Caroline Basarab-Horwarth, Living Donor Transplant Coordinator, at Sheffield Teaching Hospitals NHS Foundation trust talks about becoming a living kidney donor.
In May 2018, Kidney Matters visited Sheffield Teaching Hospitals NHS Foundation trust to talk to living Donor Transplant Coordinator (LDTC), Caroline Basarab-Horwarth about the process of becoming a living kidney donor, donating either to someone you know - 'directed' donation, and to someone you do not know - 'non-directed' or 'altruistic' donation. Caroline was the coordinator who looked after Linda Pickering on her living kidney donation assessment earlier this year. Within a very busy renal department at the Sheffield Northern General, Caroline job shares with one other LDTC, Debbie Butlin, and one full time Clinical Practitioner, Lisa Hamilton.
When a person has decided that they would like to become a living kidney donor and they have made themselves known to you, what are the first steps in the process?
Usually the potential donor will contact the Living Donor Team by telephone. First of all, we thank them for stepping forward and offering one of their kidneys to someone with chronic kidney disease. General details such as their age and address are taken and questions regarding their medical history are asked. The next step is explained and a living donor information pack (leaflets about living kidney donation) is sent out in the post to them. Then, assuming nothing in their medical history is obviously going to preclude them from donating a kidney (diabetes for instance), and they wish to proceed Lisa will contact them to make an appointment for their initial assessment. This appointment is with Lisa and Debbie or myself and takes about two and a half hours. At this visit we test:
- Kidney function
- Cross match (blood and tissue type compatibility test)
- Liver function
- Carry our virology screening
- A chest X-ray
- Urine and blood pressure and record weight
Debbie or I will then go through:
- The living donor pathway
- What tests are involved and why
- The surgery involved
- Recovery time
- The risks
- Life with one kidney
- The regular check-ups they will receive for the rest of their life
- Details on how to claim travel expenses and any loss of earnings associated with the donation, whether they eventually became a donor or not.
Then we talk through any questions they may have. At this point it is important for the potential donor and their family to understand that to proceed with living donation it must be at minimal risk to the donor. Potential donors are often declined and although they are in good health it is in their best interest not to become a donor. This is reassuring for all potential donors, their family/friends and most importantly the recipient.
What medical and psychological tests are performed on the potential donor?
The results of these tests take up to three weeks to come through and are reviewed by a consultant nephrologist. The potential donor is then contacted to discuss their results. If the results indicate that they are potentially fit enough to donate a kidney, a psychological assessment is booked with a renal psychologist.
It is as important to assess the potential impact of living donation on the donor's mental health as it is their physical health. Also, the psychological assessment will reveal any additional support they may need through or after the donation, and we can put this support in place in plenty of time.
Once this has all been done we invite them back to the hospital for their 'One Stop Assessment Day'. During this day the potential donor has lots of investigations. We warn them that this is a long day and starts very early in the morning. Offering all these tests on one day reduces the number of visits to the hospital for the potential donor, as we understand it is important to reduce time required off work, travel to the hospital, etc.
During this day the tests involved are:
- Echocardiogram (heart scan) if over 50 years old.
- Very accurate measurement of kidney function (a small amount of isotope is injected through a canula (a semi-permanent access into the vein) and blood tests are done throughout the day to calculate how quickly and efficiently the kidney is clearing the isotopes).
- Medical assessment with a Consultant Nephrologist.
- Surgical assessment with a Consultant Transplant Surgeon.
- CT scan of kidneys (checking that the kidneys have no scarring, cysts or stones), and to analyse the plumbing of the kidney. The scan is reviewd by a Consultant Radiologist, the Surgeon removing the kidney and the Surgeon transplanting the kidney into the recipient, to see if donation can be arried out at minimal risk to the donor, the kidney and the recipient.
All these results are then reviewed by the living donor multi-disciplinary team (MDT). If everyone is happy that this is a healthy donor who will manage life well with one kidney, and who is both physically and psychologically well enough to donate at minimal risk, they are informed they are a suitable donor.
If the donor is an altruistic donor we let them know when the next matching run will take place. The matching runs happen every three months and we reassure them that the donation must fit into their timetable and that we will do our best to accommodate a time-scale that fits best with family or work commitments.
If the donation is a directed donation the timing of the transplant will be planned around the recipient's health as well as the donor's availability.
If a potential donor steps forward to donate to a relative or friend, but their kidney is not compatible, does the donation work-up process stop at this point?
We offer incompatible pairs the option of registering into the National Kidney Sharing Scheme (NKSS). Potential donor workup is offered in the usual way and if the donor is found to be suitable they are registered into the Scheme. Once registered in the scheme, the pair wait to be matched. This can be either in a two way exchange or a three way exchange or part of a non-directed altruistic chain. National Health Service Blood and Transplant (NHSBT) facilitate the matching runs every three months. The outcome can provide recipients with a low risk living donor transplant that they wouldn't have been able to receive directly from their donor. The transplants usually happen on the same day, irrespective of where donors and recipients live in the UK.
The wonderful thing about an altruistic kidney donation (non-directed) is that they help to trigger a chain of donations and transplants, and someone on the national transplant waiting list will also benefit from a kidney transplant.