Kidney and Pancreas Transplant
Kidney and Pancreas Pre Transplant
There are several phases of the transplant process. The first phase is considered the pre-transplant evaluation phase. This phase is an extensive pre-evaluation process in which providers and transplant nurse coordinators review your medical information, a patient access services staff person reviews your insurance benefits, and a financial counselor reviews your ability to afford all of the costs associated with transplantation. Your insurance company will need to go over your case and give authorization for the costs associated with transplant. Many forms and tests need to be completed before you can be added to the kidney transplant waitlist.
Once we receive authorization from your insurance company and hospital administration, and it has been determined you are medically acceptable, you will move to the next phase.
Evaluation
The evaluation usually requires a 1-2 day stay in Portland if you do not live locally. Your transplant evaluation is usually done on an outpatient basis unless you are critically ill and require hospitalization. During the evaluation you will have appointments with many specialists in addition to members of the kidney transplant team. You will have lab work and diagnostic test performed. These tests vary for each person.
You will also attend a transplant education class. During this class we review information from the pre-transplant packet and you will have the opportunity to ask questions.
Selection Process and Waitlist
After all the testing and appointments have been completed, your case is presented at the kidney or SPK committee review meeting which is held once a week. Members of the transplant team are present and your case is discussed. It will be decided if you meet all the criteria to be a kidney or SPK transplant candidate.
The team may require additional testing or requirements to be met before you can be put on the transplant waitlist. Once all of the recommendations from the team are completed and you are an acceptable candidate, you will be placed on the transplant waiting list.
Kidney and SPK Transplant Surgery
Once you have been called in for your surgery, it is important for you to have this day planned out ahead of time. How will you get to the hospital? Where do you go? What do you bring?
When you get the call for your transplant, you need to arrive at Admitting on the 9th floor of OHSU. You will then go to a pre-op floor where the nurses and doctors will prepare you for the surgery. The time before the surgery is very busy. A resident, intern, or PA will perform a physical examination and take a complete history. You will need to bring a complete list of all your medications. At this time, you will be asked to sign one or more consent forms giving your permission to the surgeons to perform the surgery.
The nurses will start an intravenous line (IV) for antibiotics to prevent infection. When it is time, the nurses will take you to the operating room. Once you are placed under anesthesia, the transplant team goes to work.
Length of Surgery
The average length of time for a kidney transplant is 2-4 hours, or 4-6 hours for simultaneous kidney-pancreas transplant, and may vary according to your procedure type. The length of time does not predict the success of the surgery. Patients with a past history of abdominal surgery usually take longer during kidney transplant because of scar tissue present in the abdominal cavity.
When the surgery is complete, if you have elected to have open surgery, the surgeons close your incision with sutures or staples.
While you are in surgery, your family and friends can wait in the intensive care waiting area. The operating room nurses may come out during the surgery to give you a progress report. It's helpful to identify one spokesperson when communicating to the nursing staff, who will then pass along information to family and friends.
The Transplant Unit
You will wake up from the transplant operation on the 4A Transplant Unit. When you wake up you may experience some confusion due to the anesthetic. The sights and sounds may seem strange to you. You will be attached to many tubes, IV lines and monitors. When you are stable, the doctors will remove some of the monitors, intravenous (IV) lines and tubes. The average length of stay on the Transplant Unit is 3-6 days for kidney transplant and 7-9 days for simultaneous pancreas-kidney transplant. The length of stay depends on how you respond to the surgery, how quickly you recover from the anesthetic and how sick you were prior to the transplant. This varies depending on your overall post-transplant recovery.
After your surgery, you may feel many different emotions. Many people feel relief that it is over. It is not uncommon to feel depressed or anxious after the surgery. All these emotions are common and most people feel a little of each.
While you are on the Transplant Unit you have some important responsibilities before you can be discharged, including eating, walking, coughing and deep breathing.
