• Northwestern Medicine has completed 25 awake kidney transplants using spinal anesthesia.
• The program allows patients allergic to general anesthesia to receive a kidney transplant.

In 2024, surgeons at Northwestern Medicine completed the first awake kidney transplant.

Led by transplant surgeons Satish N. Nadig, MD, PhD and Vinayak S. Rohan, MD and anesthesiologist Vicente Garcia Tomas, MD, the procedure was the first kidney transplant to be performed using single spinal/epidural anesthesia injection rather than general anesthesia at Northwestern Medicine.

After the first surgery, Northwestern Medicine established the Accelerated Surgery Without General Anesthesia in Kidney Transplantation (AWAKE) program. Since then, the program has completed 25 transplant operations.

Healio spoke with Nadig and Rohan about how the program began and which patients would qualify for an awake transplantation.

Healio: How did the AWAKE program begin?

Rohan: Dr. Nadig and I have worked together for a long time, and we were looking for ways to improve the process of kidney transplantation at our institution. We realized one way we could improve patient outcomes was by helping them recover faster after surgery. Pain control and nausea after surgery from general anesthesia may hold a patient back in the hospital after transplantation, so we explored how spinal anesthesia could enhance kidney transplant patients’ recovery after surgery.

Nadig: The average length of stay for a kidney transplant today in the U.S. is about 5 to 7 days, and we had already gotten it down to about 2 days at Northwestern. We thought about what keeps transplant recipients here for the extra day and if they can have a better recovery outside of the hospital, which provides its own benefits. On top of that, general anesthesia use affects cognitive function, and it can rule people out from receiving a kidney transplant if they are too high risk to receive general anesthesia. We thought performing an awake kidney transplant could not only lead into the next era of innovation but also allow for broader access to care for those that may not be eligible otherwise.

Healio: What are the benefits and risks of an awake kidney transplant?

Nadig: One thing to be clear is that patients are awake for a lot of procedures that are already happening today. For example, women are getting cesarean sections with spinal anesthesia, hip replacements are done under epidurals or spinal anesthesia, and colonoscopies are done with just sedation.

For these kidney transplant recipients, their pain control is better than standard kidney transplantation. In addition, we skip an invasive portion of the operation, intubation, so patients can keep breathing and talking while we’re doing the kidney transplant. The risks are that sometimes you might need to be intubated, although we have not seen that yet, and all the risks that come with any type of spinal anesthesia.

Rohan: What we have seen from our program is patients who have undergone an awake surgery have earlier recovery of bowel function, mobility and discharge from the hospital. Their pain control has also been fantastic, and few patients have required any pain medications after transplantation. Overall, this is a well-selected group with better postoperative recovery metrics than general anesthesia.

Healio: Who qualifies for awake kidney transplantation?

Rohan: We look at it in two ways. First are patients who are healthy and fit enough for general anesthesia but who you’d want to have hastened recovery after kidney transplantation. The second group of patients includes those who are considered high risk for general anesthesia, such as patients with myasthenia gravis, patients with cardiopulmonary disease and patients who are allergic to general anesthetic drugs. These two groups of patients are our primary candidates, though we also look out for contraindications before selecting them, such as for patients who had previous spinal surgery or patients on blood thinners that put them at risk for clotting around the spinal cord.

Nadig: Anybody that can have a standard kidney transplant would be considered eligible for the AWAKE program. The beauty of it is that many patients that were historically not considered candidates, like older patients, can now be candidates.

Healio: How does it feel to perform an awake kidney transplantation and communicate with the patient through the process?

Nadig: I like the cesarean section analogy because, like delivering a baby, we can experience the joy of that moment with the patient. This procedure allows for a connection to be made that no other realm of medicine can have as we’re delivering new life to the patient. That moment when we release the clamps for the blood vessel and the new kidney gets its blood flow and starts working, we’ve had patients express gratitude and joy in many ways, and we’re able to experience that moment with them.

Healio: What do you want clinicians to know about awake kidney transplantation?

Nadig: Don’t be afraid to challenge the status quo. Transplant is a young field — it’s only been around since 1954 and legitimized in 1984 when Congress passed the National Organ Transplant Act. Procedures have been done the same way for many decades, so it’s time for us to squarely get into the era of technology and set the foundation for kidney transplantation to be an outpatient procedure.

Rohan: In our patient population of 25 completed awake kidney transplants, 25% of transplant recipients have gone home in 1 day. We are already on the pathway to potentially performing kidney transplantation as an outpatient operation by perfecting the whole perioperative pathway. Soon, I think we are going to have a higher percentage of patients who can go home in less than 1 day.

Satish N. Nadig, MD, PhD, transplant surgeon at Northwestern Medicine and director of the Northwestern Medicine Comprehensive Transplant Center, and Vinayak S. Rohan, MD, transplant surgeon and associate professor of surgery at Northwestern Medicine, can be reached through Meg Hilling at megan.hilling@nm.org.