Kidney transplant

Indications

End-stage renal disease (treatment of choice)
- Refer once eGFR <30ml/min, or if dialysis expected within 12 months
- Don't transplant until eGFR <20 and irreversible
- Main causes in transplanted patients are diabetes, HTN, glomerulonephritis, and PCKD

Not routine
Indications:
- Autosomal dominant polycystic kidney disease
- Recurrent infections
- Kidney stones

Benefits
- Increased organ availability
- Elective surgery
- Less immunosuppression required due to 'a good match'
- Better long-term graft survival
Workup of living donor
- Assess motivation - free of coercion, donor interviewed separately
- Assess renal function - eGFR, must have predicted GFR >37 at age 80
- Assess health - DM, HTN, IHD, CXR, UA etc; previous malignancy; transmissible disease
- Cross match between donor and recipient
- MAG3 to confirm equal kidney function
- CTA to assess anatomy - >2 renal arteries is a relative contraindication; left kidney preferred due to longer artery
Technique
- GA, CVC
- Laparoscopic - either trans-peritoneal or sometimes retro-peritoneal
- Open can be done too
- Access to abdomen
- Medialise left colon along white line to expose Gerota's
- Incise Gerota's over kidney, and perform para-capsular dissection
- Identify ureter at lower pole and dissect onto psoas
- Identify and control renal vein and artery (including adrenal vein and gonadal vein on left)
- Ligate and divide ureter
- Remove kidney
Risks
- Death 1/3000
- Major morbidity 5%
- GA risks
- General risks
- Risk of developing ESRF
- Can develop a problem in the other kidney, but more commonly develop a problem that would have affected both kidneys
- Damage to surrounding organs
Follow-up
- Annual renal physician review for life - HTN, proteinuria, kidney function
- Join national living donor registry

Begin immunosuppression - loading dose calcineurin inhibitor
Assess donor kidney
- Usually comes with cuff of aorta, cuff of IVC and ureter with periureteral tissue
Oblique incision just above inguinal ligament - Rutherford Morrison incision often used
Dissection down through EO, IO, TA with ligation of inferior epigastric vessels, and staying extra-peritoneal
Retroperitoneal exposure of iliac vessels via blunt dissection
Artery: end to side to EIA
Vein: end to side to EIV
Ureter: to bladder
Urine should be produced immediately. Expect diuresis. Serum creatinine slowly drops over next 3-7 days.

Immediate
- Bleeding - re-explore
- Thrombosis of renal vessels - usually technical error, requires immediate re-exploration
- Hyperacute rejection - presents with intra-renal thrombosis - usually straight to nephrectomy
Early
- Infection
  - Wound
  - Pneumonia
  - UTI
- Bleeding
- Lymphocoele
  - Variable presentation - compression of vascular or ureteric structures
  - Confirm via aspiration
  - Peritoneal window may be useful to drain
- Urine leak
  - Small leaks - nephrostomy
  - Large leaks - explore
- Early obstruction of ureter
  - Often stent
- Systemic complications
- Delayed graft function
  - Dialysis required in first week
  - Exclude rejection vascular and ureteric complications
  - Dialysis required based on usual indications
Late
- Vascular
  - Renal artery stenosis, or stenosis at anastomosis
    - May present with HTN
    - Treat with PTA or surgery
  - False aneurysm at anastomosis, or mycotic aneurysm
  - Late renal vein thrombosis can present with sudden-onset haematuria
- Ureteric
  - Strictures - stent, stricturoplasty, re-implantation
  - Ischaemic strictures likely require re-operation
  - VUR
- Immunosuppression complications
  - See separate topic
- Malignancy
  - See separate topic
- Graft failure
  - Rejection - see separate topic
  - Chronic allograft nephropathy - combination of chronic rejection and damage from immunosuppression
  - Return of renal disease