Discharge
The Transplant Team will discharge you when:
- You are physically stable
- You know your medications and can set up each dose
- You know your clinic and lab schedule
- You pass the discharge review worksheet (reviewed by the coordinators)
- You have arrangements for a place to stay when leaving the hospital
Education
You will learn all about your new kidney, how to take care of it, how to prevent infection, your medications and your clinic and lab schedule. The coordinators, nutritionists, pharmacists and nurses will teach you how to take care of yourself now that you have your new kidney. You will have received a Kidney Transplant Manual. This is your lifelong guide that you will need to continue to refer to. The Transplant Team expects you and your social support participate in your education during your hospital stay. The transplant coordinator and the pharmacist will come to your room to answer questions and review your medications.
Caring for Yourself Post Kidney Transplant
You are the most important member of your care team. You need to be actively involved in your care by attending clinic appointments, getting your labs drawn, communicating with members of your care team and understanding how to take care of your new kidney.
To help care for your kidney, you will need to:
- Take medications as directed, and ask your doctor before taking any other medications, including over-the-counter medications and dietary supplements
- Eat a healthy diet, avoid alcohol and do not smoke
- Contact your doctor if you are feeling ill, and avoid anyone with colds or infections
- Have your labs drawn as directed by your doctor, including any additional testing
- Follow lifting, walking, showering and activity restrictions
- Resume employment 4-6 weeks post-transplant
Diet and Nutrition After a Kidney Transplant
Your diet will change after your transplant. If your new kidney is slow to start functioning you may need to remain on your dialysis diet of low sodium, low potassium, low phosphorus and limited fluid. However, as kidney function improves, you will be able to enjoy much more variety.
Medications
It is very important to learn how to manage your medications. You will need to understand what they are for, when they need to be taken, how it is given, and what side effects you might experience. There can be many possible drug interactions between your post-transplant medications and herbs/over-the-counter dietary supplements.
Do not take herbs or dietary supplements without first consulting with your transplant physician.
Transplant patients should never take medications or herbs intended to "boost" their immune system. Only the transplant team should make changes to your kidney drugs (immunosuppression medications). If any of your other doctors want to make changes, please have them contact the transplant team.
Post Transplant Labs
You will need to have blood tests done on Monday and Thursday mornings for several weeks. The Self Reporting Records section of this handbook is provided to track the results of your blood tests. As your kidney function stabilizes, the frequency of blood tests will decrease.
Routine Post Kidney Transplant Lab Schedule
Managed by OHSU Transplant
| Months Post Transplant | Lab Schedule |
|---|---|
| Discharge to 1 month | Monday, Thursday |
| After 1 month | Weekly |
| After 3 months | Every two weeks |
| After 6 months | Monthly |
Managed by Nephrologist (recommended)
| Years Post Transplant | Lab Schedule |
|---|---|
| After 1 year | Every two months |
| After 2 years | Every three months |
| After 3 years and thereafter | Every six months |
Routine Post SPK Transplant Lab Schedule
| Time Post Transplant | Lab Schedule |
|---|---|
| Discharge to 3 months | Monday, Thursday |
| 4 to 6 months | Monday |
| 7 to 12 months | Every other Monday |
| 1 to 1 1/2 years | Monthly |
| 1 1/2 to 2 years | Every three months |
| 2 years and thereafter | Every four months |
Biopsies
A biopsy is a procedure used for diagnosing rejection. The doctor will numb your skin with a local anesthetic and take a very small piece of your kidney using a needle. After the biopsy, a sandbag will be placed over the biopsy site for four hours to prevent bleeding. The biopsy results will be available in about 36 hours.
If you are on any blood thinning agents such as, Aspirin, Plavix, Persantine or Coumadin, you need to call your coordinator to discuss a plan prior to being scheduled for a biopsy.
Viral Monitoring
CMV
Cytomegalovirus (CMV) is a virus that is common in the general population. It is estimated that more than half of the general population has been infected with CMV by age 50. However, most adults who have been exposed to the virus do not develop CMV disease (an infection that causes symptoms and makes you feel sick).
Once infection occurs, a healthy immune system can keep the virus quiet, or dormant, in the body for a long period of time. The virus can become active if a person's ability to fight infection is reduced. If CMV disease does occur in a healthy adult, it usually causes only mild flu-like symptoms including fever, chills, and body aches. This is the mildest form of the disease. CMV disease can also be much more serious. It can cause complications that affect your lungs, liver, stomach, eyes, and intestines.
