you ask your medical team ahead of time about this.

◾ Documents relating to how the patient & the donor plan to finance their medical procedure will be asked for.

These can relate to evidence for self-funding, health insurance card, employee ID for members getting financing from their workplace or proof of funding from charities/NGOs and the like.

◾ An initial installment needs to be paid at the time of hospital admission.

This is usually a token fraction of the total amount charged for pre-transplant hospital care, all costs involved during the operation, post-op initial ICU care.

◾Aftet completing all these formalities, the respective hospital room(s) & bed(s)  assigned to the kidney patient & donor.

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5. WHAT TO DO THE DAY BEFORE THE SURGERY UPON ADMISSION

Whether you are a donor or a recipient, you need to take care that you do not develop any sudden changes to your existing health status right before surgery.

Tell your doctor right away if you have any changes in your physical condition such as:

• Sore throat
• Cold/Runny nose
• Fever
• Dental problems (Toothache, swollen gums, Gum boils with pus etc.)
• Urinating problem (new problem for donors or worsening in urination for kidney patients)
• Skin condition (rash, cuts)

These can potentially make surgery risky for you. So canceling the surgery maybe necessary.

6. WHAT HAPPENS THE EVENING BEFORE SURGERY

6a. DONOR PRE-OP PREPARATION

👉 Once admitted, a transplant nurse will come-in to ask questions to confirm the donor medical history. This is necessary to create a Donor File at the Transplant Unit.

👉 Donors need to stay empty stomach for 12 hours until planned surgery timing. So, do not eat a heavy meal the evening before surgery.

It is imperative that the donor avoids eating or drinking any liquids – even water – after midnight, else it can cause dangerous complications during surgery.

If the donor does eat/drink something with less than 12 hrs to go for the surgery, it is essential to inform the medical team about it ASAP.

The surgery may be suitably delayed or even cancelled for the day. This is keeping the best health interests of the donor in consideration.

👉 If the Donor takes any medicines, the medical team must know about it. Some medicines need to be temporarily stopped before kidney donation to avoid complications during the surgery.

The transplant team would advise on which medication to take or leave out the night before the surgery.

👉 The hospital provides with a hygiene kit. This contains a Razor/Shaver & a special soap to shower/bath with.

🔸️A nurse would shave the operating area(s) with the razor. This is necessary because hair (however tiny) can attract dust particles on it. This can contaminate the area of operation & cause infections.

🔸️The soap in the kit is anti-bacterial. Washing the skin with it removes any germs/bacteria on the skin. It also helps prevent infection around the incision.

There are some do’s & don’ts on the best way to use the soap:

• • Do not use the soap on your face.
  • Clean the buttocks, anal and genital areas towards the end after cleaning the rest of the body surface. Handwashing properly for at least 20 seconds must be the last & final step.
  • Once done, wash the soap with plain water.
  • Dry the skin with clean towels.
  • Avoid applying any skin lotions after cleansing

👉 A nurse will start an IV line (canulae) to inject medication/IV fluids or draw blood samples as needed.

👉 The donor’s blood & urine samples are sent for one final analysis of all necessary parameters before the transplant.

6b. PATIENT PRE-OP PREPARATION 

👉 Once admitted, a transplant nurse will come-in to ask questions to confirm the patient’s medical history. This is necessary to create a Recipient File at the Transplant Unit.

👉 Patients need to stay empty stomach for 12 hours until planned surgery timing. So, do not eat a heavy meal the evening before surgery.

It is imperative that you avoid eating or drinking any liquids – even water – after midnight, else it can cause dangerous complications during surgery.

If the patient ends up eating/drinking something with less than 12 hrs to go for the surgery, it is essential to inform the medical team about it ASAP.

The surgery may be suitably delayed or even cancelled for the day. This is keeping the best health interests of the patient in consideration.

👉 The Transplant Team would advise the patient ahead in time on whether you should take all your medication the night before the surgery or leave out some of those. This is to avoid any complications from arising during the operation.

Eg: Some medicines like blood thinners (some heart patients) need to be stopped at least 3 days before surgery. This is to avoid the risk of excessive bleeding during surgery.

👉 The hospital provides with a hygiene kit. This contains a Razor/Shaver & a special soap to shower/bath with.

🔸️A nurse would shave the operating area(s) with the razor. This is necessary because hair (however tiny) can attract dust particles on it. This can contaminate the area of operation & cause infections.

🔸️The soap in the kit is anti-bacterial. Washing the skin with it removes any germs/bacteria on the skin. It also helps prevent infection around the surgery wound later.

There are some do’s & don’ts on the best way to use the soap:

• • Do not use the soap on your face.
  • Clean the buttocks, anal and genital areas towards the end after cleaning the rest of the body surface. Handwashing properly for at least 20 seconds must be the last & final step.
  • Once done, wash the soap with plain water.
  • Dry the skin with clean towels.
  • Avoid applying any skin lotions after cleansing

👉 A nurse will start an IV line (double port/triple port) in the patient’s arm or hand.

This IV channel helps to inject medication, IV fluids, draw blood samples or start a blood transfusion as needed.

👉 The patient’s blood & urine samples are sent for a final analysis of all necessary parameters before the Transplant.

👉 Putting in a Neckline Catheter

All transplant patients need special medicines during the operation to keep their heart rate & blood pressure steady.

🔸️Putting in a neckline catheter is the best way to let your surgical team send medicines to your heart in the least possible time.

🔸️In addition, a neckline can also serve as a way to dialyze the patient if necessary.

When your doctors put in a Neckline Catheter can differ as below:

I. For patients going for pre-emptive transplant

◾No need for parameter correction to ensure fitness during surgery – Neckline access created in the operating theatre

◾Need for blood parameter correction to ensure fitness during surgery – Neckline access created under local anaesthesia in Minor OT/ICU by your kidney doctors. This port can be used to correct

II. Patients stable on Dialysis (HD via fistula or Peritoneal dialysis)

◾ Neckline access created in the operating theatre

III. Patients on Dialysis via a Central Line

◾ Existing access could be used.

👉 If the patient is going in for a Living Donor Transplant, the transplant team will start the patient on Anti-rejection medication before the surgery. The technical name for this step is Induction Immunotherapy.

🔸️A common drug used in this procedure is Anti-thymocyte globulin or ATG.

🔸️Such medication begins to dampen the patient’s immune system right before the transplant. It helps to create a “relatively welcome atmosphere” for the donor kidney after the surgery.

🔸️Induction immunotherapy may be initiated via one of the IV channels. Alternatively, the medical team may ask the patient to take the first dose of anti-rejection medicine by mouth.

The decision on the mode (IV or oral) lies with the respective medical team and established in-centre protocols.

5. Morning of the surgery (for both patient & donor)

👉 If allowed by the Transplant Team, the patient may take his/her morning medicine(s) as directed with a tiny sip of water. This must be under supervision of a transplant nurse.

👉 Both the patient & donor are taken to a surgery prep area where they will get ready for surgery.

👉Patient & Donor will change to a hospital gown.

👉 The members of transplant team, such as the surgeon, nurse & anaesthesiologist (doctor who gives anaesthesia) usually meet with the both the donor & the patient.

There are separate operating teams for the Donor & the Kidney Patient.

👉The nurse will start a fresh intravenous (IV) line in the patient’s & donor’s hand or arm as needed.

👉 The IV line serves as a port to inject medication, IV fluids, draw blood samples or start a blood transfusion (if needed) during surgery.

👉 The donor & the patient will be taken to the operation theatre (OT).

Usually, operating rooms for the donor & recipient are adjacent & inter-connected.

This allows for easy & rapid delivery of the donor organ to the recipient surgery team.

👉 Once in the respective OTs, the patient & donor change to surgical clothes.

The  anaesthesiologist will give you a general anaesthesia to put you to sleep for your surgery.

👉 Meanwhile, respective families/caregivers are escorted to the waiting area till the surgery is done.

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So, this is an outline of the necessary steps in the workflow right from hospital admission up until both the kidney donor & the patient get to be under the surgeon’s knife.

Keep a tab of this space for our next article on the what-why-how of the kidney transplant surgery itself. The article will provide an easy-to-understand insight into both, the donor & the patient surgeries.

Till then, stay safe, warm, informed & vigilant about your health.

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