Imagine this. You’re yet to open your eyes, but you’re conscious. You can hear hushed voices around you, sense a strong ambient smell, get a feeling of being “lifted & wheeled somewhere”. At a point, you feel a sudden pain on one side of your lower abdomen. It’s only a matter of time that you open your eyes nice & wide and if health & luck are on your side, you recognize most of those masked faces, where you are and what you just underwent. Wondering what’s this all about? Well, that’s my own experience of waking-up after my Kidney Transplant Surgery.

Of course things may differ individually, depending on how the new kidney works in a recipient and his/her general health. Despite variable experiences, once you do wake up, you officially enter the Transplant Survivor Club. Congratulations!

So how does the rest of your hospital stay look like?

That is what we aim to walk you through, with this article.

CONTENTS

1. Introduction

2. In-hospital care plan

• Anti-rejection and supportive Medication
• Physical examination & Lab tests
• Wound care
• Restoring mobility
• Lung “physiotherapy”
• Hospital Diet
• Tubes & catheters: Monitoring & removal
• Discharge

HOSPITAL STAY AFTER KIDNEY TRANSPLANT

Introduction

As you wake up after your Kidney Transplant, it is natural for you to feel groggy and tired. This is due to the effects of heavy pain killer medication started after any major surgery. Moreover, there are a number of tubes attached to your body that make it all quite restrictive. But as time passes, the effects of anaesthesia & pain killers wear-off plus your body starts adjusting to your new medicines (explained below), you feel energetic, and breathe better.

During your hospital stay, there is a dedicated team of transplant nurses and doctors who monitor your recovery and treat as and when needed. Scroll below and read on to get a comprehensive insight on all the different aspects that make up your care plan at the hospital.

NOTE

Your length of stay and recovery in the hospital will depend on a few factors including:

• • The type of transplant procedure (Living or deceased donation)
  • Your body’s acceptance of the new organ
  • Your overall health

Each patient has a different rate of recovery. It is only after your Transplant Team determines that you have regained your strength and your health is stable that you receive your discharge clearance.

Your in-hospital care plan

1. Start anti-rejection medicines & continue co-morbidity medication

Right after your kidney transplant, most (or all) of your medication that you were on for chronic kidney disease (CKD) will be replaced for medication meant to support your new kidney to survive. These medicines work by “training” your immune system to be kind to the new kidney, allow it to settle in and start functioning.

The rationale is pretty straight forward. Your immune system is akin to a stringent immigration official who is extremely particular about the specific identity requirements of what gets to survive within the body and what doesn’t. Each of our organs has a specific set of identity proteins approved by the immune system, that allows them to function in peace. These identity proteins are unique for each of us. Since a donor kidney comes from another individual, it would contain an alien set of identity proteins. So, a fully active immune system will naturally attack the donor kidney as an “outsider” and cause graft rejection. To prevent this, immuno-suppressive medication become the mainstay of maintenance treatment after a kidney transplant.

For details on anti-rejection medicines prescribed after a kidney transplant, click here

The downside of using anti-rejection medicines is that they suppress your immune system’s overall ability to fight infections. This makes you prone to contracting infections easily or letting even minor infections cause more serious symptoms. Some bacterial and viral infections (CMV, EBV, BKV) are notorious in this regard. If unchecked, these could even cause your body to reject your new kidney. To prevent this from happening, you will also be given a course of Antibiotics and Anti-viral medication for some time as a precautionary measure.

Kidney recipients will still continue any medication they had been taking for the root cause of their chronic kidney disease such as for Diabetes mellitus, high blood pressure, auto-immune conditions etc. Similarly, transplant patients with co-morbidities unrelated to kidney disease will continue their treatment post-transplant. However, such medication will be duly reviewed by your transplant physician to ensure they do not harm your new kidney. If necessary, the dose and/or the class of medicine will be suitably modified.

2. Physical Examination & Lab Tests

During your hospital stay, a team of transplant nurses will look after you during your hospital stay. These professionals are specially trained to monitor & look out for any potential complications associated with kidney transplants. Your nurse will check on you periodically for the following:

• NOTE YOUR VITALS

Your transplant nursing team will maintain a chart of your Pulse, BP, Heart rate & rhythm and Blood Oxygen & Carbon dioxide saturation from the Monitoring system attached to you. Further, they will record your body temperature, how conscious and alert you are, check for any collection around your surgical wound, note if there is any discharge from the wound or via the surgical drain temporarily inserted into your abdomen.

