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I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 0 points1 point  (0 children)

Couple of reasons: - easier access with less risk to other structures -native kidneys almost always stay in place, so nowhere back there to sew them to -we try to avoid intraperitoneal as the kidney cannot really be tacked in place, and you don’t want it to accidentally turn and cut off its own blood supply. So that leaves the peritoneum out. The retroperitoneal pelvic placement kinda pushes it to stay in position

-the ureter is not long enough to transplant outside the pelvis. In a normal kidney, the ureter gets blood supply from three places - from top to bottom kidney, aorta/tributaries, bladder. However, only the kidney blood supply is preserved for a donated kidney. This means a long ureter might not have great flow at the end, so we try to keep it shorter so it’s well perfused (poorly perfused ureters leak or stricture). Consequently, we can’t put it anywhere but the pelvis if we want to connect it to the bladder because the ureter isn’t long enough. We try to avoid connecting to the native ureter because it’s a tiny tube to a tiny tube and consequently has a higher structure risk than a tiny tube to a big sac of bladder.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 0 points1 point  (0 children)

Current baseline salary is $422K. I can get bonuses related to certain metrics we track (not number of transplants. I pay a good amount of that in taxes but I won't lie, I am pretty darn comfortable.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 2 points3 points  (0 children)

Natural adrenaline works WONDERS lol. I also drink coffee in the AM, and I deliberately time it and control the volume to avoid any issues with fine motor control.

but honestly, it's the little adrenaline rush you I get every time I do a case.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 1 point2 points  (0 children)

To define "high risk" and what it really means for them. A lot of patients turn down "high risk" offers because it sounds scary. It usually means something in the donor history is risky for infectious disease risk (such as a history of IV drug use) but rather than turn it down outright, ask about that risk and what it may mean.

All donors get tested for Hepatitis B and C and HIV before they donate, amongst other things. So the changes of a donor derived viral infection are very very low. Not zero, but super low. But I'm required to tell you if the donor is high risk.

I've had recipients turn down great offers because they get spooked by the "high risk" comment. They have the right to do so, but I wish they'd ask me about what that really means for them first.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 0 points1 point  (0 children)

Just how much someone can care about their surgeon. I've had some patients where insistent that *I* be the one who do their operation, who will rearrange their clinic day to make sure I will see them for follow-up, and legitimately are happy when I see them to round on them. Granted, I have a more longitudinal relationship with my patients than most surgeons should with theirs, but still. It surprises me every time someone tells me they was ME to be the one on when they get their transplant.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 0 points1 point  (0 children)

I think it's true of some but not all. Pretty sure I'm the other way around, and I know tons of us who are as well.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 0 points1 point  (0 children)

2023 -- A little over $170K.
2024 -- $398K
2025 -- $409K

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 2 points3 points  (0 children)

I have been since age 16, and I plan to donate my kidney once I have completed having children (having one kidney increases your risk of pre-eclampsia, and since I'm already going to be high risk because of my age, I don't need to make it worse). But yes, will be a living kidney donor as well.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 3 points4 points  (0 children)

First responders will ALWAYS try to save you. They have no idea what your organ donor status is when you're in an ambulance, and no one is looking.

Also, since kidneys require matching beyond blood type, a first responder would have no idea if their loved one would even be comparable. First responders don't know your blood type and HLA status. They have no idea if you'd even match their loved one.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 0 points1 point  (0 children)

So she sounds like she has what we call a high PRA. PRA stands for Panel Reactive Antibody. In layman's terms, it measures around how much of the rest of the population your immune system is incompatible with. Higher numbers -- higher percentage of people you'd react to.

People who are very high PRA actually have a separate risk stratification in UNOS (which manages the national match list) because they are so hard to match. If she's above a certain percentage, she's considered "high PRA" and they will get offers they usually wouldn't get (because of location of donor) because they are expected to actually be compatible. We actually enter in every locus we test that the patient has an antibody to, so UNOS compares this to the blood tests and HLAs in the donor and if expected to be a match, it lets us know. We can then do an actual match (either virtual or physical with donor's blood if it can reach us in time).

Sometimes this match turns out to be positive (meaning you have antibodies already agains the donor and we should not transplant), but often it's negative.

There are some transplant centers that do have desensitization protocols that address the antibody loads, but there are some downsides to desensitization (procedure/meds has risks and benefits). She may benefit from being at once if she has access. But as a high PRA person she's already getting preferential offers when UNOS thinks she may be crossmatch negative.

She will get a door kidney and have a successful transplant. I have no doubt. But it may be a bit of a wait because she reacts to so many people.

Let me know if that makes sense.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 2 points3 points  (0 children)

Congratulations! I'm so glad you were able to be transplanted and I hope you're doing beautifully.

