RENAL TRANSPLANTATION

Renal transplantation is the renal replacement therapy for end stage renal disease (ESRD)

Indication
Irreversible glomerular filtration rate of less than 10ml/min
Serum creatinine level of greater than 8 mg/dl
Symptomatic uraemia
Patients contraindicated to dialysis as
1.Vascular problems
2.Cardiac disease
3.Diabetes mellitus
4.Long distance


Patients contraindicated to peritoneal dialysis as
1.Obesity
2.Hernia
3.Poor hygiene
4.Obliterated Peritoneal Space

Symptoms
1.Oedema
2.Uremia
3.Recurrent infection
4.Proteinuria
5.Hyponatremia
6.Hyperkalaemia

Preoperative
Patient preparation:

1. The pretransplantation evaluation is a multidisciplinary process that is performed well in advance of the renal transplantation operation and

immunosuppression.
2. The purposes of the evaluation are generally considered to be diagnose the primary disease and its risk of recurrence in the kidney graft and to rule

out active invasive infection, a high probability of operative mortality, non compliance, active malignancy & unsuitable anatomy for technical access.

Preliminary screening :
It includes
1.drug abuse
2.morbid obesity
Kidney disease recurrence:
1.Glomerulosclerosis
2.Hemolytic-uremic syndrome
3.Primary oxalosis
4.Diabetes mellitus
5. IGA nephropathy
Infection
Infection must be detected and treated before transplantation or prevented with immunization
1.Dental sepsis must be treated
2.Pulmonary infection
3.Cholecystitis
4.Small gall stones
5.Cholelithiasis has to be treated




]Serological testing includes for
a. Cytomegalo virus
b. Herpes simplex virus
c. Epstein-barr virus
d. Hepatitis b & c

Active malignancy :
1.Adenocarcinoma
2.Wilms tumour
3.Transitional cell carcinoma
4.Melanoma

To reduce the risk of cancer recurrence a waiting time of 2-5 cancer, free years from the time of the last cancer treatment is recommended for patients who

have had invasive malignancy.
• ABO blood group identify determined
• Negative micro toxicity
• Lymphocyte cross matching between recipient and donor.

Investigation :
1. Preliminary screening tests
2. Donor –CT angiography
3. Recipient –Doppler flow studies
4. Ultrasound
5. Uroflow
6. Cystoscopy biopsy (bladder)
7. Urodynamics
8. Renal CT
Further study of the urinary tract is indicated for a history of urologic abnormalities,
1. Non Glomerular Haematuria
2. Calculi
3. Hydronephrosis
4. Autosomal dominant polycystic kidney disease
5. Significant bladder residual urine
6. HLA typing – HLA-A,B and DR

Donor selection:
1. The basic criteria for a renal donor are on absence of renal disease, on absence of active infection and an absence of transmissible malignancy.
2. Whether the kidney is removed from a living donor, the surgical goals are to minimize warm ischaemia time, to preserve renal vessels and to presence

urethral blood supply.






Living donor:
Donor must assure of normal renal function after unilateral nephrectomy.
The better kidney is left with the donor
1. It is preferable to use right kidney from women who may become pregnant because of hydronephrosis and pyelonephritis of pregnancy
2. The living donor is unsuited when he has
• Mental dysfunction
• Significant renal disease
• Significant transmissible disease
• ABO incompatibility
• Positive cross match between donor lymphocytes and recipient serum.
Cadaver donor:
The criteria for an ideal cadaver kidney donor are
1. Normal renal function
2. No hypertension
3. No diabetes mellitus
4. No malignancy
5. Generalized viral / bacterial infection
6. Age between 6 and 45 years
7. Negative assays
For
• syphilis
• Hepatitis
• HIV
• Human T-lymphoproliferative virus

The principles of Cadaver donor organ retrieval are
1. Adequate exposure
2. Control of great vessels
3. Initiation of preservation insitu
4. Removal of organs
5. Completion of preservation
6. Removal of histocompatibility specimens
7. Removal of iliac vessels
8. Organ packaging




Evaluation of donor:
1. Psychological support
2. Family support – kidney disease
3. No evidence of diabetes
4. Hypertension
5. Haemoglobin
6. Renal function test
7. Urine analysis
8. Urine culture
9. 24-hour urine protein



Recipient operation:
1. After the patient is generally anaesthetized a prophylatic antobiotic is started just before the surgery & continued postoperatively
2. Immunosupperession is started before the surgery in case of cadaver recipient and a week before in case of living related graft recipient
3. Then a three way Foley catheter is placed in the bladder for the intraoperative fillingand draining of the bladder and the bladder is washed with

the broad spectrum antibiotic solution and it is clamped still the ureteroneocystostomy is performed
4. The kidney graft is usually placed extraperitonealy by the Gibson incision
5. The placement of the kidney on the right side provides wider arteries and veins for thye vascular anastamosis
6. In men’s the spermatic chord is preserved and iin case of women the round ligament is dissected between the ligatures
7. Before vascular occlusion heparin is give n intravenously to the recipient
8. The kidney must be kept cool by ice cool electrolyte
9. Then renal artery us usually anastamosed with the end of the internal iliac artery or to the side of the external iliac artery
10. The renal artery anastamosis is done before the vein
11. The renal vein is anatamosed to the external iliac vein
12. Furosemide is usually infused just before the release of vascular clamps
13. Then extravesical ureteroneocystostomy is performed


Rejection (or) renal allograft rejection:
There are four types of rejection
10. hyper acute rejection
11. accelerated rejection
12. acute rejection
13. chronic rejection
1.Hyper acute rejection
• It is analogous to a blood transfusion reaction
• It occurs immediately after renal revascularization
• It is an irreversible process mediated by performed circulating cytotoxic antibodies that develop after pregnancy, blood transfusion or an earlier

failed transplantation
• It is very rare when the micro lymphocytotoxicity cross match between recipient serum and donor lymphocytes is negative
• The graft turns from white to a mottled bluish black and should removed immediately.

2.Acute rejection
• It can occur any time after transplant
• The symptoms of acute kidney transplant rejection are those “the flu” accompanied by pain over an enlarged kidney graft, hypertension, decrease urine

output, fluid retention, increase serum creatinine levels and radioisotope renography indicating decrease renal blood flow, