preparing for kidney transplantation | Singapore General Hospital

As a concerned family member witnessing a loved one's diagnosis of chronic kidney disease (CKD), it's natural to feel a sense of worry and anxiousness as your doctor discusses treatment options. However, amidst this uncertainty, the mention of "Living Kidney Transplantation" sparks a newfound interest and hope.

Indeed, there may be a way to offer a lifeline in this challenging situation.

Hit "Play" on the video below for more information about what you need to know before donating your kidney:

Alternatively, read on. In this article, we embark on a comprehensive exploration of the remarkable path that countless individuals have taken to make a difference in the lives of others. Whether you're considering becoming a living kidney donor or seeking information to support a loved one on this journey, this guide is designed to illuminate every step of the way.

Stages of Living Kidney Donation

Before the actual transplant takes place, both donor and recipient would need to undergo various consultations and checks with the clinician team. Hit "Play" to find out how these work:

We're going to deep-dive into each stage to demonstrate what considerations are made before deciding if one is a suitable donor.

Stage 1: Counselling

If you have questions about how kidney transplant works, this is the time to ask them.

Counselling addresses fears, provides information about the procedure, and help both donor & recipient prepare themselves mentally and emotionally for the procedure.

Stage 2: Evaluation

Evaluating the living kidney donor and recipient will take place in several stages as follows:

1st stage: Tests to check general health of the potential donor and recipient
1st Nephrologist review: A doctor will conduct an interview and physical examination, as well as check on the results of the 1st stage tests
2nd stage: Clinic visits to the medical social worker and psychiatrist will be arranged. Sometimes, the visit to the medical social worker may take place earlier. The potential donor will be arranged to do a CT angiogram (kidney scan), followed by a surgeon review for both potential donor and recipient. Additional tests or visits to other specialists may be arranged depending on your health status
2nd Nephrologist review: The doctor will check on the results of all the remaining tests. When the donor assessment is complete and you are healthy to donate, the doctor will ask you to sign the consent forms required for the donation to take place if you are healthy to donate

These documents will then be submitted to the Transplant Ethics Committee (TEC), which is appointed by the Ministry of Health to approve all kidney donor transplants in Singapore.

Stage 3: Interview

The TEC will review the reports made by the transplant team to decide if transplantation can be authorised.

Additionally, they will also interview the potential donor & recipient as well as evaluating the nephrologists to facilitate its decision-making.

Upon approval, the transplant must be performed within 8 to 60 days, failing which a re-application to the TEC is required. The TEC’s decision is final.

This is a flowchart of the full process:

Tests Before The Surgery

Now that you know more about kidney donation and have decided to follow through, further examination of your health history and suitability to donate are required. These tests seek to confirm the following:

Overall fitness to be a donor

Blood pressure readings: Blood pressure readings will be performed when you are in our clinic. You may need to undergo 24-hour blood pressure monitoring at home
Electrolytes, kidney function, liver function, complete blood count, clotting test, cholesterol and triglycerides (blood test): These tests are done to ensure general good health status
Blood sugar +/- 2-hour glucose tolerance test: This test screens for diabetes or early diabetes
Urine testing: Urine samples will be required to determine if there is any blood, protein, or bacteria in your urine
Viral screening such as Hepatitis B, C, Syphilis, HIV: Check for viruses which can be transmitted to the recipient during the transplant
Chest X-ray: This test is done to ensure that your heart and lungs appear normal
Electrocardiogram: A tracing of your heart rhythm is done to make sure it is normal
Specialised heart tests: Ultrasound and stress testing of your heart if you are > 50 years old
Pap smear: Required for all women who are sexually active, or have ever been sexually active. If you have had a hysterectomy you will not need a pap smear
Mammogram: Required for all women ≥ 40 years old
Chromium-51 EDTA GFR: A nuclear medicine kidney test that measures the clearance of your kidneys. It is a confirmatory test to ascertain your kidney function.
CT Angiography for kidney donor: This test shows the anatomy of your kidney, arteries, veins and ureter

Compatibility with your recipient

Tissue and Crossmatch

During this test, you will be tested for HLA antigens on up to 12 different markers, which can have thousands of different combinations. The purpose of the HLA typing is to find out how similar your tissue is to your recipient’s tissue. Although a better match may result in better outcomes, excellent results can also be seen in less than perfect matches as several other factors play a part in a successful transplant.

Crossmatch tests determine if your recipient has antibodies against your HLA antigens which may injure the donated kidney.

Blood Typing

While the donor need not be of the same blood type as the recipient, there may be limitations depending on the donor's blood type.

Other tests may be needed depending on your medical history and results of the tests. The doctor will certify that you are fit to donate if you are medically fit based on your complete evaluation.

