Adult living kidney donor pathway

Steering group

• Derek Manas (DMM) Medical Director, OTDT, NHSBT
• Lisa Burnapp (LB) – Project Chair, Associate Medical Director, Living Donation and Transplantation, NHSBT
• Carrie Scuffell (CS) SME for ERAS in Transplantation, Transplant development Manager, NHSBT
• Temi Adams (TA) Secretary, Medical Director and Group Support, OTDT, NHSBT
• Aimen Amer (AA) Consultant Surgeon, Freeman Hospital, Newcastle
• Emily Bonner (EB) Consultant Anaesthetist, Freeman Hospital, Newcastle
• Aisling Courtney (AC) Consultant Nephrologist, Belfast Health and Social Care Trust
• Jess Hollingsworth, Liver transplant Clinical Nurse Specialist Leeds
• Elaine Jolly, Consultant Nephrologist, Cambridge University Hospital
• Jen Lumsdaine, Lead Nurse-Living Donation, NHSBT
• Sapna Marwaha (SM) Lay Member, NHS Blood and Transplant
• Jan Shorrock (JS) Executive officer, Give a kidney UK
• Michael Spiro (MS) Consultant Anaesthetist - intensive care medicine, The Royal Free Hospital, London
• Ben Stutchfield (BS) Consultant Surgeon, Royal Infirmary of Edinburgh
• Rachel Thomas, Consultant Surgeon, Edinburgh

Adult living kidney donor working group

Working group co-leads

• Aisling Courtney (AC) Consultant Nephrologist, Belfast Health and Social Care Trust
• Aimen Amer (AA) Consultant Surgeon, Freeman Hospital, Newcastle

 
Members

• Caroline Basarab-Horwath Living Donor Coordinator, Sheffield
• Amy Bostock Living Donor Coordinator, Nottingham
• Lucy Chester Living Donor Coordinator, Portsmouth
• Charlotte Crotty Transplant Lead Nurse, Leicester
• Dilan Dabare Consultant Transplant Surgeon Birmingham
• Rachel Davison Consultant Nephrologist, South Tyneside & Sunderland
• Frankie Dowen Consultant Nephrologist, Newcastle
• Jeremy Fabes Consultant Anaesthetist, Plymouth
• Lisa Higginson Transplant Ward Manager, Cardiff
• Orla Hobson Advanced Nurse Practitioner, Edinburgh
• Jen Lumsdaine Lead Nurse, Living Donation NHSBT
• Claire Monaghan Physiotherapist, Living Donor, Sheffield
• Tracey Roberts Transplant Coordinator, Cardiff
• Rebecca Rowsell Living Donor Coordinator, Portsmouth
• Stuart Falconer Consultant Transplant Surgeon, Leeds
• Shazia Shabir Consultant Nephrologist, Birmingham
• Jan Shorrock Executive Officer Give a Kidney charity, Living donor
• Rachel Styles Living Donor Coordinator, Leeds
• Rachel Thomas, Consultant Transplant Surgeon, Edinburgh
• Leigh Vassallo, Living Donor Coordinator, Newcastle
• Jules Briggs - Lead Renal Physiotherapist, King's College Hospital NHS Foundation Trust
• Siobhan Freeman Physiotherapist, King's College Hospital NHS Foundation Trust

Experts by experience panel

(With thanks to Jan Shorrock at Give a Kidney for her help in reaching out to donors)

• Kiran Gupta​
• Edward Hibbert
• James Collins​
• Clare Monaghan
• Prafula Shah 

It is best that the principles of enhanced recovery are embedded at the earliest opportunity and be revisited at contact points such as clinic and pre-admission visits.

Core elements include:

• Introduction to principles of ERAS
• Managing expectations for the peri-operative period including mobilisation, incentive spirometry, and analgesia (aiming to facilitate function rather than eliminate all pain)
• Identifying potential challenges and barriers to optimal recovery
• Standardised information, relevant to individual transplant units, reflected in all pre-donation interactions to ensure consistent messaging

Desirable elements include:

• Introduction to a living donor shared care plan to optimise engagement throughout the hospital stay
• Provision of other ERAS-specific educational documents and audio-visual resources. Consider accessibility options and translated versions to overcome disability and language barriers
• Development of a local living donor peer-support network or signposting to national buddy support

Many donors will already be fit and have a healthy lifestyle. For others however, there will be opportunity to optimise fitness and well-being prior to surgery. Some of these are relatively easy to adopt.

