By Nathan L. Walls

Kidney Transplant – Part II: Surgery

Read Part I

After our day of pre-admission testing in Philadelphia, my donor flew home while Robin and I drove the 90 minutes back to Williams Township. For the rest of the week, work was a whirlwind as I transitioned from development work to focusing my time on wrapping up training and documentation. The best case scenario my transplant nephrologist presented to me was being out of work for a month. August for my team is operationally the busiest month of year, and typically my time in August focuses on addressing emergent issues.

This year, that would be different in that I had to make sure my team understood the sorts of issues that land on my plate in August and similarly, ensure they had the knowledge to confidently address any of those that came up while I was away. I work with a fantastic team, and everyone was enthusiastic about both my surgery and in filling in while I was away.

The day before surgery, we finalized packing (we packed way too much stuff), brought pets to Robin’s folks for caregiving, and drove down to Philadelphia. The drive in was splendid, driving to City Avenue from Lincoln Ave along Wissahickon Creek. It reminded me, in a way, of Rock Creek Parkway in Washington, DC.

We arrive at our hotel, unloaded the car, and brought everything to our room. This would be the last substantial lifting I’d do for weeks. My donor and their post-surgery caregiver were also staying in same hotel, so we dropped by their room for a long-overdue family reunion. The prior week’s pre-admission testing visit presented the first opportunity to see a directly-related family member I’d seen since early Dec. 2019. Knowing my kidney function numbers and how risky Covid has been with organ damage, Robin and I have been staying away from large gatherings, dining in, etc. since mid-March 2020. So, this being only the second such opportunity, and with a few more opportunities through the week, it made sense to take as much advantage as we could.

After a brief visit, it was time for all four of us to head to our respective beds since our call time was 6:45 AM the following morning. My donor and I had a pre-bed shower and anti-bacterial wipe routines to complete, too.

As I fell asleep, my thoughts focused on what surgery would look like in the morning, and the remarkable fortune that brought me to this point. I had similar drifting to sleep thoughts in the weeks leading to now.

Day 0: Wednesday, July 27

Robin and I were up early to get ourselves ready. I had a second round of anti-bacterial wipes to complete. I also had the last liquids I could have until after surgery. A little after six, we headed the few miles across North Philadelphia to Temple. Our route focused on surface streets down to Fairmont Park West, across the Schuylkill River into East Falls and on towards N. Broad Street. I used the opportunity for the last driving I’d be doing for about six weeks.

We parked and headed to the Ambulatory Care Center where I checked in. My donor was already here and we waited for our calls into the prep area. That was soon enough and a registered nurse showed me to a curtained off area with a gurney, a gown, and hospital socks. I changed out of my own clothes, into the gown and pulled a blanket onto my legs in the bed. The pre-surgical registered nurse started an IV and a medical assistant came by and took my vital signs.

Over the course of the next hour and a half, I had visits from my anesthesiologist, anesthesiology residents, my surgeon, Dr. Karhadkar, surgical residents, my donor’s transplant coordinator who’d been helping both of us in the last stages of preparation, my donor’s surgeon, and, once things were far enough along, Robin.

The general process was the medical team working through a set of process paperwork and checklists in a binder that would end up traveling with me to the operating room. I was informed again about my anesthesia treatment , what to expect for IV lines (one or two IVs, a possible central line in my neck, and an arterial line, useful for quick access to my bloodstream for short interval testing to see how well or not the transplant was going.) I was given information about the incision site, and what to generally expect on the other side of surgery. I was briefed that my incision would be closed up with staples, and there was a decent possibility I’d have a surgical drain in place. Another element of prep, going back to the pre-admission testing, was post-surgery pain management.

John, my donor’s transplant coordinator, came over to say hello. Robin and I shared some warm wishes with my donor and his caregiver, and then it was time to go.

My donor and I would be in adjoining operating rooms. The medical team had already wheeled my donor to their operating room. Now, my turn as I was pushed through the hallway to my operating room. My glasses were with my clothes, so my trip was fuzzy, but exciting. I wasn’t nervous about going into surgery. I had’t been nervous ahead of time and I wasn’t now. Getting into the operating room, what surprised me straightaway was how small it was versus what I mentally expected it to be, how filled with equipment it was, and how many people there already where. The OR nurse took the binder and read out my name, my birthdate, and my medical record number, which was cross-checked. He announced the procedure being undertaken, also cross-checked. It was somewhat formal, but I was happy for the checklist formality. Nurses leveled my gurney with the surgical table, and I shuffled off the gurney, onto the table. A nurse took my right arm perpendicular to my body, and not long after that, I was out.