Preparing for Your Kidney Transplant Surgery

It is important to protect yourself before the donation surgery. By protecting yourself, you will decrease the risk of harm to your recipient.

If there is a change in your health, it will not only put you at risk but also the recipient. Here are some recommendations to reduce the risk of complications and increase the chances of a successful procedure:

If you are overweight, target achieving a healthy weight
Stop smoking at least six weeks before surgery
Check with the transplant team regarding any medications you are taking, and when to stop prior to surgery
Stop taking over-the-counter or herbal medications at least two weeks before surgery
Avoid crowded places to protect yourself from the common flu
Avoid having unprotected sex
Avoid body piercings and tattoos to reduce the risk of infection from contaminated needles

Surgical Procedure

Next, let's take a closer look at the kidney transplant procedure.

The left kidney is usually removed for living kidney donation as it has slightly longer blood vessels. Sometimes, there may be more than one blood vessel or a slight difference in the size of the kidneys. In these situations, the right kidney may be removed instead. The donor is always left with the “better kidney” of the two.

There are 2 types of procedures: open and keyhole method.

1. Open Method

Open method involves making a large cut on the side of your abdomen to retrieve the kidney.

At SGH, most kidney donor nephrectomies are done by the laparoscopic method as it leaves a smaller scar, has a shorter recovery time and is less painful. However, the open method is used when the laparoscopic method is considered difficult, or if a complication occurs during laparoscopic surgery that requires conversion to open surgery.

2. Keyhole method (Laparoscopic kidney donor nephrectomy)

In the laparoscopic method (also called “keyhole”), several smaller incisions are made progressively on the front of your abdomen.

First, a small incision is made near the upper left side of your abdomen. An instrument called a port is placed so that surgical instruments can be introduced into the abdominal cavity. The abdominal cavity is inflated with carbon dioxide to lift the abdominal wall away from the organs and create adequate room for the surgeon to operate. The inside of the abdominal cavity is visualised using an instrument called a laparoscope. The laparoscope allows a video camera to project images from inside your abdomen onto video monitors in the operating theatre for your surgeon to view and perform the operation.

The surgeon will inspect your abdominal cavity through the laparoscope to ensure that it is safe to proceed with surgery.

Two to three additional small ports are then inserted to allow other instruments to be used for surgery. Once the kidney is separated from the connecting tissues and blood vessels are safely controlled, the surgeon will remove the kidney from your body through another incision in the lower abdomen.

Another surgeon will collect the kidney and proceed to do the kidney transplant for the recipient.

In the meantime, your surgeon will check that there are no areas of bleeding and empty the carbon dioxide gas from the abdominal cavity and close all your incisions.

Surgery Aftercare

Recovery after surgery is often perceived as being bedridden at the hospital and in pain for a long time, but this is not true. Here's what you can expect after the surgery is complete.

Hospital stay

The average length of stay in hospital is 3 to 4 days but may be longer, depending on your condition.

Follow-up consultations

The standard practice is to have a follow-up consultation 6 weeks after the surgery.

Post-discharge lifestyle changes

You will be able to walk and shower when you are discharged. You may require painkillers for 1-2 weeks. You will not require any long-term medication. We encourage walking and light activities as soon as the donor is able to, However avoid heavy lifting, exercise, and physical labour until 6 weeks have passed.

Many people start driving around 2 weeks after being discharged from hospital but it is important not to drive while taking narcotic pain medication such as tramadol and codeine.

Post-surgery pain

Pain after the surgery can be managed well with painkillers. Some donors may be prescribed patient-controlled analgesia (PCA). This involves the use of a machine that delivers controlled doses of intravenous painkillers when the donor pushes the button during pain. This machine does not allow overdose of the drug.

Going back to work after surgery

Your recovery time will depend on the type of surgery you had and whether there were any complications. Most people will resume normal activities and be back to work within 4 to 6 weeks after the surgery. If you are working, hospitalisation leave will be issued for this period.

Long-term Care

In the long term, you are encouraged to live a healthy lifestyle to prevent the development of hypertension and diabetes by:

The hospital will schedule yearly clinic visits and tests to check your general health as part of donor care. It is important that all donors continue regular follow-up with a doctor after donation.

Frequently Asked Questions

Finance

How do I finance my kidney donation?