During rounds, your doctors will be updated on these nursing records plus check on how well your surgery wound is healing. They may conduct an ultrasound scan of your lower abdomen right in your room to check on your new kidney. In addition, they will also look for any sudden water retention & weight gain, signs of anaemia or any breathing difficulties.

• CHECK YOUR URINE OUTPUT

The best bedside parameter to assess your how well your new kidney is functioning is to assess your Urine.

After your kidney transplant, a urinary catheter will be in place up until 5 days or more (if required).  This catheter is attached to a urine bag with graduated measurements printed on it, attached by your bedside. The nurse will note down your urine volume at different time points, any abnormal discoloration of your urine, any sediment from the urine collection bag. A daily urine sample will also be sent from this bag for lab tests (physical, chemical & microbiological analysis) for further scrutiny.

• SEND BLOOD SAMPLES FOR LAB TESTS

Your nurse will also collect your blood samples everyday and send for labs. These help your medical team assess:

◾How well your body has accepted the new kidney

◾How efficiently, the new kidney is working

◾The state of your co-morbidities (eg: Diabetes, Heart disease etc), if any

◾The levels of some of your immunosuppressant medication

RATIONALE

Among the possible early complications of Kidney transplant, there is a chance of losing the new kidney graft to Hyperacute & Acute rejection. This could be due to a hostile immune system in the recipient despite all medication or following an infection. Such conditions manifest as high fever, raised BP & pulse rate, headache, malaise, fatigue, sudden low/no urine output despite adequate hydration, sudden weight gain and an acute deterioration in blood parameters. Checking vitals, urine parameters and conducting routine blood tests helps catch such untoward situations early on and treat them to salvage the new kidney.

3. Wound care

Any surgical wound requires dedicated regular sterile dressings to prevent any wound infection. This is more significant in case of transplant patients who are on immune system-dampening medicines. This is because weakened immune system could snowball any minor infection into major trouble that could cost the patient their new kidney unless treated in good time.

Your nursing team will ensure your wound dressings are changed everyday or every time any oozing from the wound soils the dressing, whichever be the case. This will involve them checking up on your stitches and the surrounding area for:

• Any signs of possible infection (such as redness, sharp pain upon contact, any pus,blood or fluid discharge)
• Wound dehiscence (coming off of a few sutures/staples impacting wound closure)

Your medical team will note and act upon any deviation from a normally healing surgical wound at the earliest.

4. Restoring mobility

Staying immobile for a prolonged period of time, especially in obese patients could cause abnormal blood clotting in deep veins running between the muscles of your legs. The technical name for this condition is Deep Vein Thrombosis (DVT).

Why does this happen?

Well, normally our muscles contract and relax periodically with average daily activity. Such muscle movements help to squeeze blood through deep veins situated between them. In patients who are bedridden for prolonged period of time, say over a week without any leg movement, the usual “muscle-led coaxing” of blood flow in deep veins stops. This effectively slows down the pace of blood flow. Such sluggish flow may cause red blood cells to clump up to form clots. Refer to the illustration below (by Bupa healthcare UK) to see how this happens.

This is more of a possibility in patients who have risk factors for heart disease like obesity, high blood cholesterol, high blood pressure, smoker or on medication such as steroids that can promote clot formation.

Such blood clots may gradually obstruct blood flow right below where they form or sometimes may dislodge to travel upwards & block tiny blood vessels of lungs – a potentially fatal condition.

To prevent such untoward complications, it is imperative that all patients after their kidney transplant regain muscle movement as soon as possible. Based on your health, your medical team will advise you to:

• Exercise your foot and calf muscles as shown by the visiting physiotherapist, at frequent intervals whenever awake.
• Start walking around the ward slowly by Day 3 or 4

If your pace of recovery is slow such that you are unable to adopt the above practices, your medical team will:

• Prescribe compression stockings
• Advise procedures like intermittent pneumatic compression of legs and Venous foot pumping

All through your hospital stay, your medical team will try and ensure prevention of such abnormal clotting (DVT). However, please immediately report any swelling, pain, discomfort or redness in your shin and calf (however minor), to the medical staff on duty. These may point towards an abnormal clot. Early diagnosis is critical to treat the condition successfully.

