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End stage renal disease (ESRD) is the final stage in the progression of chronic kidney disease (CKD). CKD has a multitude of etiologies, presents in a variety of ways, and progresses in a patient-dependent manner. Despite the heterogeneity of CKD, once ESRD ensues, patients require Renal Replacement Therapy (RRT). RRT is one of three prongs: hemodialysis, peritoneal dialysis, or kidney transplant. Of these, kidney transplantation provides the patient with the best quality of life, an improved survival, and an opportunity for cure. However, the success of kidney transplantation with improved outcomes and tolerance to the required immunosuppression has led to an extreme organ shortage despite the increase in deceased organ donors. As a result, the push for living donors has become increasingly more important. For recipients, the best outcomes are with transplants from a living donor due to superior graft quality and elimination of the need for waiting and dialysis. This article will present such a case and discuss the important considerations a physician must make preoperatively and intraoperatively when performing kidney transplantations.
The National Kidney Foundation definition of chronic kidney disease (CKD) was established in order to standardize the approach to care for this patient population. CKD is defined as kidney damage for greater than or equal to 3 months by structural or functional abnormalities of the kidney and/or a glomerular filtration rate (GFR) of < 60 mL/min/1.73m2. The stages of CKD vary by GFR level: in stage I, GFR is ≥ 90; in stage II, GFR is 60–89; in stage III, GFR is 30–59; in stage IV, GFR is 15–29; and in stage V (kidney failure), GFR is < 15 or dialysis dependence.2 In this case report, we will discuss a patient with end stage renal disease (stage V CKD) who underwent living related kidney transplant prior to the initiation of dialysis.
This patient is a 56-year-old female with a past medical history of type I diabetes mellitus, hypertension, hypothyroidism, hyperlipidemia and ESRD secondary to diabetic and hypertensive nephropathies who presented to the Massachusetts General Hospital for a living related kidney transplant from her sister.
Her past surgical history is significant for a cesarean section and left upper extremity AV fistula. Her notable medications include amlodipine, calcitriol, levothyroxine, olmesartan, pravastatin, lasix, and kayexalate. She is allergic to aspirin and penicillin. Socially, the patient lives with her husband and teaches in a local elementary school. She has a vaccinated dog and a turtle as pets but notes she will no longer care for her turtle following transplant. She does not drink alcohol and was a former smoker with a 1 pack-year history, quitting in 1979. She denies any illicit drug use. She denies any recent travel or tuberculosis exposure in her past.
On preoperative exam the patient was noted to be a well-appearing 56-year-old female. Her abdominal exam was noted to be within normal limits with a soft, non-distended abdomen and a well-healed surgical incision from her cesarean section. Her femoral and pedal pulses were palpable bilaterally. In a patient with ESRD that is being considered for renal transplant, it is important to assess the lower extremity pulses for evidence of significant peripheral vascular disease. This is to ensure minimal atherosclerotic disease where the transplanted kidney’s artery will be anastomosed on the recipient’s iliac vessels. Any significant peripheral arterial disease (PAD) in the aortoiliac system could compromise circulation to the allograft or to the ipsilateral lower extremity due to dissection in the iliofemoral arteries distally, or it could steal from the lower extremity circulation by the allograft.2
In general, cardiac evaluation prior to kidney transplantation includes: EKG and echocardiography. Additionally, a stress test and/or coronary angiography is conducted for inpatients with history of CAD or significant risk factors (diabetes mellitus, hemodialysis for greater than one year, left ventricular hypertrophy, age of > 60 years, smoking history, hypertension, or hyperlipidemia). In patients with symptoms or signs of voiding abnormalities or urinary obstruction (e.g. prostatic), a voiding cystourethrogram and complete lower urinary tract evaluation is necessary to rule out outlet obstruction.3 If the patient has any history of peripheral vascular disease or any concerning findings on vascular exam, the patient should undergo pulse volume recordings (PVRs) of the lower extremities and/or a CT scan of the abdomen and pelvis (without contrast) to assess for iliac calcifications.
This patient underwent preoperative EKG that showed no arrhythmia or ischemia. However, given that her past medical history included several coronary artery disease (CAD) risk factors, she underwent coronary angiography that excluded severe atherosclerotic lesions. A preoperative chest x-ray showed evidence of prior granulomatous disease, and a follow up chest CT scan confirmed this without other concerning findings (Figures 1–3).
Additionally, her donor sister underwent the standard donor preoperative work up. This includes assuring adequate renal function and minimal risk from being uninephric postoperatively. Infectious disease and malignancy clearance are also required. Finally, renal imaging to compare the size of the kidneys and their vasculature was performed to determine the laterality of the donor procedure..
Figure 1. Preoperative Non-contrast Chest CT. Coronal View. Granulomatous changes in the right apex.
Figure 2. Preoperative Non-contrast Chest CT. Axial View. Granulomatous changes in the right apex.
Figure 3. Preoperative Chest X-ray. Calcified granulomas in the right upper lobe.
ESRD has a very heterogeneous presentation and disease progression. In the United States, the most common cause of chronic renal failure is diabetes mellitus, which accounts for 45% of all renal failure. The second and third most common causes are hypertensive nephropathy (27%) and chronic glomerulonephritis (11%), respectively.4 Progression of CKD to ESRD requires a patient to undergo hemodialysis to aid in whole body fluid balance and filtration of electrolytes, metabolites, hormones, and toxins. If the patient does not undergo dialysis, they must undergo kidney transplantation or their disease will be fatal.
