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Video Transcript: Living Kidney Donor

Part One:

Ellen Beth Levitt: Welcome to "Maryland Health Today." I'm Ellen Beth Levitt. Advances in organ transplantation are enabling more people to survive serious health challenges but the need for transplants is much greater than the supply of donated organs. When it comes to kidney transplants though, living donors are helping to fill the void and on the show today we'll learn about the process of living kidney donations for both the donor and the recipient. My guest is Dr. Matthew Cooper, he's a transplant surgeon at the university of maryland medical center. Dr. Cooper is also an associate professor of surgery at the University of Maryland School of Medicine. Welcome to the show.

Matthew Cooper, M.D.: Thanks for having me, Ellen Beth.

Ellen Beth Levitt: Could you tell us a little bit about the need for kidney transplants in particular?

Matthew Cooper, M.D.: Well, unfortunately there are a number of people that are waiting for the gift of life. Organ transplants, particularly kidney transplants have been demonstrated to give people not only a better quality of life but to increase the length of their life better than dialysis. So it is truly a lifesaving procedure and a lifesaving gift. The numbers of people that are donating far undersupply those who need kidney transplants.

Ellen Beth Levitt: And you're a kidney transplant surgeon?

Matthew Cooper, M.D.: Correct.

Ellen Beth Levitt: Do you also do pancreas and liver transplants?

Matthew Cooper, M.D.: Fortunately I do kidney and liver and pancreas transplants but by far the largest number are kidney transplants.

Ellen Beth Levitt: How long have kidney transplants been performed since sometime in the 1950s?

Matthew Cooper, M.D.: Correct, we celebrated our 50th anniversary just a couple years ago. Dr. Murray first did the transplant it was between two identical twins and at that point anybody who have believed we'd come this far.

Ellen Beth Levitt: What are some of the advances?

Matthew Cooper, M.D.: In part, we recognize that the immune system is very intelligent in what it's designed to do. Without that immune we'd be a constant threat. But our immune system if we were just to perform a transplant without the medications that are now necessary called immunosuppressant drugs, our body would reject it. So the majority of the interventions and the innovations that have been made in transplant over the last 50 years have been in the improvement of the imunosuppressant drugs that have allowed transplants to happen. In addition, some of the techniques, some of the ways in which people receive transplants, particularly living donor transplants, some of the techniques with which our donors have been able to do it have moved that far.

Ellen Beth Levitt: Tell us about our kidneys.

Matthew Cooper, M.D.: They regulate the amount of fluid in our body and they regulate a lot of the electrolytes, calcium, sodium, they do that without us appreciating that is going on. So it's sometimes troubling when we recognize people can have kidney problems for a long period of time and not recognize it because the kidney can compensate for small issues and it's not until a good portion of their function is lost do that have any symptoms of kidney disease.

Ellen Beth Levitt: One kidney was higher than the other, is that the case for everybody?

Matthew Cooper, M.D.: Well, developmentally our kidneys actually start from below and move their way up to their normal position. Because our liver is on the right side, the right kidney is actually slight lower than the left kidney is. Anatomically everybody is sort of their own textbook, so although the picture may show one, some people may have a different anatomy and part of the things we're doing in evaluating a kidney donor or recipient, we take x-rays to see what their kidneys look like.

Ellen Beth Levitt: That's interesting. What kind of medical conditions can lead to kidney failure?

Matthew Cooper, M.D.: By far the most common causes are diabetes and hypertension. The number of people who have those illnesses are great. That doesn't mean having diabetes or hypertension leads to kidney failure. Sadly, it's the lack of treatment or the inability to control those problems well, that leads to kidney failure. But over 60% of people who are on dialysis have lost their kidneys from hypertension and diabetes. There are also some genetic conditions that can cause people to lose their kidneys. There are some conditions which cause their kidneys to actually grow out of proportion to the need and the kidneys lose their function for that reason.

Is that polycystic disease. Also chronic infections, so problems with kidneys from kidney stones and reflux disease and infections as well.

Ellen Beth Levitt: A lot of things can make the kidneys vulnerable. What are the symptoms of kidney failure?

