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Kidney donation: preoperative preparation & facing challenges generally - goals and journey

I'm due to donate a kidney soon, and I have been writing about what's involved - see "Kidney donation: why it's well worth considering", "Kidney donation: what are the risks?" and "Kidney donation: preoperative preparation & facing challenges generally - values are central".  Primarily these posts are for other donors, but aspects of what I write are also relevant for facing challenges more generally as well.

I wrote in the last post "... values are central" - "So how does one "prepare for a challenge"?  How am I preparing for this challenge of a rapidly approaching kidney operation & the planned post-surgical recovery?  Well, as a doctor & psychotherapist, I specialise in helping people with stress.  This is my "business" ...  this is my vocation and it's also how I earn my living.  Here's an opportunity to "walk the talk", and probably to learn a whole lot in the process.  I have hundreds of books, journals & databases of theories & intellectual knowledge about this territory of working through challenging circumstances, but how do I approach it now?  How do I cope effectively?  It has seemed helpful to organize my responses into four general categories ... Values, Goals, Journey, and Self-Compassion.  This four part way of organizing my coping responses tracks well onto the "Bus driver metaphor" (see a downloadable description of this metaphor as a Word doc or as a PDF file) ... it's one of the most usual "maps" I suggest clients try using when responding to challenging experiences.  Values, Goals & Journey are the "Bus driver's" responsibility, while Self-compassion is the territory of the friendly "Bus conductor" & the rather tiresome "Passengers"."

Having already written that "... values are central" ... in today's post I want to say more about Goals and Journey. I think it's helpful for me to see Goals as involving primarily donating a healthy kidney & recovering well, but also allowing this challenging time to deepen my relationships with others, and too, being inquisitive & open to new experiences & learning.  The Journey splits into arriving at the operation in as good a physical & psychological state as I can, the initial days & weeks of recovery as I work back towards full functioning, and the long-term management of my health when I'm living with just one kidney.

So how do I arrive at this operation (how does anyone arrive at a surgical operation or other major challenge) in as good a physical & psychological state as possible?  The concept of "resilience" is potentially helpful here. Graham & Becerril-Martinez, in their 2014 paper "Surgical resilience: A review of resilience biomarkers and surgical recovery", reviewed the literature on the impact of resilience on surgical recovery and wound-healing. They comment "Qualitative analysis of recovery trajectories following stroke, spinal cord injury and amputation consistently find that “resilient” trajectories are associated with better outcomes than less resilient trajectories.  These resilient trajectories were characterised by positive affect, good mood, less distress and active coping styles ...  While there is a physiological dimension that cannot be discounted, evidence indicates the psychological aspects may in fact dominate post-surgery recovery."   And looking beyond the surgical literature they also highlight that in life more generally "Resilient individuals have diminished stress reactivity and better emotional recovery than individuals who are less resilient. Importantly, resilience is protective against state and trait anxiety and anxiety disorders.  It is essentially a 'psychological shock absorber'”.

Meanwhile Powell et al, in their 2016 Cochrane Review - "Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia" - (and Cochrane Reviews are typically pretty cautious about their conclusions) wrote "We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion-focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post-surgery ... The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay". The authors noted that there's a real need for bigger & better-designed studies, but overall the evidence for the value of pre-surgery preparation is encouraging ... and as Graham & Becerril-Martinez pointed out "Resilience ... is essentially a 'psychological shock absorber'" for life more generally.

Hannah Maple has looked this issue (of what helps post-surgery recovery) straight in the eye for kidney donors.  The abstract of her 2015 paper - "Stress predicts the trajectory of wound healing in living kidney donors as measured by high-resolution ultrasound- comments "Psychological stress has been shown to be an influential factor on the rate of wound healing; however these findings have been demonstrated predominantly on artificially created wounds. Due to the absence of major co-morbidities, living kidney donors are a unique group in which to study this relationship. This study investigated the effect of preoperative stress and personality on surgical wound healing ... High-resolution ultrasound scans of surgical wounds were performed on the first three post-operative days and once following discharge (mean = 15.3 days; s.d. 2.8) ... 52 living kidney donors participated. Higher pre-operative life stress, lower optimism and lower conscientiousness were associated with delayed wound healing in living kidney donors for both outcomes. Increased emotional stability was associated with faster wound healing ... Conclusions This study, which measured wound healing in a novel patient sample using a novel technique, has demonstrated a negative association between stress and wound healing and the positive influence of optimism, conscientiousness and emotional stability."

In further Ph.D research - see her fascinating 350 page thesis "Psychosocial outcomes in living kidney donors: Predictors and processes" - Hannah carried out the world's largest study of unspecified/altruistic donors comparing them with a matched sample of specified donors (who know the recipient they are donating to).  Her 2014 paper - "Motivations, outcomes, and characteristics of unspecified (nondirected altruistic) kidney donors in the United Kingdom"states "Unspecified (nondirected altruistic) kidney donation is becoming increasingly common in the United Kingdom. Questions regarding motivation and characteristics of these donors persist, alongside concerns about regret and long-term psychosocial outcomes. The aims of this study were to compare psychosocial and physical outcomes in unspecified kidney donors (UKDs) versus specified kidney donors (SKDs). Methods: We performed a cross-sectional study, in which a detailed assessment of psychosocial outcomes was made using validated questionnaires. Additional questions specific to donation were also asked, including questions regarding motivation, regret, and anonymity. Results: One hundred ninety responses were received from 296 participants studied (110 UKDs [74.3%] vs. 80 SKDs [54.1%], P<0.001). Unspecified kidney donors were older (54 years vs. 44 years; P<0.001), predominantly white (99.1% vs. 78.5%; P<0.001), and donated more recently (1.3 years vs. 2.6 years; P<0.001). There was no difference in psychiatric history or personality type, or current depression, anxiety, stress, self-esteem, or well-being between the groups (P>0.05). Unspecified kidney donors were more engaged in other altruistic behaviours (P<0.001). There was no difference in physical outcomes, although UKDs recovered quicker (P<0.001). Regret was low (3.7% UKDs vs. 7.5% SKDs; P=0.078). Conclusion: This study has demonstrated that UKDs have comparable physical and psychosocial outcomes to SKDs. These favorable outcomes may be, in part, because of the rigorous evaluation process which currently includes a mental health assessment. We conclude that the program can continue to expand safely across the United Kingdom."  