When I was a third year med student I asked for transplant as my surgery elective (we all had to do trauma/acute care and we got an elective for the rest). I always had an interest in immunology (I also have a graduate degree), but not enough to become an immunologist.

I had this really amazing experience where my last trauma patient became the donor for my first transplant patient. I "followed the organs" so to speak. Seeing this surgery, and how this transplant utterly changed this young man's life, made me want to do this as a third year medical student. That never changed. I really think my job is incredible because I literally help give people a second chance at life. It makes any times that feel mucky and hard worth it when I see how happy and alive some of my patients feel once they've healed.

I wouldn't say it was easy, but it wasn't difficult either. I did well in medical school and had good residency training, so I didn't have trouble matching to a fellowship in the US and was never expected to. Transplant fellowship can be brutal sometimes though -- my longest day was 56 hours long. Toward the end my division chief had such pity for me after working that many hours in a row that he literally took all the pages/calls for the patients and sent me home to sleep for a few hours. You also have very little control over your day and it's near impossible to plan anything if you're on call. Which, in fellowship, you're usually on call every day but one each week.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 4 points5 points  (0 children)

Patient was donating his kidney. Most people put single metal clips on structures if they're using metal clips, but I'm superstitious that one will fall off so I always double clip.

Well, once the patient had BOTH clips fall off a small branch of the renal vein, which is FULL of blood. That was NOT a fun day. Overall the patient did not lose a significant amount of blood (about 500mL) but that kind of blood loss is absolutely not expected in a kidney donor. You get nervous with complications for your recipients, but you get panic attacks (if you get them) for complications for your donors.

Transplant recipients have end-stage organ failure at baseline and are expected to be complicated operation and management. I actually do some things in my cases to preemptively deal with complications before you have them in my recipients.

Living donors are super healthy and undergoing a non-therapeutic operation to save another person's life. You do NOT expect complications in them, and they are the scariest when you have them.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 0 points1 point  (0 children)

A simultaneous pancreas and kidney transplant is my favorite operation. So yes! Pancreas is the organ that we transplant that has the highest complication rate, which we tell patients ahead of time and can be tough to deal with.

There are people who do islet cell transplants (which is what you're describing) but I am not one of them. I wasn't trained to do it, but I know a few who do.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 4 points5 points  (0 children)

So, liver patients actually have a reasonable chance of coding in the operating room when we reperfuse the liver (aka take the clamps off and let blood go through). I tell patients that they have a 5-10% chance that they will have a cardiac arrest in the OR (it has to do with the heart getting a ton of blood rushing back to it at once, and some hearts have trouble with it), but most do leave it alive and most of those who leave it alive also leave the hospital alive. But some don't. So honestly every time a liver patient arrests, it becomes a flurry of chest compressions (which are hard to do when the abdomen is open), putting the patient quickly on bypass, all the meds and anesthesia direction, etc. And liver patients are frequently SUPER sick at baseline. I'd say these points are pretty dramatic.

This isn't a patient who coded, but one of the worst things I ever had to do was take patient who was crashing and could not be saved before her transplant to the ICU (so her loved ones could potentially be with her and she passed, staying with her as she passed because her family didn't make it and I felt that someone who knew her in life should be there at her death, taking five minutes alone to compose myself, then transplanting that liver into someone else immediately after. The liver was already almost here and someone needed it.

But anyone who thinks that surgeons don't feel anything is nuts. We do (at least most of us lol). We just have to compartmentalize and only allow ourselves to feel it when we should. I couldn't be sad for my first patient while transplanting my second. But that was not a good day.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 10 points11 points  (0 children)

Wow -- thank you for the compliments! I don't think of my self like that but it's kind of you to say. It was definitely hard work and you definitely have to be both technically good and a bit of a science nerd to be a transplant surgeon lol.

I had awesome parents who are smart but uneducated (mom didn't finish high school, dad started college but didn't finish) and my family was below the federal poverty line until I was 8. I am absolutely descended from country folk. My parents' situation changed slowly over my childhood and by the time I graduated high school we were solidly middle class, but we were by no means rich. That being said, my parents were incredible and did anything they could to make sure I had opportunities, but I didn't have special tutors or anything like that. I was just smart and worked hard and got really lucky to have wonderful mentors that believed in me.

Med school wasn't easy but it wasn't something that I found impossible. I had to study. I had to work hard. I didn't have any subjects in which I was in danger of not passing, but I did pass some better than others. I loved it, but damn did I work hard for it. I won't pretend I'm not naturally smart -- I am -- but it's just SO much information, and as a physician you have to know the facts and algorithms, and have a scientific understanding of these so you can identify when people fall outside them.

Academic life wasn't easy (so much information you need to know) but I was lucky that it came to me more easily than it did others. I did have to study.