Matthew Cooper, M.D.: As I said, it's not until sometimes 80% of our function is lost that they have symptoms. The most common symptoms are people are feeling swollen or a great deal of edema, they feel fatigued because part of the role is to make red blood cells that give us our energy. People complain of nausea and vomiting and they complain of a metallic taste in their mouth.

Ellen Beth Levitt: You talked about dialysis and I guess, first of all, kidney failure as gradual process, right? Even though the term makes it sound like suddenly your kidneys are working and the next day they're not, but is it gradual?

Matthew Cooper, M.D.: Correct. Most of the time it does take years for people to develop the chronic illness of kidney disease. Sometimes, you know, it can occur acutely but the overwhelmingly majority of the kidney losses are chronic in nature, and that's why it's always important for people to have regular healthcare checks with their physician because even people that have demonstration of some kidney problems, the earlier that we can identify the problem, we can oftentimes prevent that from requiring intervention or even transplant.

Ellen Beth Levitt: That's good to know. What is dialysis like for people who have to go on dialysis? It affects the quality of their life.

Matthew Cooper, M.D.: If you've never been in a dialysis center, it's somewhat of a frightening experience. It's a difficult life for people. The kidneys perform their jobs 24 hours a day, 7 days a week, but the dialysis machine tends to mimic that three or four times a week. People are unable to function outside of the dialysis center because their lifesaving therapy is in that period.

The optimum, of course, is what we believe is transplant because we replace kidney failure with a transplanted kidney which performs the same function that a new kidney will do.

Ellen Beth Levitt: Who would be eligible for a transplant?

Matthew Cooper, M.D.: We say anybody. There are very few absolute contraindications for people to have a transplant. We need to make really good clinical decisions for that patient rather than say without question that they're not a transplant candidate. So we say give us the opportunity to meet most individuals because there are very few people who are not candidates for transplant.

Ellen Beth Levitt: How long do the kidneys continue to function after a transplant?

Matthew Cooper, M.D.: We've really come a long way. So the immunosuppression has allowed most transplants on average to last about ten years or a decade of life. Living donor transplants on average last almost twice as long so 19 or 20 years for a kidney transplant.

Ellen Beth Levitt: We hear of people on waiting list not just for kidneys or heart transplant or liver or pancreas. Can you tell us a little bit about the waiting list? What does that mean? Are there national lists or local lists?

Matthew Cooper, M.D.: The waiting list is unfortunately a necessary evil. In part we say we have a supply and demand problem. We wish we had the trouble of too few recipients and too many kidneys. But it's the opposite. United network of organ sharing is the group that monitors that list and people are transplanted based on a waiting time on that list. The average waiting time varies among the country but on average, the waiting time is about three to five years. Some significant changes can occur we know the time people are actually begun on that list and they the time they reach the transplant.

Ellen Beth Levitt: In order to get a kidney, for example, that would work for somebody, they have to have a good match. Is that right?

Matthew Cooper, M.D.: The match has received a lot of publicity and a lot of credit. The reality is that really the important thing is that they're blood type compatible and if a match is possible that does demonstrate some survival advantage. But the reality is that truly the best thing for a patient to receive is a transplant and the match itself has not been demonstrated to be as important as we once thought it was. So it's really just making sure that the donor and recipient are blood type compatible and they have a negative cross match before beginning the transplant.

Ellen Beth Levitt: You were mentioning that if you get a kidney from a living donor it's more likely to last longer or function longer. Why is that?

Matthew Cooper, M.D.: It's in part because of the controlled environment in which the operation proceeds. Again in a very controlled environment, the donor operation occurs in one operating room, the recipient in another and in a very short period of time, the kidney is carefully removed laparoscopically from the donor and moved to the recipient room where the recipient surgeon actually transplants that kidney right away and because of that very short time that the kidney is not being profused or not receiving blood, it's less time.

Ellen Beth Levitt: Is that because they're put on ice and sometimes they're shipped to another -- like across town or another state or that kind of thing?