There are a few options available:

Mediasave & Medishield Life: You can utilise your Medisave monies and make claims from Medishield Life for your inpatient and surgery charges. If you have purchased other private insurance plans, do check with your insurance agent on making claims for your kidney donation expenses. In addition, you should also enquire about how the kidney donation will impact your future insurance purchases
National Kidney Foundation's (NKF) Kidney Live Donor Support Fund: This fund provides financial assistance to needy live kidney donors who are Singaporeans or Permanent Residents. It assists with kidney-related medical welfare and insurance. Eligibility for the programme is subject to assessment by NKF
Reimbursement: The Human Organ Transplantation Act (HOTA) allows for the reimbursement of living kidney donors for direct and indirect costs incurred as a result of the donation from their recipients. You and your recipient will need to declare any arrangement for reimbursement of your expenses
Others: Check if your employee benefits cover kidney donation

For more information, feel free to speak to a medical social workers about coping with the expenses.

Will I have trouble applying for insurance and making claims for kidney-related issues after I donate?

Before purchasing, check with the insurance companies if donation is covered or will affect life coverage or premiums post-donation. Speak to a financial agent about your condition and ask for an appropriate coverage plan that meets your needs.

Personal Health

Are there risks associated with kidney donation?

As with any surgery, there is always a possibility of complications. Some important surgical risks of living kidney donation include:

Will I develop health problems in the future?

You will undergo several tests before donation to ensure that your health is not affected as a consequence. You may notice a slight increase in blood pressure by a few points but this should not be significant enough to cause hypertension.

Does kidney transplant increase my risk of kidney failure?

Living kidney donation does not affect life expectancy or lead to poor health. However, after donation, by virtue of having a single remaining kidney, 25 - 35% of kidney function will be permanently lost. The absolute risk of kidney failure after donation is <1%.

Should a donor develop kidney disease, he/she will be put as a priority in the waitlist for a deceased donor kidney.

I'm worried that my kids and spouse may need kidney transplantation in the future and I will not be able to help them. Should I still proceed?

There are things that you need to consider:

Do you believe that your child or spouse will likely suffer kidney failure in the future? Do they have any pre-existing conditions that may lead to kidney disease? Will there be other potential donors in the family who will donate to them should they face this situation in the future?

Speak to the transplant team if you are not sure if your loved one is at risk of kidney disease in the future.

I'm 70 years old. Am I too old to donate a kidney?

If you are in excellent health, you may still be considered as a potential donor.

In fact, our oldest living kidney donor donated one of her kidneys to her daughter at the age of 75!

Will kidney transplantation affect my fertility?

Kidney donation will not affect your fertility. It is important that you discuss family planning with your partner before donation.

A potential female kidney donor needs to avoid pregnancy for at least six months after surgery to allow the body to recuperate.

Will I need long-term medications after donation?

There is no need to take any specific medications after living kidney donation.

Lifestyle

Do I need to make a lot of changes to my current lifestyle?

There are some adjustments to your lifestyle after kidney donation so as to avoid injury to your remaining kidney and prevent development of medical problems that increase your risk of developing kidney disease.

You are encouraged to adopt a healthy lifestyle, especially to prevent diabetes and high blood pressure
You will need to avoid certain medications that may damage the kidneys e.g. diclofenac/etoricoxib and herbal medications
Avoid contact sports e.g. martial arts, football

Are there any religions that do not support donation?

Consult your transplant coordinator to find out more about religious perspectives.

Will I need to taken extensive time off from work after the surgery?

Each person will take a different length of time to recover from the surgery. Most people will resume normal activities and be back to work after 4-6 weeks. Donation should not affect your long-term health and your ability to work.

Will my employer see me as a "sick person" or someone with a medical condition?

Only very healthy individuals can donate a kidney. Your medical condition should not change because of your donation.

If your employer is unsure of your medical condition after the surgery, we endeavour to clarify your health status to your employer with your permission.

I do not have enough annual leave. What should I do?

The tests to evaluate your suitability for donation will need to be done during office hours. You should seek your employer's understanding to excuse you from work and notify them in advance.

We will try to arrange the appointments to suit your availability and minimise the number of trips you have to make as much as possible. Additionally, our team will issue time chits, medical certificates and supporting medical letters when required.

If necessary, we can also consider admitting you to complete most of your tests.

What happens if I decide to change my mind?

No one should feel undue pressure to donate a kidney. If you are not sure or feel uncomfortable about donating, inform your transplant coordinator. Please be assured that you may change your mind at any time.

When can I start to travel again?

It is advisable to travel only 3 months after your surgery. You can seek your nephrologist's advice before making your travel arrangements.

Finally, as overwhelming as it may seem to embark on this path with a loved one, don't forget to acknowledge the emotions that may arise as you undergo the various tests & briefings, surgery, and more. Should you need a listening ear at any point, feel free to reach out to the transplant team to talk about the emotional difficulties you face.

Alternatively, seek solace in inspiring quotes from real kidney donors in this booklet below:

Living Donor Renal Transplant Guidebook Part 2.pdf