Living Donor Kidney Transplant Program

A living donor kidney transplant is a highly-complex major surgical procedure performed under general anesthesia. It involves placing a healthy kidney removed from a living donor into the recipient’s abdomen. The kidney can be offered by a living donor because his or her other kidney is able to perform the functions normally carried out by two kidneys.

Living donation in Italy is regulated by Law 458 of 26 June 1967. A living donor may be genetically related to the recipient (a parent, sibling, cousin, son, or daughter), or emotionally related to the recipient (a spouse or a partner). For several years, so-called Samaritan donation has also been possible. In this case, a completely healthy person chooses to donate a kidney to someone they do not know.

Before donating a kidney, the prospective donor undergoes a series of tests and assessments to evaluate his or her health, donor-recipient compatibility, and suitability for donation and transplantation.
The following tests are performed:

Blood type
Until a few years ago, blood type compatibility was considered an essential requirement for transplantation. Today, thanks to scientific advances, it is possible in some cases to donate a kidney even when the donor and recipient have incompatible blood types.

Cross-match
This test can detect antibodies in the recipient that are directed against the prospective donor. When such antibodies are present, participation in the national kidney paired donation program may be considered.

HLA compatibility
The human leukocyte antigen, or HLA, profiles of both the donor and the recipient are evaluated. Six antigen determinants are considered, meaning that the degree of matching may range from 0 to 6. Regardless of the degree of HLA mismatch, transplantation may still be performed.

Blood Tests and Diagnostic Procedures
The donor undergoes an extensive and thorough clinical evaluation to assess their overall health, kidney function, and the possible presence of risk factors. These tests enable the medical and surgical team to ensure that donation does not pose an unacceptable risk to the donor.

A kidney transplant lasts from a minimum of 2 hours to a maximum of 4 to 5 hours. It is performed in an OR by a team of 8 to 9 professionals (surgeons, anesthesiologists, nurses, and technicians). The procedure is performed under general anesthesia.

The donor’s procedure is performed first
The donor’s surgery, known as donor nephrectomy, lasts approximately 2 to 3 hours and is carried out laparoscopically. Four small incisions are made in the abdomen to allow the insertion of the laparoscope, a small camera, and the surgical instruments.
The kidney is removed through an abdominal incision above the pubic area, similar to, although slightly smaller than, the incision used for a Cesarean section. Most donors remain in the hospital for 3 to 5 days after surgery.

At the same time, the recipient is prepared so as soon as the kidney is removed that the transplant, the procedure that enables the donated kidney to function in the recipient, can start. This is also performed under general anesthesia. The donor’s kidney is placed in the recipient’s abdomen. The surgeon makes an incision and positions the new kidney in the lower part of the abdomen. The blood vessels of the new kidney (the renal artery and renal vein), are connected to the iliac artery and vein, the large blood vessels that carry blood to and from the legs. The ureter, the tube that drains urine from the new kidney, is connected to the recipient’s bladder. The procedure lasts approximately 3 to 4 hours.

A so-called crossover transplant is performed if there is an incompatibility that cannot otherwise be overcome, such as the presence of antibodies able to attack the transplanted organ causing rejection.
This procedure involves an exchange of living donors between two donor-recipient pairs who would otherwise be incompatible. Eligible pairs are entered into a database.

In 2019, the crossover program was expanded further. A kidney from a deceased donor is used to initiate a chain of donations and crossover transplants. The kidney from the deceased donor is allocated to a compatible recipient in a pair enrolled in the program, initiating the paired transplant chain. The chain ends when the kidney donated by the final living donor is transplanted into a recipient on the active deceased-donor waiting list, selected on the basis of compatibility.

When the donor’s and recipient’s blood types are incompatible and there may or may not be antibodies that could attack and cause the rejection of the transplanted organ, an ABO-incompatible transplant may be an option. Before surgery, the recipient undergoes a treatment called plasmapheresis that involves removing antibodies from the blood. The treatment is carried out at a transfusion medicine center over several sessions before the transplant.
At the same time, immunosuppressive drug therapy is started in the recipient three weeks before surgery to suppress the production of unwanted antibodies.

Living-donor kidney transplantation is one of IRCCS ISMETT’s main surgical activities. The program is based on the fundamental principle that donating a kidney, especially to a loved one, can be one of the most rewarding experiences in a person’s life.

Laparoscopic nephrectomy is the standard approach at IRCCS ISMETT. Laparoscopic surgery is designed to reduce postoperative pain and make it easier for donors to recover and resume their normal routines at home after discharge. Donors who undergo laparoscopic nephrectomy experience less pain, better cosmetic outcomes, shorter hospital stays, faster recovery, and an earlier return to their daily tasks.