Matthew Cooper, M.D.: Correct. Some of our deceased kidneys can actually be on ice for sometimes two days or so. That has some effect on the function of those kidneys and the amount of time that we can reduce the time on ice often demonstrates an improved survival advantage for the recipient.

Ellen Beth Levitt: Are their some people for whom a living donor kidney is not the best option?

Matthew Cooper, M.D.: You know, the simple answer to that is no. Really everybody should be considered for a living donor transplant because it does have a much shorter waiting time on average than waiting that three to five years for a deceased donor and the survival advantage compared to the deceased donor. The few individuals might do better with a deceased donor as individual who is in perhaps their sixth or seventh decade with a shorter time on that waiting list so the risk of waiting does not demonstrate an advantage over the benefits.

Ellen Beth Levitt: The number of living donors has increased a lot in recent years, hasn't it?

Matthew Cooper, M.D.: It has and that's been one of the greatest breakthroughs in kidney transplantation is the fact that living donation has reached such a high. In 2002, there were more living donation transplants done than deceased transplants. We pioneer at the university of maryland to try to encourage not only recipients to receive a living donor transplants but being more comfortable in asking their donors to potential consider that gift of life.

Ellen Beth Levitt: Do you want to talk about this minimally invasive or laparoscopic approach for giving a kidney where you don't need a big incision any more?

Matthew Cooper, M.D.: It's probably the most exciting operation that we do. At the same time it does have some risks and great responsibility. But it is a procedure in which the operation occurs through very small incisions, less than a centimeter in length, one of which the camera is put into the abdominal cast of the donor. And we look at the video screen and do the operation outside the body and remove the kidney through a very small incision, it's similar to a c-section scar. It's much more comfortable for the donors, a shorter stay in the hospital, they're out of the hospital in about two days and back to doing everything before the donation in about two to four weeks. It's revolutionized living donor transplants and brought more people to consider it than we probably could have imagined.

Ellen Beth Levitt: I think the University of Maryland Medical Center started this in March of 1996.

Matthew Cooper, M.D.: Correct.

Ellen Beth Levitt: So there's been a lot of experience with it?

Matthew Cooper, M.D.: We just recently celebrated our 1200th donor laparoscopically. We still believe that every operation demands the same respect as the first but, at the same time, we have a great deal of experience in both our surgeons and our operating rooms. And we think that we stand to continue to learn more and more about this procedure.

Ellen Beth Levitt: What kind of evaluation does a living donor have to go through? I guess you have to make sure that the person is healthy, they have two healthy kidneys so that they'll be able to live with one for the rest of their life?

Matthew Cooper, M.D.: I tell my donors we leave no stone unturned.

Ellen Beth Levitt: Not even a kidney stone?

Matthew Cooper, M.D.: Very good. So a medical evaluation, a surgical evaluation, a psychosocial evaluation, that's very important. We want to make sure that the donor can afford the time off from work and they have a good support system at home. They have an extensive medical evaluation and sometime x-ray evaluation and oftentimes additional tests are necessary because in part we're trying to predict somewhat the future for that individual who's going to donate the kidney because we don't want to hurt someone who very kindly wishes to do something very, very good for another person and have them in the future have trouble with their remaining kidney.

Ellen Beth Levitt: Can a non-blood relative be a donor?

Matthew Cooper, M.D.: Absolutely, we have people who come from all walks of life. It's impressive and amazing some of the stories that people bring that they wish to be a living donor.

Ellen Beth Levitt: Because the drugs are so good at preventing rejection?

Matthew Cooper, M.D.: Absolutely.

Ellen Beth Levitt: You don't have to have as many antigens matching, is that the correct term?

Matthew Cooper, M.D.: The match was very, very important when we were very learning about transplants. We've recognized the most important thing about a donor is that they're healthy and medical suitable to undergo the donation that the match really isn't that important. So a family member or a friend, no matter who that match is going to be a suitable donor assuming the evaluation goes through smoothly.

Ellen Beth Levitt: Who pays for the transplant?

Matthew Cooper, M.D.: That's a great question. Anybody who kind wishes to do something for someone else to have a bill at the end of this. The recipient's insurance pays for the donor workup, the surgery and the hospital stay is paid for by the recipient's insurance.

Ellen Beth Levitt: We have to take a break, but when we come back, we will talk about what it's like to receive a kidney. So stay with us. We'll be right back.

Part Two:

Ellen Beth Levitt: Welcome back to "Maryland Health Today." I'm Ellen Beth Levitt, and we are talking about kidney transplants on the show. My guest is Dr. Matthew Cooper. He's a transplant surgeon at the University of Maryland Medical Center and he's also an associate professor of surgery at the University of Maryland School of Medicine.

Could you tell us a little bit about what kinds of medicines people who get a kidney transplant need to take the rest of their life in order to prevent rejection?

Matthew Cooper, M.D.: So the reality is that we need immunosuppressant medications for the transplants to be successful. We have recognized the amount of immunosuppressant that people need has become less and less. So the medications we also appreciate have some side-effects so the way we try to avoid the side-effects, we have several medications that each help one another out in preventing rejection. And as people get further and further out from the operation, we're able to remove some of the medication and reduce the amount of medications. It's important to impress upon people that they need to take those medications for the rest of their life.

Ellen Beth Levitt: A commitment that they have to be willing to take?

Matthew Cooper, M.D.: Absolutely.

And it's either a commitment to dialysis or a commitment to taking medications and enjoying a successful transplant.

Ellen Beth Levitt: Are there still dozens of medications that people have to take or has that improved over the years?

Matthew Cooper, M.D.: Absolutely. As further and further out from transplant, they take fewer and fewer medications and they have to see their doctors less and less which indicates that transplant is here to stay and it's not something that we want people to feel is running their life or ruining their life. It's very common to see people following transplant to only be taking two or three medications for immunosuppressant and treatment of their medical problems following transplant so it's changed a lot since we begun 50 years ago. At the university of maryland, we have protocols where people are no longer taking steroids which was very important early in transplants. We thought steroids were necessary. We also found out that they had a good number of complications so we found ways to do transplant and allow the immunosuppressant without medications with such large side-effects.

Ellen Beth Levitt: What's induction therapy?

Matthew Cooper, M.D.: It's given as soon as the patient is put asleep before the transplant happens. So it's not in comparison to what we call maintenance therapy or therapy people take for the rest of the life. It is only given at the time of the kidney transplant and not necessarily needed for the rest of the patient's life.

Ellen Beth Levitt: We were talking earlier how the operation is performed for a living donor to get the kidney out, and it's done in a minimally invasive way with an only few small holes and the person goes home the next day but you can't put the kidney into the recipient in a minimally invasive way?.

Matthew Cooper, M.D.: It's important to realize that the incision for the recipient is the standard. But it's totally separate from where our native kidneys are located. We make an incision around the hip bone. And we do the surgery and connect the kidney to the artery and the vein that supply blood to our leg. So although it's not minimally invasive it's still a pretty small incision. It's an easily recoverable incision than some operations and relatively it's a very cosmetically appealing incision if I can say that.

Ellen Beth Levitt: How long do people stay in the hospital after a kidney transplant?

Matthew Cooper, M.D.: Our average it's four days or seven or eight days for the recipient.

Ellen Beth Levitt: Why is it longer if they get the kidney from a cadaver?

Matthew Cooper, M.D.: Typically as we mentioned the deceased donor transplant has some time with which it's been on ice and sometimes that means that it takes time for the kidney to start working. And that usually means that patients have to stay in the hospital a little bit longer as we’re waiting for their kidney to wake up sleep, as we say. Sometimes people need a little bit of dialysis after the transplant as the kidney starts to do its function. The living donor transplants start working really when the kidney is profused or when the kidney transplant surgery.

Ellen Beth Levitt: Sometimes in the operating room, right?

Matthew Cooper, M.D.: Absolutely.

Ellen Beth Levitt: What is rejection?