The treatment options for ESRD are dialysis (peritoneal dialysis or hemodialysis) and/or transplantation. In the United States in 2018, 85.9% of all incident cases of ESRD began renal replacement therapy with hemodialysis, 10.9% started with peritoneal dialysis, and 2.9% received a preemptive kidney transplant.5
Kidney transplantation occurs from either a deceased or a living donor. If a family member or friend wishes to donate but is incompatible, live-donor paired exchange (where a donor exchanges their donation with another donor so the recipients receive compatible kidneys) could be an option, which would exchange donors who are incompatible with their intended recipients so that instead each donor donates a kidney to a compatible recipient. Finally, non-directed altruistic donors require a very rigorous process to carefully select a donor and in one study it was found that almost 60 percent of non-directed altruistic donors dropped out after initial evaluation and education session, thus making this a non-sustainable source of donors.6 If the altruistic donors complete the evaluation and are accepted as potential donor candidates, it is our practice to have them start a paired exchange chain. This is done by matching them with a recipient who has an incompatible donor, who will then donate to someone else, and so forth. Multiple recipients will benefit as opposed to matching them with one recipient.
Despite a variety of treatment modalities for ESRD, kidney transplantation remains the most definitive and durable renal replacement therapy. It offers an improved quality of life, is more cost-effective than dialysis, and has an overall improved survival.3 In fact, life expectancy approximately doubles with kidney transplant across all age ranges when comparing mortality of pretransplant patients to post-transplant patients.4
When choosing between a deceased and living donor kidney, several studies have determined that living donor kidneys have better post-transplant outcomes with lower incidences of delayed graft function postoperatively given the short ischemic time. Living donors also provide longer kidney graft functions in the recipient, likely related to the donor being healthy. Other benefits include avoidance of prolonged waiting time on dialysis and the ability to coordinate donor and recipient procedures in a timely fashion.3 The best postoperative graft survival has been found in patients that receive kidney transplantation predialysis initiation.4 For the patient presented here, she was able to find a living related donor prior to initiating hemodialysis thus has the highest likelihood of graft survival when compared to patients who receive a deceased donor kidney or transplantation after being on dialysis.
As mentioned above, given the variable presentation of ESRD and differences in progression of disease, a very thorough preoperative evaluation with complete history, physical exam, and appropriate imaging is necessary. The absolute contraindications to kidney transplant that need to be ruled out preoperatively include active infection, malignancy, active substance abuse, and poorly controlled psychiatric illness.3 Other important considerations include a thorough cardiovascular and peripheral vascular evaluation as these both could preclude the patient from being a suitable kidney recipient.
Emerich Ullman reported the first attempt at kidney transplantation in 1902, but the first successful kidney transplant was not completed until 1954 when Joseph Murray circumvented the immunologic barrier and completed a kidney transplant between two identical twins without using any immunosuppression.3 In the same decade, steroids and radiation were the first immunosuppressants used, but it was the introduction of Azathioprine (Imuran) around 1960 that began a new era of kidney transplantation. Throughout the next three decades, immunosuppression continued to evolve such that these medications now have a lower toxicity profile and are better tolerated by patients.7
Unfortunately, the biggest challenge to transplantation is the shortage of organs available for those in need. The success of solid organ transplantation is ironically the single factor most responsible for the critical shortage; improved survival rates and tolerance of immunosuppression has encouraged both physicians and patients to opt for transplantation.1,8 Patients in need of these organs are those that suffer from ESRD. In 2018, the prevalence of ESRD in the United States was 785,883 with an incidence of 131,779.5 There are 88,627 people on the kidney transplant waitlist with approximately 3,700 patients being added each month. The number of kidney transplants performed yearly from both living and deceased kidney donors has increased, but it remains less than 30,000 (25,500 in 2022).9 Thus the median wait time is 3.6 years.10 The patient presented in this case is a 56-year-old female who suffered from ESRD secondary to diabetic and hypertensive nephropathies and underwent a preemptive living related kidney transplant.
Preemptive kidney transplant is a unique situation in that the patient with ESRD has not yet initiated dialysis before undergoing transplantation. Only 2.9% of patients in the US underwent kidney transplantation as their initial mode of ESRD therapy.5 In review of the literature, there are several papers that suggest that living donation provides better patient and allograft survival when compared with deceased-donor transplantation, especially when the live donor transplant is performed preemptively without dialysis.6 Living donor transplantation reduces wait times on dialysis, has shorter and less expensive hospital stays, and overall improved post-transplant outcomes.11 When done prior to dialysis initiation, the patient is able to avoid the morbidity of dialysis, dialysis access procedures, and the cost associated with this treatment. Waiting time on dialysis before transplantation has been studied and shown to quantitatively be one of the largest independent risk factors for graft loss after kidney transplant.12 Postoperative outcomes of patients that receive a transplant predialysis show lower rates of delayed graft function when compared to non-preemptive transplants.13 From a donor perspective, the living kidney donors have survival similar to that of non-donors, and their risk of ESRD is not significantly increased.14
From a surgical perspective, there were several decisions made throughout this case that warrant further discussion. The first clinical decision was related to the surgical exposure. In the history of kidney transplant, there was a time when the upper thigh was the location of transplantation. However, this was discontinued because it requires a skin ureterostomy, which is at significantly higher risk for ascending infection. In 1956, Merrill and Murray described the first transplant using the iliac fossa. They noted that the renal fossa was not chosen because it requires simultaneous nephrectomy and necessitates an ureteroureteral anastomosis, which places the ureter at high risk of stricture formation. As a result, it was concluded that the iliac fossa allowed access to adequate blood supply using the iliac vessels as well as an accessible ureteral drainage into the bladder directly via ureteroneocystostomy.15 Kidneys are typically placed in the right iliac fossa (the contralateral side of donated kidney) because most donor nephrectomies are left sided given the increased length of the renal vein.2 However, in this case presentation, the patient underwent transplantation into the left iliac fossa given that she has a history of type I diabetes mellitus and may require a pancreas transplant in the future (which are usually placed in the right iliac fossa). The last approach that is sometimes considered, pending the patient’s prior surgical history and vascular anatomy, is an intraperitoneal approach.