5. Lung compliance exercises

Kidney transplant is a major surgery. Your surgical team will put you to sleep with General Anaesthesia during the surgery. This works by temporarily dampening all your nerve signals to all parts of the body including your lungs and chest muscles that help you breathe. As you wake up after surgery, all your nerves gradually regain near-complete function over a few hours to a couple of days.

Now, lungs are major organs that supply life-saving oxygen to all parts of your body. The faster your lungs start to inflate/deflate normally, the better, right? Starting lung compliance exercises is the best way to achieve this. Else like after any major surgery, there is a risk of your lungs collapsing. A common method is using a personalized Spirometer Respiratory Exerciser for sustained maximal inspiration (SMI) as below:

Your Physiotherapist will ask you to take the longest & deepest breath as you can, comfortably, via the pipe attached to the Spirometer device and exhale slowly. Doing so will coax your lungs to inflate to their maximum capacity at that time point. How high the balls in the three columns rise while you inhale, gives a rough idea of how much your lungs inflate with that breath. The target is to make all three balls rise to the top of the column with each breath. However, it is imperative that you DO NOT INVITE DISCOMFORT just to meet the target. Remember, it is all about being gentle, steady and sustained.

Doing this Lung exercise regularly improves the efficiency of your breathing muscles in your chest, restores normal lung inflation/deflation and prevents lungs from collapsing.

6. Hospital Diet

When you start to drink and eat after surgery depends on how well your intestines are prepared to handle digestion right after surgery.

As with lungs (explained above), general anaesthesia during the transplant surgery temporarily dampens nerve signals to muscles that make up your bowels. This causes your natural bowel movement to be absent for sometime (usually 24 hrs) after you wake up from surgery. As a result, your intestines are unable to digest food until nerve signals normalize.

Your doctors & nurses can check if your bowel movement is back by placing a stethoscope on your abdomen. Further, if you pass any flatus (wind), it is also a sign of restoring bowel movement.

• Hence, your medical team advises you to not eat or drink anything on Day 0. You will be on IV fluids that will continue to nourish you on that day.
• As soon as your medical team ascertains that your bowel movement is back, you can start taking Liquids (water, juices & soups) on Day 1 & Day 2.
• Day 3 is usually about gradual transition, diet-wise. Expect bland semi-solid food with liquids that day.
• Further on, if no other complications set-in, you can start Solid diet with continuing liquids from Day 4. This will be as per medical diet requirements set by your renal dietitian based on your lab test results.

7. Tubes & Catheters: Monitoring & Removal

Once you wake up after surgery, you find a number of wires & tubes restricting your movement. These tubes serve various purposes like:

1. Docking you to the ICU monitor to record your vitals
2. Oxygen mask helping you breathe well
3. A neckline catheter with triple port to pump in medication during surgery and in the ICU
4. IV lines on both hands/forearms often with multiple ports for medication, fluid balance, nutrition
5. Surgical drain temporarily inserted around the transplant wound with a collection bag
6. Urinary catheter attached to a collection bag

Under normal circumstances, when the transplant patient recovers along clinically expected lines, all the tubes named above are removed sequentially.

Your transplant nurse will remove your Oxygen mask as soon as you’re comfortable breathing on your own. Normally this is by Day 2 once you’re out of intensive care unit (ICU).

The neckline catheter is removed by Day 3, your surgical drain by Day 4 provided there is no/minimal collection and the Urinary catheter by Day 5. The IV lines are removed at the time of discharge (usually Day 8).

Once the patient starts using the toilet, maintaining local hygiene and not straining during nature’s calls is of utmost importance. Your medical team will advise you on this matter at discharge.

8. Discharge if all good!

If you recover on clinically expected lines and no new complications arise, you should be good to go home by Day 8 after your Kidney Transplant. Your medical team will provide you with a folder containing your  discharge sheet, medical records during hospital stay, bill receipts and follow-up schedule. In addition, you will also find your personalized guide on self-care after kidney transplant. This includes but is not limited to:-

1. Your medicine schedule and the importance of taking them on time
2. Wound care
3. Stress on hygiene maintenance
4. Importance of regular follow-ups
5. Slow dietary transitions
6. Importance of moderate activity to limit weight gain but avoid vigorous exercise/contact sports
7. Advice on restoring normal life activities (daily house work, employment/academic commitments, eating out, traveling, marriage, family planning etc.)

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