Core elements include:

• Dietary support and weight management advice
• Smoking cessation and substance misuse support
• Cardiovascular health counselling

Desirable elements include:

• Signpost to national resources such as Surgery Hero or Kidney Beam

Download health promotion evidence (Word 27KB)

A prolonged recovery following an open nephrectomy is a disincentive for potential living kidney donors.

Living kidney donors have normal bladder function prior to surgery and there should be no reason for prolonged catheterisation.

Core elements include:

• A minimally invasive procedure as standard, such as fully laparoscopic, laparoscopic hand assisted, mini incision or robotic
• Removal of urinary catheter on day of surgery

Desirable elements include:

• Avoidance of urinary catheterisation

Download evidence for surgical technique (Word 15KB)

There is increasing evidence to support a beneficial effect of pre-operative carbohydrate loading in ERAS particularly in colorectal and cardiac surgery. Avoidance of prolonged fasting can be achieved without detriment intraoperatively.

Core elements include:

• Minimisation of period of fasting, no pre-operative intravenous fluids
• Judicious fluid replacement avoiding excessive intravenous fluid administration
• Avoidance of routine insertion of central venous catheter

Desirable elements include:

• Carbohydrate supplements pre-operatively
• Routine use of laxative medication

Download evidence for carbohydrate loading (Word 14KB)

A multimodal stepwise approach to perioperative analgesia is important in enhanced recovery protocols as it improves patient mobility, reducing the risk of respiratory and thromboembolic complications.

Core elements include:

• Selective drain insertion on a case-by-case basis
• If required, aim to limit to one non-vacuum surgical drain (dependent on state of surgical field)

Desirable elements include:

• Regional anaesthetic approaches (TAP) with consideration of local anaesthetic infusion catheters or long-acting agents
• Consideration of:
  • PCA avoidance
  • NSAID use
  • Adjunctive interventions including non-pharmacological approaches e.g. acupressure plasters
• Availability of pain team input when required

Download analgesia evidence (Word 17KB)

An early return to normal oral diet is part of many ERAS protocols.

Core elements include:

• Discontinuation of IV fluid administration at conclusion of surgery
• Normal oral intake as desired from the immediate post-operative period

Desirable elements include:

• Consideration of regular laxative until normal bowel motion

Early mobilisation after surgery has several demonstrable benefits, and these can be extrapolated to living kidney donor surgery. In addition to this, all donors can be encouraged to complete active cycle of breathing exercises, and bed exercises to reduce the risk of thrombosis.

Core elements include:

• Sitting out of bed on the afternoon of surgery
• Walking to the bathroom on the evening of surgery
• Mobilising around the ward as a minimum the morning following surgery
• Increasing walking distances in the afternoon
• Consideration of non-pharmacological strategies for thromboprophylaxis

Desirable elements include:

• Dedicated physiotherapy staff with a focus on patient engagement if indicated

Download evidence for early mobilisation (Word 28KB)

Optimal multimodal analgesia will encourage effective breathing, improve mobility and minimise postoperative complications.

Core elements include:

• Regular paracetamol (PO or IV)
• Judicious use of opioid-based analgesia postoperatively with minimisation when possible
• Non-pharmacological therapy e.g. appropriate early mobilisation techniques

Desirable elements include:

• No routine opioid-based analgesia beyond 12 to 24 hour.
• Local anaesthetic wound infiltration for 12 to 24 hour.
• NSAID use (PO or PR)

If the above elements of enhanced recovery are applied, then early discharge can be safely achieved.

Setting expectations for this early in the LD pathway is important.

Core elements include:

• Standardised post-operative education programme with targeted day for discharge
• Contact details for living donor team and out of hours advice and support
• Defined pathway for re-admission when required
• Clear identification of out-patient review arrangements
• Consideration of thromboprophylaxis as per national guidance

Desirable elements include:

• Aiming for day 1 discharge for the majority of donors

Optimisation of donor recovery does not end at the time of discharge and should ideally continue in the early post discharge period.

Core elements include:

Donor specific written advice for the initial weeks post donation including:

• a mobility plan and guidance regarding activity levels
• appropriate titration reduction in analgesia
• advice on return to normal activities e.g. bathing, driving, sex, flying
• information on what to expect psychologically post donation

Download rehabilitation evidence (Word 25KB)