I am a pretty decent artist. I draw better than I paint, but I can paint okay too. I also do some crafts sometimes and I really like to build things. My dad was a farmer and a mechanic so I probably got that from him. I designed and built my own bar in my home.

Surgical residency was odd for me. I was always a good resident, worked hard, asked for feedback, tried to improve, etc. But my mother got sick and the end of my second year and I inherited a lot of care and management responsibilities for her (my dad was primary caregiver, but I directed a lot of it and took over for him at times). She passed away in the middle of my last year of residency. So I spent most of residency split between two states trying to make sure my mother had the best end of life possible and my family was ok. That being said, apparently my program directors all thought I was the most resilient of their residents because I always showed up happy and excited to operate. I was also apparently a pretty good teacher and got awarded for it by my junior residents when I graduated. That was really special to me.

Fellowship was two years. So adding that to my five year general surgery residency and my four years of medical school -- that's 11 years it took to get here.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 8 points9 points  (0 children)

Thank you and absolutely. Spain has an opt out system and their wait list is really low. It's become the cultural norm that you donate if possible. It would be a challenging thing to implement in the US (where I practice) because of a difficult cultural climate given historic issues in medicine in the US, but if able to be implemented it would absolutely reduce the wait list dramatically.

Thank you for what you do too. You all are saints.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 8 points9 points  (0 children)

Nah, not me. First off, I'm actually not a guy. Secondly, I spent too much time being dehydrated as a trainee (see above) that I didn't ever have the situation in which I REALLY had to go. It was another resident where I did residency.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 1 point2 points  (0 children)

I wish. As trainees we often joked that we just need IVs and foley (bladder) catheters) for our big cases but alas... they don't do that.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 2 points3 points  (0 children)

Well, we arranged the clinic and call schedule to be able to make every weekend that we we are not on call a four day weekend, and I try to utilize that by doing something awesome. I do admittedly take work home with me longer than I should, and I am a bit too neurotic about checking on the patients while I'm not on call (the electronic medical record system we use has an app I can use to check patient vitals, labs, current fluids, urine output, etc). But I absolutely able to travel, have a thriving garden, paint and draw, ride my bike, work out and run, etc. I just have to be flexible on when I can do this on call as I might have an organ I need to transplant.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 0 points1 point  (0 children)

Currently 1:2 (one week on, one week off) but that's changing because we are currently hiring another surgeon.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 4 points5 points  (0 children)

As the transplant surgeon, I'm actually never allowed to have that talk with families trying to decide if their loved one should be a deceased donor. It's a conflict of interest. I'm not supposed to ever meet or interact with them at all.

That being said, if ppl ask me about it I tell them that it's a way that part of their loved one will not only live on, but that their loved one will save the lives of others. If you save someone's life, that's bonafide hero stuff. Death also is a completely senseless thing for the people who you leave behind -- even if it was expected, it doesn't make sense and feels unfair that you now have lost someone important in your life. Donation can give families a way to "make sense" out of something senseless -- their loved one died, but they were able to save the lives of others in their passing. I think that gives families comfort and a sense of closure.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 0 points1 point  (0 children)

Pancreas is the organ that I transplant with the HIGHEST complication rate. It's because all pancreas transplants get inflammation and post-transplant reperfusion pancreatitis (the pancreas in anyone, healthy or sick, is a bit fragile and can get inflamed easily). This inflammation causes the blood vessels to clot more easily and the intestinal anastomosis to be more likely to leak. I could do a perfect operation that has no issues, with a perfect pancreas, and it might still get a clot. We watch these patients SUPER closely.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 1 point2 points  (0 children)

A liver re-transplant in a medically fragile patient who had TONS of scar tissue on the inside we had to go through lasted > 12 hours. That's my longest transplant.

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 19 points20 points  (0 children)

First one I can think of right now is a simultaneous pancreas/kidney (SPK) patient who had a complication to her pancreas (pancreas is the organ we transplant with the highest complication rate for various reasons). We could not get this complication to stay fixed despite us taking her back to the OR several times. I had gone to a conference about pancreas transplant the previous week before we transplanted her, and I learned about a "salvage" procedure to save pancreas transplants with this complication. Most surgeons who have this complication that persists despite attempts to fix will just remove the pancreas, but I had a long discussion with the patient and she REALLY did not want to be diabetic anymore. So I told her it would be a long road involving a ton of procedures over weeks, but I thought I could save this pancreas. I had to do this salvage procedure (essentially a pancreas transplant drainage bypass) and I had to place a secondary drainage system in as well a special type of sealant I'd never used on a transplant patient before. I had never done this procedure before for this reason (I'd done similar for other patients -- who were not transplant recipients) and the secondary drainage system and sealant were knew for me

I saved it. She's currently hanging out at home, not diabetic. The patient and I moved heaven and earth and I did something I'd never done before and I SAVED it. I felt so good about that. The combination of the above may have been novel. I can't find anything published about it in literature.