The next significant step in this operation is the vascular anastomoses. The renal vein is most often anastomosed first and usually to the external iliac vein in an end-to-side fashion, but this location varies relative to the arterial anastomosis. The arterial anastomosis can connect the donor renal artery with the recipient common, external, or internal iliac artery, and the procedure has evolved over time. Historically, the internal iliac was preferentially selected for an end-to-end anastomosis to the donor renal artery; however, this was not shown to be superior to the later approach of end-to-side of the renal artery to the common or external iliac artery. Thus, the most common anastomosis performed today is between donor renal artery and the side of the recipient external iliac artery as this vessel has no branches in the pelvis and is in close proximity to the bladder which facilitates the creation of the ureteroneocystostomy without compromising the distal ureteric blood supply. If the kidney was recovered from a deceased donor, the donor aorta is also recovered and could be fashioned into a Carrel patch and used for the anastomosis to the common or external iliac artery.2 During the procurement of the donor kidney, one important consideration is the number of renal arteries. When the donor is a deceased donor, it is possible to preserve all renal arteries originating from the donor aorta, including their origins in the Carrel patch. However, in a living donor, this is not feasible and multiple arteries are either anastomosed separately, or more commonly, they are anastomosed together into one artery prior to implanting the kidney. If there are small accessory arteries supplying the upper pole of the kidney, they are often ligated. Lower pole arteries are more likely to supply the ureter and consequently less likely to be ligated as the blood supply to the ureter needs to be optimal.
The final anastomosis to consider is the construction of the donor ureteral to recipient bladder anastomosis. Throughout the years of kidney transplantation there have been several approaches to the ureteroneocystostomy, the implantation of the donor ureter into the recipient bladder. Initially, the most widely used anastomosis was the Leadbetter-Politano technique, an intravesical technique that requires exposure via an anterior cystostomy to allow submucosal tunneling of the ureter and placement of the neo-orifice in a near anatomic location.16 The more recent extravesical approach, developed by Lich and Gregoir, is employed by most transplant centers today and is the approach used in this case. A single small cystotomy is created at the bladder dome, and the distal donor ureter is anastomosed to the bladder mucosa. A seromuscluar layer is then closed over the ureter.2 The final method is an ureteropyelostomy, an anastomosis between the recipient ureter to the lowest portion of the donor renal pelvis. This approach is not frequently used because it often requires an ipsilateral native nephrectomy and has been shown to have a higher ureteral leak rate.2
The final consideration in this case - and one that remains controversial in the kidney transplant literature - is the use of a ureteral stent. Several studies have investigated the risks and benefits of ureteral stents. Of the urological complications after renal transplantation, most originate from the vesicoureteric anastomosis. The therapeutic benefit of a ureteral stent is that it simplifies the creation of a watertight ureteric mucosa to bladder mucosa anastomosis and reduces anatomic kinking. However, the significant risks associated with the use of a stent include recurrent urinary tract infections and eventual graft loss. Overall, the literature has not been able to adequately assess the morbidity and cost of universal stenting, and therefore, this practice remains a surgeon-to-surgeon assessment and decision at the time of surgery.17 In this case, the attending surgeon discovered that the donor kidney had an extra renal pelvis, and prior to completing the ureteral anastomosis, there appeared to be a fullness of the renal pelvis. Consequently, a 4.7 Fr. double J stent was placed.
In summary, this case highlights a living related preemptive kidney transplant. The patient presented was fortunate enough to have a living donor who was not only willing to donate but was deemed suitable for donation as well. The outcomes of living donation are superior to deceased donation, especially when performed prior to the initiation of dialysis, as was the case with this patient. As the wait list for kidney transplantation continues to grow, the importance of living donation will continue to increase. It is therefore imperative for kidney transplant centers throughout the United States to encourage living donation. One promising development is the dissemination of laparoscopic donor nephrectomies. This technique, now used in more than 90% of donor nephrectomies, reduces the recovery time for living donors.11 This is one example of the work that needs to continue to incentivize donation - both decreased and living - in order to help combat the shortage of organs for those with ESRD.
Fogarty Hydragrip Clamps were used when clamping the iliac vessels. Edward Lifesciences provides the Hydragrip inserts for the Fogarty Clamp. These less traumatic clamps are believed to decrease the risk of dissection. When performing the arterial anastomosis, an aortic punch by Teleflex Medical is used for the arteriotomy.
Corey Eymard, MGH Transplant Fellow performed this procedure with Dr. Nahel Elias.
Consent for the use of clinical history, radiology, and intraoperative video was obtained from the patient and providers involved in compilation of this case report and filming.
- Institute for Healthcare Improvement. Organ Donation Update: Success Brings New Challenges. Available at: http://www.ihi.org/resources/Pages/ImprovementStories/OrganDonationUpdateSuccessBringsNewChallenges.aspx
- Pereira BJG, Sayegh MH, Blake P. Chronic Kidney Disease, Dialysis, & Transplantation. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005.