Hannah also noted the interesting finding that, although the unspecified donors (UKDs) were on average 10 years older than the specified donors (SKDs) "Subjective, patient reported markers of recovery demonstrated faster recovery in the UKD group. Donors were asked to select a time frame in which they returned to work and driving (Less than 4 weeks, 4-6 weeks, 6-12 weeks or more than 12 weeks). UKDs returned to work faster (25 UKDs 4-6 weeks vs. 30 SKDs 6-12 weeks; p<0.001) and returned to driving faster (52 UKDs <4 weeks vs. 23 SKDs 6-12 weeks; p<0.001). Donors were additionally asked to note how many weeks it took for them to feel back to normal. The median return to normal time for UKDs was 6 weeks versus 12 weeks for the SKD group (p=0.001)."  She also commented that "Both groups felt that donation was one of the best things they had done".

There is so much that could be said about this territory and there are so many interesting & relevant research studies - for example "Patients’ expectations predict surgery outcomes: a meta-analysis""Hypnosis for acute procedural pain: a critical review""From donation to everyday life: Living kidney donors’ experiences three months after donation""The course and predictors of health-related quality of life in living kidney donors: a systematic review and meta-analysis""Development of a donor-centered approach to risk assessment: rebalancing nonmaleficence and autonomy""Understanding donation experiences of unspecified (altruistic) kidney donors" and "More than a decade after live donor nephrectomy: a prospective cohort study".  And more good work is emerging all the time.

Having looked at all of this information over the last few weeks, what's the bottom line?  As a doctor who has worked over many years both in the psychological field and, in earlier years, in the treatment of persistent pain ... what's my current take on how to donate a kidney & recover well, how to arrive at surgery in as good a physical & psychological state as possible, and how to manage the initial days & weeks as I work back towards full functioning?  Ideally one is already in excellent physical & psychological shape before even making the decision to donate.  Typically there are several months between initially considering becoming a donor and actually going through the operation.  It's really worthwhile to "train" for the surgery.  Get physically fit, review use of alcohol (and of course smoking), eat healthily. The benefits of improved health behaviours are huge - see, for example, the post "Would you like to be 14 years younger - it's largely a matter of choice!".  And once the kidney has been donated, use the fact we only have one left as motivation to continue living really healthily - this way we may well end up, with our single kidneys, with better quality & quantity of life than we would have if we had lived less healthily with two.

Coming up to hospital admission it's good to try to get a fair amount of sleep.  Doing what one can to stay relaxed & upbeat makes excellent sense as well.  Try not to go into the surgery feeling totally frazzled from rushing around tying up loose ends pre-operatively.  We tend to do well using our "strengths".  What has helped us feel relaxed & positive in the past?  Is exercise helpful, spending time with friends & family, being absorbed in hobbies & interests?  All of these approaches (and others too) may well be ideal for different people.  For some people expressive writing may be useful (see the next blog post in this series).  Even better supported by research is the use of relaxation, imagery and related approaches.  If this interests you, do practise meditation/relaxation forms pre- and post-surgery.  It's well worth underlining that relationships too are really important for our health - see "Strong relationships improve survival as much as quitting smoking".

Knowing what the territory ahead typically looks like is often helpful too.  So as a 66 year old kidney donor, in good physical & psychological health, I am likely to be in hospital for three days (plus or minus).  I am likely to experience a fair amount of pain, but I'll get through it.  I have a significant chance of developing some kind of complication (for example an infection or a bleed), but this is very likely to be fixable quite quickly.  Hannah Maple's work suggests that, as an altruistic non-directed donor, I may recover particularly quickly.  I'm scheduled to go back to work about four weeks after the operation (quicker than I'd intended, but the operation was pushed back eight days later than I'd originally been led to expect).  This is a challenge, but not a ridiculous one.  Startingly it seems that quite a high percentage of non-directed donors said they felt "back to normal" in six weeks.  I doubt that means I'll be quite ready by then to play my usual weekly two hours of full on badminton or two hours of crazy free dance or strong stretch yoga exercises ... but hopefully I won't be far off.

In many ways this feels like a very stretching, extended solo trek up into the Scottish mountains.  I know the long period of planning, the preparation of equipment, the many miles of driving, the dread I can sometimes feel looking up at the long days walking ahead (I nearly killed myself on one occasion).  I know the mindfulness of just letting the fear pass, the reappraisal of reminding myself that the task is reasonable & eminently achievable, the repeated refocusing on the next few steps, the long slogging hours of effort & tiredness, the problem solving when an unexpected obstacle to the initial plan emerges, the flashes of joy, the appreciation of beauty, the satisfaction & contentment, the sheer aliveness of tackling big worthwhile challenges.  I can use these body-mind memories to help me through.

For the next in this series of posts looking at the approaching surgery, see "Kidney donation: preoperative preparation & facing challenges generally - aspects of self-compassion".


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