Matthew Cooper, M.D.: It's that horrible term that is something that is very treatable. It means that the body has in part recognized that the kidney is really not part of ourselves, it was put in by someone else and it means that the immune system has recognized that and is trying to do something about it. Rejection is a very treatable thing. It's important for us to identify it early because the earlier that we identify a rejection, the better chance we have of treating it and the less long-term effects it has.

Ellen Beth Levitt: How do you identify it?

Matthew Cooper, M.D.: The easiest way to identify is with lab testing, that's the non-invasive way so we can watch blood testing.

The earlier that we recognize it, we can treat that, typically sometimes out with outpatient medications but sometimes it requires patients to come in the hospital for a short stay so we can take care of that rejection so it doesn't create long-term troubles for the kidney transplant.

Ellen Beth Levitt: What percentage of people who have a transplant have rejections?

Matthew Cooper, M.D.: It's a great question because it's not an unforeseen complication. And we can't always predict it. But 15% of all patients in the first year have some of rejection.

Ellen Beth Levitt: Sometimes people need a pancreas along with a kidney transplant. Is that because they have had diabetes and their pancreas no longer produces insulin so you're taking care of two problems at all?

Matthew Cooper, M.D.: Amazing operation. We take care of not only the effect of type 1 diabetes and its causing in causing kidney failure but we protect the kidney transplant with a pancreas transplants so now we're in an environment where the insulin is produced, and we don't have the worry that potentially the diabetes can affect the kidney transplant.

Ellen Beth Levitt: I wanted to ask you about research because I know you're also involved in research to make these kidney transplants even more successful; is that right?

Matthew Cooper, M.D.: Absolutely. I mean, I think we are -- we're obligated to do what we do now even better. There's always a possibility of finding better ways to do things, of learning about new immunosuppressant medications that have less side-effects and better results for our patients. At the university of maryland because of the number of transplants that we do and our reputation, we're often involved in many different trials for many exciting medications. And we often ask our patients to participate in those trials. It's not an experiment, it's a desire to try to figure out if we can make their life better in the future and those who experience transplant in the future better.

Ellen Beth Levitt: And some of the medications used today have only been out for a few years and that's as a result of research that was done?

Matthew Cooper, M.D.: Exactly. Patients interested in helping us and helping themselves are really helping to improve the transplants.

Ellen Beth Levitt: Is there anything else that you want to mention that people might not know about living donor transplants, for example?

Matthew Cooper, M.D.: Transplant is the best job in the world and working with transplant patients and listening to the stories of people that are interested in helping not only transplanted but also in living donation is a wonderful part of my job and I say if there's any questions that you need answered, don't hesitate to ask us. It's better to have the right information than to search for the information and find out that the wrong information has been shared with you. We're always available. We're always interested in answering questions, and we're always interested in providing people with the miracle of life which is transplants.

Ellen Beth Levitt: It's gratifying when you've seen someone who's been on dialysis and they get a transplant, what impact does it have on their life?

Matthew Cooper, M.D.: Words can't express. There's an amazing change in their life. There's an improvement in not only their overall health but in sort of their expectation of what life is to come forth for them. They've spent their life so long feeling ill and following a transplant, they feel so much better, it's tremendously rewarding to see it happen.

Ellen Beth Levitt: Do most people return to work?

Matthew Cooper, M.D.: They do, and most are out there campaigning and trying to tell others about how wonderful transplant is. So they're our best indicators of what a remarkable thing transplant is.

Ellen Beth Levitt: It sounds like you find your work very gratifying. Thank you for being with us.

Matthew Cooper, M.D.: It's my pleasure.

Ellen Beth Levitt: My guest is Dr. Matthew cooper. He's a transplant surgeon at the university of maryland medical center and an associate professor of surgery at the university of maryland school of medicine. And if you have any comments or questions about this program, please send me an e-mail, eblevitt@umm.edu. If you’d like to reach dr. Cooper or any other university of maryland physician, call 1-800-492-5538 or visit the Web site, there you'll find a great amount of health information and be able to see other "maryland health today" programs. That address is www.umm.edu. Take good care of yourself, and we'll see you next time for "Maryland Health Today."

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This page was last updated on: June 19, 2008.

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