- Humar A, Dunn DL. Chapter 11: Transplantation. In: Schwartz’s Principles of Surgery. 9e ed. New York, NY: McGraw-Hill; 2010.
- Punch, JD. Chapter 45: Organ Transplantation. In: Current Diagnosis & Treatment. 13e ed. 16,New York, NY: McGraw-Hill; 2006.16. Monga M. Ureteroscopy. New York: Humana Press, 2013.
- United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020.
- Davis CL, Delmonico FL. Living-donor kidney transplantation: a review of the current practices for the live donor. J Am Soc Nephrol. 2005 Jul;16(7):2098-110. doi:10.1681/ASN.2004100824.
- Murray JE, Merrill JP, Harrison JH, Wilson RE, Dammin GJ. Prolonged survival of human-kidney homografts by immunosuppressive drug therapy. N Engl J Med. 1963 Jun 13;268:1315-23. doi:10.1056/NEJM196306132682401.
- Klein AS, Messersmith EE, Ratner LE, Kochik R, Baliga PK, Ojo AO. Organ donation and utilization in the United States, 1999-2008. Am J Transplant. 2010 Apr;10(4 Pt 2):973-86. doi:10.1111/j.1600-6143.2009.03008.x.
- Organ Procurement and Transplantation Network. Data. Available at: https://optn.transplant.hrsa.gov/data.
- Organ Donation and Transplantation Statistics. National Kidney Foundation. 2016. Available at: https://www.kidney.org/news/newsroom/factsheets/Organ-Donation-and-Transplantation-Stats.
- Axelrod DA, McCullough KP, Brewer ED, Becker BN, Segev DL, Rao PS. Kidney and pancreas transplantation in the United States, 1999-2008: the changing face of living donation. Am J Transplant. 2010 Apr;10(4 Pt 2):987-1002. doi:10.1111/j.1600-6143.2010.03022.x.
- Meier-Kriesche HU, Kaplan B. Waiting time on dialysis as the strongest modifiable risk factor for renal transplant outcomes: a paired donor kidney analysis. Transplantation. 2002 Nov 27;74(10):1377-81. doi:10.1097/00007890-200211270-00005.
- Kasiske BL, Snyder JJ, Matas AJ, Ellison MD, Gill JS, Kausz AT. Preemptive kidney transplantation: the advantage and the advantaged. J Am Soc Nephrol. 2002 May;13(5):1358-64. doi:10.1097/01.asn.0000013295.11876.c9.
- Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidney donation. N Engl J Med. 2009 Jan 29;360(5):459-69. doi:10.1056/NEJMoa0804883.
- Merrill JP, Murray JE, Harrison JH, Guild WR. Successful homotransplantation of the human kidney between identical twins. J Am Med Assoc. 1956 Jan 28;160(4):277-82. doi:10.1001/jama.1956.02960390027008.
- Monga M. Ureteroscopy. New York: Humana Press, 2013.
- Wilson CH, Bhatti AA, Rix DA, Manas DM. Routine intraoperative stenting for renal transplant recipients. Transplantation. 2005 Oct 15;80(7):877-82. doi:10.1097/01.tp.0000181197.21706.fa.
- Aravindan N, Shaw A. Effect of furosemide infusion on renal hemodynamics and angiogenesis gene expression in acute renal ischemia/reperfusion. Ren Fail. 2006;28(1):25-35. doi:10.1080/08860220500461229.
- Siedlecki A, Irish W, Brennan DC. Delayed graft function in the kidney transplant. Am J Transplant. 2011 Nov;11(11):2279-96. doi:10.1111/j.1600-6143.2011.03754.x.
Cite this article
Westfal ML, Elias N. Recipient kidney transplant from a living donor. J Med Insight. 2023;2023(171). doi:10.24296/jomi/171.
Table of Contents
- This procedure is performed under general anesthesia.
- Patient Positioning
- The patient is positioned in the supine position on the operating room table. In cases of ipsilateral native nephrectomy consideration, a small bump under the flank is recommended.
- A Foley catheter is inserted after induction of anesthesia, and an antibiotic solution with blue-coloring is infused into the bladder.
- The abdomen is prepped and draped in the standard sterile fashion.
- Discussion of Surgical Approach
- The transplanted kidney may be placed in the left or right iliac fossa.
- The access to the right iliac vein and artery is easier in general.
- Given that pancreas allografts are often placed in the right iliac fossa, a patient that is first undergoing a kidney transplant will often have the kidney placed in the left iliac fossa.
- Future pancreas after kidney transplant is a consideration relevant to the patient presented in this case given her history of diabetes.
- Modified Gibson Incision
- A left lower quadrant incision was made.
- Dissect through Lateral Abdominal Muscles
- This resulted in entering the left iliac fossa.
- Mobilize Peritoneum Medially
- Notes of any defects in the peritoneum were made as these would have to be closed primarily.
- Dissect to Retroperitoneal Space
- Divide the Round Ligament
- Expose External Iliac Artery
- Expose External Iliac Vein
- Expose Bladder
- Simultaneous to the dissection described above the backbench preparation of the donor kidney was occurring.
- Verification of Kidney
- Improve Length and Exposure of Vessels
- Expose Ureter
- Dissect Perinephric Fat
- Shorten Renal Artery
- Test Artery for Missed Branches
- Test Vein for Missed Branches
- Check Positioning
- Spatulate Renal Artery
- The external iliac vein was clamped.
