It was a standard open kidney transplant operation, with a twist: Surgeons at Northwestern Medicine in Chicago on May 24th transplanted a live donor kidney into 28-year-old patient John Nicholas. What was the difference? Nicholas was awake throughout the procedure.
In a setup similar to a cesarean delivery, Nicholas was given spinal rather than general anesthesia, and a drape blocked his view of the operating field. He chatted with the surgical team during the procedure, chose his favorite music to listen to (the rock band The Killers), and was able to view the donor kidney before it was implanted. Less than 24 hours later, he was discharged pain-free to his home, where he continues to recover well.
Nicholas, an engineer, was the perfect candidate for this trial, said his nephrologist Cybele Ghossein, MD. “He was young; thin; otherwise healthy; and willing, able, and interested in anything that moved medicine forward,” said Ghossein, a professor of medicine at Northwestern University Feinberg School of Medicine who has cared for Nicholas for about 2½ years. Additionally, there was time to plan the procedure, as Nicholas was not yet on dialysis and had a living donor.
The transplant team had been thinking of ways to potentially improve the patient experience and decrease hospital length of stay, said Vinayak Rohan, MD, one of the surgeons who performed the procedure. Kidney transplant operations have become so standardized that surgeons can perform them in under 2 hours, he said, coupled with efforts regarding pain management to minimize the use of opioids and enhanced recovery after surgery protocols that focus on optimal fluid intake and movement before and after operations. “Kidney transplantation is really a transformation process for somebody who is undergoing dialysis,” Rohan said. “We are excited every time we see a kidney looking good and making urine. If [a patient] can be part of it, that would be amazing. These are the kind[s] of things which made us say, ‘Hey, can we do this?’”
Because Nicholas had been interested in clinical trials, the transplant team reached out to him to assess his commitment. He talked through the option with Ghossein as well before moving forward. “This is a wonderful new option,” Ghossein said, noting that it could be useful in situations in which general anesthesia is too risky for a patient or in which a patient might previously have had a bad reaction. “General anesthesia carries a risk. We don't think of it that way because we do it all the time…you’re put on a ventilator, the grogginess after, the recovery for weeks. In someone who doesn't necessarily need it, why complicate a transplant with this added issue?”
When patients with chronic kidney disease first meet with a nephrologist, the thought of transplant can be overwhelming, and the patient is often fearful and anxious, Ghossein said. “Thankfully, we sometimes have the benefit of time to build a relationship with the patient and get them to the point where they are not as fearful of going through the transplant. Once you get them to that point, the idea of maybe you can do it without general anesthesia doesn't feel as big of a barrier.”
Although spinal anesthesia had been used decades earlier during transplant operations in India and the Republic of Turkey, Rohan noted, the transplant made news headlines nationwide. “We were pleasantly surprised by the amount of media attention we got,” he said. “We thought it was a very interesting concept, but I think media loved it because it was not just about the technique; it was the patient experience.”
The team has since performed two similar procedures, he said. The second surgery involved a 74-year-old man who was at first fearful but encouraged by his daughter, his kidney donor. Just 1 day after the operation, the man had a pain score of 2 out of 10 and was eating and drinking normally, Rohan shared: “He said, ‘This is the best experience I’ve ever had.’” That patient was discharged in 36 hours.
The success of these procedures and enhanced recovery time presents a promising opportunity in the transplantation field, opening possibilities for patients in the United States. Since the procedure on Nicholas, the surgical team has received emails from multiple patients around the country potentially interested in the procedure because of tracheal issues or glottic stenosis from a previous surgery. Older patients also may be good candidates, as they can become disoriented from general anesthesia, Rohan explained.
“Transplantation is a serious thing,” Rohan added. “But making it more humanized and making people think it is not all that bad, I think, will encourage a lot of people to [undergo a transplant] who are maybe sitting on the fence.”
Top: Nicholas in the operating room seeing the donor kidney. Bottom: Nicholas and the transplant team at the end of surgery.
Citation: Kidney News 16, 9
Northwestern Medicine.