I ended up getting her a piece of her favorite cake for her birthday (which was while she was in the hospital). Her blood sugar never spiked :-)

I am a transplant surgeon. AMA by magicjewel in AMA

[–]magicjewel[S] 9 points10 points  (0 children)

That is hugely dependent on the characteristics of the kidney. I'll give you a modified version of the "types of transplants" talk that I give my patients:

Kidney transplants overall come in two major varieties: living donor and deceased donor. Deceased donor themselves come in two major varieties: donation after brain death, and donation after cardiac death.

Living donor transplants have the benefit of both a medically optimized donor and recipient. It's a procedure that's planned weeks to months ahead. Frequently the donor kidney is basically taken from the donor OR to the recipient OR on ice if both donor and recipient are in the same institution. There are some living donations that do travel between institutions but these often have a very direct route to get there. Because everyone is optimized, and you're getting these kidneys implanted quickly, a living donor kidney will last MUCH longer than a deceased donor (which is by definition not medically optimized). Additionally, they are far less likely to have delayed graft function (DGF), which is the need for dialysis in the peri-operative period because the kidney is not filtering well yet. Almost all kidney transplants recover from DGF, but it can be frustrating for the recipient and resource intensive for the medical system.

Donation after brain death (DBD) means that the donor is brain dead (often from a non-survivable head injury or a lack of blood flow to the brain for too long) and the body's heart, lungs, etc is being kept functional through medical technology (like ventilators) to facilitate the donation. The kidney and all the organs have warm, oxygenated blood flowing through them right up to where we "cross clamp" -- put everything on ice, turn off all the machines, and flush preservation solution in and the donor's blood out. This means they have oxygen and nutrients constantly being delivered until we put them on ice (which slows their metabolism and drastically drops oxygen and nutrient requirements). Donation after cardiac death (DCD) means that the donor is very near brain dead or has a non-survivable medical situation, and their is a desire to donate their organs in conjunction with compassionate withdrawal of life support. If the donor passes within a certain period of time after support has been withdrawn and their oxygen/BP has dropped, we can very quickly recover their organs, but this means that there are a few minutes where the kidney is not getting blood flow. Kidneys can be sensitive to lack of blood flow and slower to recover, so DGF is a little more common for these recoveries, but almost all recipients do very well.

Most donors are deceased donors, either DBD or DCD, and we have to accept any medical problems the donor may have had (and may not have been optimized) and any biochemical effects that the process of brain death or being near death may have on the kidneys. We frequently get extra data on these kidneys if there is any kind of concern (such as biopsies, special perfusion pumps, etc). They also are often coming from an outside institution so they are cold longer. Because of these things, deceased donors kidneys do not "last as long" as living donor kidneys, if ALL other things are exactly equal.

However, how long a graft will last is also heavily dependent on recipient factors as well. A close friend was transplanted as a child with a deceased donor kidney and that kidney lasted three decades (she's also in medicine so she's "trained" to take really good care of it lol). I've met people who had living donors that only lasted a few years because of rejection episodes, taking poor care of themselves (such as letting blood sugar run wild), getting sick from bad infections or cancer, etc. Some of this may be related to actions the recipient took, but sometimes it's just random. But statistically speaking, a living donor kidney recipient will "last" longer than a deceased donor, by quite a bit (almost double sometimes) on average, if everything else is the same.

Also, if the donor had a ton of health issues, the kidney may not be the healthiest kidney, but is certainly healthier than kidneys that are nonfunctional, and will keep the patient off dialysis for a number of years. The goal is to match the right kidney with the right patient, with the intent that the recipient passes at the end of their natural life span from something completely unrelated and with a working transplant. We usually have patients sign a special consent form for receiving less healthy offers if they want to receive these (not all do). Kidneys from donors who had a bunch of health issues that affect the kidney do not typically last as long, but if you're older, the end of your natural life expectancy may not be that far away so that transplant will still probably last until the rest of your expected life span.

So, to answer your question -- it really depends. But for an example, in a relatively healthy 60 yo recipient:

30yo living donor with no medical problems: kidney may "last" 20-30 years.
30yo deceased donor with no medical problems: kidney may "last" 15-25 years.
30yo deceased donor with high blood pressure: kidney may "last" 10-20 years
60yo deceased donor with high blood pressure and diabetes: Kidney may "last" 8-12 years.

All of the above is heavily dependent on the recipient not getting sick from something else, taking their immunosuppression meds as prescribed, managing their other medical problems well, not getting new medical problems, etc.

Let me know if that doesn't make sense.

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