- Venotomy Incision
- A venotomy was created.
- Back Wall Anastomosis
- The donor renal vein was then anastomosed to the recipient external iliac vein in an end-to-side fashion using a running 5-0 Prolene suture.
- Front Wall Anastomosis
- After completing the anastomosis, we clamped the renal vein and unclamped the external iliac vein to make certain the venous anastomosis was hemostatic.
- The external iliac artery was then clamped.
- An arteriotomy was created using a 4-mm aortic punch.
- The recipient artery had no evidence of atherosclerosis.
- Back Wall Anastomosis
- The donor renal artery was anastomosed to the recipient external iliac artery in an end-to-side fashion using a running 6-0 Prolene suture.
- Front Wall Anastomosis
- Kidney Reperfusion
- The kidney was then reperfused and had excellent reperfusion and hemostasis.
- Assess Volume Status
- Divide Muscle to Mucosa
- The ureter was then passed to the level of the bladder. This is usually posterior to the spermatic cord in men, but in women we divide between ligatures the round ligament.
- The inferior epigastric vessels may need to be divided depending on their location, the patient’s body habitus, and the exposure.
- The bladder had been distended by clamping the drainage tubing and infusing the blue-colored antibiotic solution into the foley catheter.
- The muscularis was incised, and the mucosa of the bladder was identified.
- Shorten Ureter
- Bladder Incision
- Spatulate Ureter
- It was then anastomosed to the mucosa of the bladder using a running 6-0 Maxon suture.
- Place Stent
- Prior to completing the anastomosis, a 4.7 Fr double J stent was mounted on wire and placed into the ureter because some fullness of the renal pelvis was noted prior to completing the anastomosis.
- Finish Anastomosis
- The anastomosis was completed, and the muscularis was then closed with interrupted 5-0 Vicryl sutures. This created a non-refluxing tunnel in the standard Lich-Gregoir technique.
- Evaluate Blood Flow
- The total warm ischemia time was 31 minutes, and the total cold ischemia time was 36 minutes.
- Use RF-Sensitive Wand
- The retroperitoneum was inspected to ensure hemostasis.
- Close Wound
- The abdominal wall muscle layers were closed with 0 PDS sutures.
- A 3-0 Vicryl was then used to close the subcutaneous tissues.
- A running 4-0 Monocryl was used to close the skin.
- A sterile occlusive dressing was applied.
- A drain is not necessary in most cases.
- Postoperative Care
- The patient was extubated in the operating room and brought to the postanesthesia care unit in stable condition.
- The patient received a dose of 12.5 gm of Mannitol and 60-100 mg Furosemide (Lasix) just prior to completing the vascular anastomoses and reperfusion of the allograft.
- There is evidence that intraoperative diuresis with lasix has decreased the risk of ischemia reperfusion injury.18 It is our practice that the patient remain on a continuous rate of D10 at 30 cc/hr.
- It is imperative that the urine output of the patient be monitored hourly to assess the function of the newly implanted allograft. The hourly urine output is also matched 1:1 with lactated ringers. This is continued for the first 12-18 hours postoperatively. The patient’s Foley catheter remains in place until postoperative day 3 when it is then removed.
- Without any postoperative complications, patients receiving a kidney transplant are most often discharged on postoperative day 3.
- Primary Nonfunction
- Acute Rejection
- Disease Recurrence
- Delayed Graft Function (DGF)
- This is seen in up to 20% of deceased donor kidney transplants but only in less than 3% of living donor kidney transplants.4 This complication is a manifestation of acute kidney injury and is defined by the need for dialysis within seven days of kidney transplant. Patient with this diagnosis should undergo biopsy, if it persists beyond 14 days postoperatively, to exclude acute rejection and differentiate it from other causes (ATN, disease recurrence, infectious, etc.).19
- Vascular and Urologic Complications
- Fluid Collection (Lymph, Blood, Urine)
- Ureteral Leak or Stricture
- Vascular Thrombosis
- The above two complications are rare and only occur in 1-2% and 4% of transplant respectively.4 Ultrasonography of the renal allograft is extremely useful in making the diagnosis of complications postoperatively as it diagnoses renal perfusion, perinephric fluid collection, and hydronephrosis. If negative, it is followed by a biopsy, and the two diagnostic tests are the cornerstone of working up any renal allograft dysfunction early or late in the post-transplant period.
