(donation after cardiac death, or DCD donors). After a kidney donor and potential recipient are identified the transplant center will need to confirm that the ABO blood types are compatible, and that there are no concerning HLA (human leukocyte antigen) antibodies in the recipient against the donor’s kidney. The reason for the antibody test is to determine if the kidney can be safely transplanted; if there are circulating antibodies present, they can immediately bind to the kidney and cause a severe “hyperacute” rejection, graft thrombosis and graft loss. The transplant center may often receive HLA information regarding the transplant donor, including a blood [KIDNEY TRANSPLANT TOOLKIT] May 13, 2019 © Copyright, Forum of ESRD Networks, 2019 Page 12 sample, before the kidney is removed from that donor in a procurement operation, which will allow time to complete the HLA compatibility testing. If HLA testing and information about the procurement are acceptable, the transplant center will “accept” the offer and the patient will be prepared for surgery. Transplant centers will typically prepare the patient for surgery well before the organ is “accepted.” The patient is admitted to the transplant center’s hospital and the confirmatory HLA testing is obtained. The patient’s recent history will be reviewed, a physical exam performed, and blood and x-ray testing performed. Sometimes the patient is found to have an active medical issue and cannot be transplanted on that day; if so, the operation will be cancelled and the next patient on the list will be offered the kidney. The patient may require dialysis prior to transplantation depending on the patient’s dialysis schedule, and the physical exam and lab results. For instance, if the patient has signs of fluid overload, or a significantly elevated potassium level, urgent dialysis will be performed. If the patient is found to be healthy enough to undergo the procedure, the patient will not be permitted to eat within six to eight hours before surgery. The risks of kidney transplantation are always discussed with the patient, and informed consent is always obtained prior to the transplant surgery. Kidney Transplant Surgery Pre-Transplant Kidney Preparations and Cold-Ischemia Management Most deceased donor kidneys are stored using a cold storage solution, which is instilled into the kidney at the time of the procurement operation, before the kidney is placed inside a cooler for transportation. Sometimes kidneys are also placed on a perfusion pump. A perfusion pump is used by some transplant centers to reduce the risk of delayed graft function (DGF). DGF means that the patient requires dialysis after the transplant surgery, since the kidney has not yet started to work well enough to allow the discontinuation of dialysis therapy. The practice of using perfusion pumps to prevent delayed graft function varies across the United States. Common risk factors for DGF are kidneys with greater than18 hours of cold ischemic time (the time the kidney has been stored cold since being removed from the donor’s body), kidneys from older donors, kidneys from deceased after cardiac death (DCD) donors, and kidneys transplanted into patients who have been on dialysis for many years. Delayed graft function occurs in about 25-30% of all recipients of deceased donor kidneys (and about 2-4% of living donor kidneys). Patients who experience delayed graft function will usually go on to have a kidney that functions well. Transplant Surgery The nursing team and the transplant teams will confirm that the patient and the kidney have the correct identifying information, including blood types and results of the final crossmatch. The patient will be placed on the operating table, and intravenous and intra-arterial catheters will be placed, as will be a catheter into the urinary bladder. General anesthesia is required for this surgery. An antibiotic will be given to address possible skin bacterial contamination. The surgical incision is in the lower abdomen, either on the right or the left. The peritoneal sac is pushed to the side, and the artery and vein going to/from the leg (usually the external iliac artery and vein) are identified. The kidney is placed, the artery and vein are attached, and then the vascular clamps are released, so that the kidney receives blood and it is assured that there is no leaking of blood. Then the ureter is sewn into the wall of the bladder. Many surgeons leave a temporary stent in place to protect the ureteral implantation. The incision is then closed, layer by layer. [KIDNEY TRANSPLANT TOOLKIT] May 13, 2019 © Copyright, Forum of ESRD Networks, 2019 Page 13 Recovery from Kidney Transplantation After kidney transplantation, the patient may be in the hospital 3-7 days, or longer if complications occur. Kidney function and other lab work will be measured daily, and ultrasound of the kidney will likely be performed. If there is concern about the blood flow to the kidney, other tests may be needed. Urine output will be carefully monitored. About 25-30% of deceased donor transplant recipients will need to continue dialysis for a period of time after the surgery because of delayed graft function (DGF). In spite of this delay in function, most of these kidneys will recover and have good function in the coming months and years. Before discharge, the patient must have return of