After transplant surgery, you will receive immunosuppressant medications. These drugs are important to help prevent you from rejecting your new kidney, but they also leave the body less able to fight infection. In the transplant recipient, a CMV infection can develop into CMV disease and cause serious health problems such as fever, pneumonia, gastrointestinal infection, retinitis (an infection of the retina of the eye), hepatitis or rejection of your transplant. Rarely, pneumonia can be fatal. A CMV infection can also make you susceptible to other infections by reducing your level of immunity even below what is caused by the immunosuppressant medications.
BK
The BK virus is a member of the polyoma virus family. Past infection with the BK virus is widespread, but significant consequences of infection are uncommon, with the exception of people who have impaired immune systems or are immunosuppressed.
The BK virus rarely causes disease since many people who are infected with this virus are asymptomatic. If symptoms do appear, they tend to be mild: respiratory infection or fever. These are known as primary BK infections. The virus then disseminates to the kidneys and urinary tract where it persists for life. It is thought that up to 80 percent of the population contains a dormant form of this virus, which remains latent until the body undergoes some form of immunosuppression. These cases are usually more severe and lead to renal dysfunction.
EBV
Epstein-Barr virus (EBV) is a member of the herpes virus family and one of the most common human viruses. The virus occurs in a vast majority of the population, and remains latent until the body undergoes some form of immunosuppression.
Monitoring Vital Signs
Your care does not stop once you are discharged from the hospital. All the things you have learned during your hospital stay will play an important part in your care at home. It will be your responsibility to perform the following measures, and will assist the transplant team in evaluating your health care and kidney function as an outpatient. The Self Reporting Records section of this handbook is provided to track the results of your temperature, weight and blood pressure.
Temperature
Take your temperature at least once a day and record it. If your temperature is 100˚ Fahrenheit or greater call the transplant nurse. If you feel like you have a fever or the chills, take your temperature and record it more often. If you have a fever of over 100˚ Fahrenheit after 3 months post-transplant, call your local doctor.
Celsius and Fahrenheit equivalents
37˚ C = 98.6˚ F
38˚ C = 100.4˚ F
39˚ C = 102.2˚ F
40˚ C = 104.0˚ F
Weight
Weigh yourself every morning at approximately the same time, wearing the same amount of clothes, on the same scale, and record it. Use your scale as a guide to help control weight gain. If you gain more than two pounds over one day or four pounds over seven days, call the transplant nurse.
Blood Pressure
Take your blood pressure at about the same time every day, twice a day and record it every time. Know what your blood pressure should be before you leave the hospital. Do not take your blood pressure on the arm with a dialysis fistula or graft. Remember, blood pressure that is too high or too low can damage your kidney.
Financial Considerations
It is important for you to have a complete understanding of what your insurance benefits cover and what expenses are your responsibility. Terms and coverage for transplantation vary widely among insurance companies. Read your policy and talk to your insurance company's benefits office to understand your coverage.
Many insurance companies have a co-payment for services or a deductible. Some insurance companies have a lifetime maximum on transplant benefits and caps on medication coverage.
Medication
Medications can create a financial strain on you and your family after transplant. These medications are required for the rest of your life. It is very important that you understand what kind of medication coverage your insurance benefits offer and have a clear understanding of what medication costs are your responsibility.
Other costs to consider
For patients living far away, other costs to consider when you are here in Portland, not only for yourself but for your support person and family members as well include:
- Loss of wages for you and your support person
- Transportation
- Lodging
- Food
Resources
Our financial coordinator is an invaluable resource for the transplant team and yourself. They, along with the transplant social worker, will help you with any questions you have regarding the costs of transplantation. Because transplantation is very complex, it may take several weeks to determine your eligibility and coverage. If you do not have enough coverage, we will try to help you find possible alternatives and resources. If resources cannot be identified, you may be responsible for a deposit of funds in advance of your evaluation.
After your transplant
After you receive your transplant, you continue to be responsible for understanding your insurance benefits, and to inform our office of any changes to your coverage. Benefit coverage can change from year-to-year, so it is important to contact your insurance provider periodically to confirm your benefits.
Contact Us
Clinical Transplant Services
3181 SW Sam Jackson Park Road, CB569
Portland, OR 97239
Phone: 503-494-8500
Fax: 503-494-4492