Hello, my name is Nahel Elias. I'm the surgical director of kidney transplant at Massachusetts General Hospital. The procedure we're doing today is a kidney transplant from a live donor. The main purpose of the procedure is to restore kidney function to this patient who has advanced stage kidney disease. In this case, it's secondary to diabetes, which is the most common cause of kidney disease in the United States. Kidney transplant is performed heterotopically. The transplant is performed in the iliac fossa, extraperitoneally. And in this situation, we have a live donor who is the patient's sister. She is actually HLA identical, which carries some minor advantage with minimizing immunosuppression. The procedure itself, we will expose the iliac fossa, expose the external iliac artery and vein where the kidney will be implanted and the bladder where we will drain the ureter of the donor kidney. The procedure starts with a lower quadrant incision, modified Gibson incision is what we use. The right side or the left side is acceptable. In general, the right side is easier. Although this patient has type one diabetes and she is also listed awaiting pancreas transplant, that we would prefer the right side to transplant her pancreas in the future. And for that reason, we're planning on transplanting the kidney into the left iliac fossa. So we'll make an incision, dissect the skin subcutaneous tissue down through the lateral abdominal wall muscle layers: the external oblique, internal oblique, and transversalis fascia. Mobilize the peritoneum medially, and expose the external iliac artery and external iliac vein. Both these vessels have no branches and the pelvis, which makes it easier and we can dissect them free fully and retract them. I usually retract the artery medially and do the venous anastomosis lateral. This permits the arterial anastomosis without the vein being in the way. This is not routine and some anastomose the vein medially and then the artery lateral. Once we completed the vascular anastomosis, that's when we reperfuse the kidney and assure the hemostasis with the vascular anastomoses. And afterward, we take the ureter down to the level of the bladder where we perform the typical Lich-Gregoir ureteroneocystostomy In the iliac fossa, when we mobilize the vessels, it's important to pay attention to the inferior epigastric vessels, which most of the time we divide them. This is a female, so we will have the round ligament, and we usually divide that. In men, the spermatic cord will be transversing the iliac fossa, and we usually maintain that and retract it as we mobilize the vessels. And we usually pass the ureter posterior to the spermatic cord. In preparation for this procedure, we also place a Foley, and with a Foley catheter, I usually have an infusion, which is saline with methylene blue to identify the bladder and distend it. Occasionally, patients with prior surgery in the area, or depending on their body habitus, it may be difficult to identify the bladder. So distending the bladder would be easier. Additionally, I use antibiotic irrigation, usually gentamicin, especially for patients who are anuric and have been on dialysis for a long period of time, as their bladders may be colonized. And especially that we are opening the bladder in the field, and antibiotics would minimize the risk of infection around the new allograft. The vascular anastomoses are performed in an end-to-side fashion. So we usually clamp the external iliac vein first. I use a Satinsky, create a venotomy, and then anastomose the renal vein to the external iliac vein. I prefer to clamp the renal vein and release the Satinsky off the external iliac vein to test the venous anastomosis and also restore continuity of the iliac vein flow. Following that, I clamp the external iliac artery, create an arteriotomy, and anastomose the renal artery to the external iliac artery, also in an end-to-side fashion. If the kidney comes from a live donor, this is where the vessels will be shorter. Obviously living donors have a much better quality kidney compared to deceased donors. These kidneys tend to be younger, and we know that the half-life of a kidney from a live donor is longer than that from a deceased donor. On the other hand, deceased donor kidneys have longer vessels, as we recover the aorta from the deceased donor, and we would have an aortic patch on the artery. Depending on the quality of the artery of the recipient, we will decide if that is necessary to be used. In that situation the anastomosis will be potentially larger using an aortic patch from the donor. Some patients have multiple vessels with their kidneys. So depending on the donor anatomy, as far as the renal vessels, that will make the decision about using multiple vessels. If it's a deceased donor, multiple vessels could come on a common patch from the aorta of the donor and we can anastomose that, or occasionally preparation on the back table prior to transplanting the kidney is necessary to connect the vessels together, depending on the type of vessels we have and the length of them, different types of anastomoses could be performed either a side-to-side or an end-to-side or from a deceased donor, occasionally the aortic patch is available but too long, that could be shortened by cutting the distance in between the two vessels. It is important to maintain flow to the lower pole vessels, regardless of their size, more so than upper pole, specifically to maintain blood supply to the ureter as the donor ureter will be supplied primarily by the renal vessels in this situation. And that is the main reason we shorten the donor ureter prior to implanting it into the bladder, to assure that it has distal flow and blood supply to the tip of it to maintain that anastomosis healing after the transplant. On the venous side, if there are multiple veins, most of the time, the smaller veins could be ligated. If they're equal size and they're together on a common patch, it could be used and it could be drained fully. Prior to transplanting the kidney, the kidney is prepared on the back bench and specifically identify the vessels, assured their patency, assure there are no branches that needed to be a ligated, and obviously in a kidney that comes from a live donor, during the dissection of the kidney in the living donor, many of these branches have been already divided and either cauterized or ligated that the majority of the time there is no need for too much work on the back bench. From a deceased donor kidney, this is where the kidney usually has more perihilar fat and perinephric fat. And there is more work than needs to be done on the back bench in preparing the kidney.
So to plan the incision, the superior anterior iliac spine, this is pubis tubercles. I usually mark by one fingerbreadth of both.
Incision. A Bovie, please. So we're just going through this skin and subcutaneous fat down to the abdominal wall muscle layers. Can I have a Weitlaner up? Another one.
This is the external oblique, and we're going to go through it. Give me a buzz right here. You have an Army-Navy? So you see the rectus extending to here. I like to stay in lateral to the rectus. And going through the internal oblique and transversalis fascia gets us down to the peritoneum, which we're seeing right here. Buzz me. There will be a point where we we'll fix it. Just a couple of minutes. Now we're all the way down. So that's good exposure. I think I need to divide it. Yep. Do you have a right angle? 2-0 silk tie. I'm dividing the inferior epigastric vessels.
So now we're going to mobilize the peritoneum off the muscle and stay lateral to it. Looks like the transversalis fascia. We hadn't gone through it yet.
We're now in the preperitoneal space. We dissect the peritoneum down to the retroperitoneal space. Small vessels will be crossing in here, and we'll just assure hemostasis through cauterizing. This is mostly blunt dissection. Careful, close to the peritoneum. Here's the vessel there. And here's the external iliac artery. Continue mobilizing peritoneum, exposing the psoas, external iliac. That's the round ligament. You can put ties on it. 2-0 tie. Obviously in men, this will be the spermatic cord. Then we would not divide it.