Back during pre-admission testing and my surgical consultation, Dr. Di Carlo gave Robin and I a bit of a briefing about what the surgery would look like. It would take somewhere between four and six hours, even if the actual moving time was substantially less. Dr. Di Carlo would be leading the donor surgery, while I had fellow abdominal transplant team surgeons Dr. Karhadkar and Dr. Lau operating on me. As I found out later, various surgical residents would also be assisting.

Dr. Karhadkar and Dr. Lau would have me prepped and incised before Dr. Di Carlo began the nephrectomy on my donor. Dr. Di Carlo, told me the ordering minimizes the time a donor kidney is unconnected from blood supply. The nephrectomy would be through a lower abdominal incision with additional laparoscopic incisions1. My donor’s left kidney would be disconnected from arteries and veins, nerves, the lymphatic system, and the ureter. Once extracted, the medical team flushes my donor’s kidney with saline, cools it, photographs it2, and then brought into my operating room for the transplant. The goal was a transfer time of about 15 minutes.

In my operating room, the surgical team connects the donor kidney to blood supply, then connects the donor ureter to my bladder. They would also install a stent ending in my bladder to keep the ureter graft open and free from potential scar tissue. I had a Foley cather inserted to drain urine3. Once the connections were all made, Dr. Karhadkar and Dr. Lau would close me up, and then the medical team would transfer me to post-surgical recovery. The anesthesiologist wakes me up. Robin is brought in to see me (TK: check with Robin on the ordering here) and I’d then transfer to a surgical intensive care unit.

By the time Robin received updates on my surgery, the timing was closer to the six hour mark, mid-afternoon. I came to a little after that with blurry vision, without my glasses, to voices discussing how to get hold of her. I remember giving her phone number out loud as the first things I was cognizant of saying. She was brought back to see me.

I think I was back out while I was brought through the hospital and up to the surgical ICU floor. My overriding memory of that early time getting into the ICU room is shivering as I was transferred from a gurney into bed. The RN brought in a warmer and, my memory is fuzzy here, I think additional blankets.

Not long after I’d been in the room, the medical team came in and said the initial post-surgery labwork already looked good. My donor’s kidney, my new kidney, was already producing urine and filtering blood. The pretty crappy results like my creatinine and glutamine filtration rate were showing marked improvement just in a couple of hours. This fortitous result demonstrated a key benefit of getting a preemptive living donor transplant. Deceased donor kidney donations can be “sleepy”, and require post-transplant dialysis before they wake up. My initial results looked like that would not be the case with my transplant. Dinner was due to arrive——chicken broth, fruit-flavored gelatin, some water, and apple juice if I recall——and the surgical team cleared me to have solid food, which was a pleasant surprise. Not having eaten since 10 or 11 pm the night before, two dinners was a luxury.

Robin shared some initial messages and photos with family and friends, letting them know surgery was a success. Thankfully, I was all smiles at this point with the initial post-surgery shivers having subsided.

Not long after I’d been brought to my ICU room. Tired, but smiling.
Everything was thumbs up.

At this point, I had an IV line, the arterial line, the central line in my neck, EKG monitoring, pulse oxygenation monitoring, and the Foley, which drained to a large, graduated container. The RN gave a brief orientation on the time-based morphine pain pump hooked into my IV. I had yet to feel any meaningful discomfort from the surgery itself.

Visiting hours wrapped up about 8 pm, and Robin headed back to the hotel with my donor’s caregiver. I read a bit, then tried my best to sleep. As I would come to find out, sleep in a hospital is a rare and precious quantity.

My IV tree, pumps and vitals monitoring.

In Part III, I’ll cover more of the surgical recovery through going home. Thanks for reading.

  1. I found out much later my donor received seven incisions.
  2. Wait, photographed? Yes. Apparently it is a [UNOS][unos] policy for surgeons to photograph donor organs.
  3. There were two reasons told to me. One was that a lot of transplant patients, coming from dialysis, stop urinating and their bladders shrink. With the volume of fluids delivered via IV, they don’t want to make patients get up to pee every 15 minutes.

    Two is that it allows the medical staff to monitor fluid output and ensure the transplanted kidney is properly producing urine.