DeBakey. Once the round ligament is divided, the rest of the retroperitoneum is exposed. I usually like to put lap sponges to create that dissection, two or three, depending on the size of the patient and the size of the kidney. That creates enough space to place the kidney. And we can get our retractor set up.
There you go. So we'll take - how about the small right angle blades? So we retract the peritoneum medially. On the lateral retraction, we make sure we're above the pelvic bone so we don't cause any nerve injury here. DeBakey? And right angle, short right angle. So this is the psoas, this is the external iliac artery, we can see it. And we're just going to expose it. Quick buzz. Can we turn the Bovie down, please, to 20? We had decided to place this kidney on the left side because - do you know why, Maggie? So, I thought the artery crossed over the vein on the left. Yeah. Oh, she might get a pancreas transplant. Correct, so - she's a type 1 diabetic, she's listed for a pancreas transplant. In general, the right is easier because of the cava being lateral on the right, so it's easier to expose the vein. And for that reason, patients who are potentially a pancreas transplant candidates, we prefer to put the pancreas on the right. So we would put the kidney on the left side. She's getting a living donor kidney, so you don't want to burn that bridge. Dissecting some of the lymphatics around the external iliac artery. If we find a large lymphatics, I usually ligate it with a 3-0 silk tie, but everything we're seeing here is small. There may be a lymphatic that's not crossing across the artery. And we can just maintain it. I like to retract the artery with a Penrose. The angulation of the retraction is less, so it's softer than a vessel loop. Dissect here on the artery and free it up.
Can you grab the vein? Again, just like the artery, dissect the vein free. Right angle? DeBakey?
Can we confirm the ABO, please? Can I get the Q-tips, please? Can you open the donor just to make sure the UNOS ID and the - do you have the donor? All right, we can do it on the field then. So this is the live donor kidney. It's already been flushed in the donor room, where the blood has been flushed out of it, and preservation solution has been used. We maintain the kidney cold while it's ischemic.
So this is the donor artery, the donor vein. Another Pickup? And this is the donor ureter. We position the kidney. So this is superior pole, inferior pole. And this is a left kidney. And the left renal vein has multiple branches into it. This is a lumbar vein. This is the adrenal vein. And this is the gonadal vein. Stevens scissors? Can you grab the adrenal and pull the vein over to you? Actually, let me have the vein, yeah. So this is anterior to the vein. There may be a small branch in here. Jake, you want to tie this one? We can tie this one, sure. Okay, you can ligate this if you want. Can I get a 3-0 silk tie? Actually, let me have a 4-0 first. Let me just tie this off. Tie this. Jake - going to grab the vein over here. Any branches in here, yeah? Uh, I don't know. We'll check on those. Thank you. So we're dissecting the perihilar lymphatics and the fat to get adequate length on the vessels and better exposure and especially anterior to the vessels and superior.
We can do that quite liberally, posterior and inferior, this is where we got to maintain the blood supply to the ureter and here can see the ureter. And it's ureteropelvic junction. So the ureter blood supply is lateral from the lower pole of the kidney. And this is where we can dissect that free here. See the ureter from its origin at the renal pelvis. Occasionally, there are some larger vessels or lymphatics in here, and we can ligate those. 3-0 silk? Can I have a Jake? Jake? Yep.
So, dissect the perinephric fat, to free the kidney fully. Occasionally, deceased donor kidneys are also biopsied, and that biopsy site needs to be closed if the donor surgeon did not close it.
So in this situation, the renal artery origin was significantly higher than the renal vein. And that's why we have additional length on it. It's not unusual to have a small dissection. And we're going to shorten that. Stevens? Heparinized saline?
We test the artery for any branches that we missed. We don't see any.
We'll see how we are going to spatulate it. So we can use the gonadal to make the venous anastomosis longer. You want to cut into that and then you'll cut the gonadal. Stevens scissors? We can come across. Longer. Yes. You want to cut that? Looks good. So this, I would say, we'll ligate it. Heavy needle holder? 3-0 silk tie. Hep saline?
DeBakeys? Wanna occlude the vein at the hilum? Jake? 4-0 silk tie? This is exactly why we test this. Hep saline. DeBakey. Good. All right, perfect. Maintain the kidney on ice.
DeBakeys? Quick check for the positioning of the kidney. We'll clamp the artery. I think that looks great. More inferior.
Since the artery is going to be inferior, we can spatulate the upper pole. Can we get Stevens? So we'll make a larger anastomosis. And can I get the ruler, please? And the venous anastomosis is large given that we elongated it using the gonadal and the - I mean, the gonadal and the adrenal vein. It's about 3 cm.
So we're going to start the anastomosis, and about 20 minutes from now, we'll give the manitol and the Lasix, please. A folded blue towel - two of them.
So we use the 12 blade to create the venotomy. 11 blade is also... So something like this. Stevens. Stevens. Let me just take this off, let go. The 5-0 Proline. I prefer U stitches in the corners. Obviously, some may just place regular suture, all right? Nope, you're outside. You're going outside-in.
We'll start with the... Forceps. Nope, this is fine. I don't need it anymore. So that's the corner stitch. It's a U stitch. And I start with a U stitch while the kidney is still on ice to minimize the warm time. Yep. Take the basin and save it, please. All right. Can bring the kidney down. Hold on to this. Sorry, this. Can you hold the kidney with a forceps or something? Ice cold on my hand, please, and on the kidney, Some wrap the kidney with an icy wrap. I don't find it always necessary. As long as we maintain it cold by irrigating with ice cold saline. Let me retract - let me follow you. It's essential to evert the edges to have intima-to-intima opposition with the anastomosis. It's also essential to separate the front from the back wall while doing this anastomosis to assure you are not taking the back wall in the stitch. Some perform this anastomosis from inside the lumen from the other side, but I prefer to do the anastomosis from outside the lumen. You need to pronate. Can I have a right angle? Let me see. Can we do this.
Let me have that. Two needles back to you. So as I mentioned, I usually clamp the renal vein with a vascular clamp. I'll take the malleable. Release the... Satinsky. Make sure that the anastomosis is hemostatic.
Ureter - I'll take that. And the renal artery - it wants to sit on this side of the vein, which is perfect. We'll anastomose it over here, I'll take a fresh icy wrap. The artery could be clamped with a softer, Fogarty-type clamp. Or a Satinsky is fine.
Hep saline. Renal artery forceps. Pots angled. Yeah, my arteriotomy is too small. Looks about right. Maybe a small bite in here. 6-0 BV-1.
Shod. You get a - grab the adventitia on the artery. Shod. Okay, let go of the needle, don't grab it. Grab it from the other side. Bring the loop where you want it. So now that we completed the back wall of the artery - Hep saline. See that the front wall of the renal artery is already somewhat everted.
Looks good. Can you give the manitol, please? Metzenbaum scissors. Ice cold, you got warm ready? My left. You can cut the other corner stitch.
So we unclamp the artery. And we see that the renal artery is nicely perfused. Then we release the vein, and the kidney reperfuse nicely. Warm saline, kidney reperfusion now.
The kidney usually gets warm with good volume and gets bigger. We recheck the anastomoses.
Let's see. We obviously don't have to check the vein because we had tested it earlier, but we can see them nicely over here. We also check around the hilum. Any of the lymphatics or small vessels that we had not ligated may bleed, and that will need to be ligated, but in this case, everything looks... So this is the renal artery and the anastomosis of the renal artery to the external iliac. And this is the renal vein. And the anastomosis of the renal vein to the external iliac vein. And here's the ureter. And shortly, we expect her to make some urine.
You can see that there's - the tip of the ureter is also perfused, which is a good sign. 4-0 silk tie. You want a pass, or...? Pass, please, yes. Shorter. There you see the bladder distended by filling it up. Please, hold on a second. So you want to do something like this? Perfect.
All right, can we turn the Bovie down to 20, please? Jake. Jake Schnidt. You want the Bovie down to 20? Yeah, Bovie down to 20, please. Give me a buzz right here. Then I get the renal artery. Right angle. You got a little more muscle. If the detrusor muscles that are divided, we identify the mucosa. You know the mucosa, right? Bulging through the muscle. We separate the muscle, lateral and medial. So we have a large surface of the mucosa identified to be able to anastomose the ureter to it. The kidney's still soft. Can we do a little more volume?
Jake Schnidt. 3-0 silk tie. Stevens. Short. Stevens. So we shorten the ureter. We want to make sure it's got a reasonable blood supply, and we can see that there's bleeding from the tip. And then we position it. Do we got the - the fine forceps, the fine titanium. That's good. Another blue, fine. There's some urine. And there's some urine. There's some bleeding. It looks like some - white towels. And that's going to be yours, at the tip, loaded.
You can unclamp the Foley. Where is it? Unclamp the Foley. Unclamp the Foley? Yep. All right, it's unclamped.
Go ahead. Big bite. So the suture is full-thickness on the ureter. You need suction? You need some - hold the sucker. Yep. And mucosa only on the bladder. And as I mentioned, this is the fluid that filled the bladder that's draining into the field. And that's why…
Okay, hold on to this. You got it. DeBakey if you're able to - yeah. You can let go of that. Don't grab the ureter.
You took both already, didn't you? Thank you. Can I have a squirt? You got 5-0 Vicryl, RB-1? I'll take a blue pickup, titanium blue. Warm saline. Asepto. One more. Not much travel. Yeah. Warm saline, Asepto.
But I don't know why it's not making urine. It's all the way up? Thank you. All right, I'm just going to close. Let it warm up. Hanky?
This was a live donor kidney transplant implanted into the left iliac fossa. The procedure included first exposing the left iliac fossa, dissecting free the external iliac artery and vein in preparation for the anastomoses. Then, because we had a little extra time waiting for the kidney to arrive from the donor room, we also dissected the bladder and had it ready. The kidney was brought over from the donor room and it had excellent anatomy with single artery, single vein. The vessels were prepared, and the kidney was ready. We implanted it by anastomosing the renal vein to the external iliac vein in an end-to-side fashion, and then the renal artery to the external iliac artery in an end-to-side fashion. The kidney reperfused and it had excellent reperfusion. We then anastomosed the ureter. The ureter is anastomosed in the typical Lich-Gregoir fashion. We used an absorbable suture for that, anastomosing full-thickness ureter to the mucosa of the bladder. Then closed the muscularis with interrupted Vicryl. The ureter, because we had some - what appeared to be slight fullness of the renal pelvis and concern for the kidney having extra renal cyst, which we knew about, we decided to place a stent. This is not routine, but we occasionally do it. The kidney appeared excellent and had excellent reperfusion throughout, and we closed, and we will see how the function of the kidney - and obviously, this patient will require immunosuppression as every kidney transplant recipient does.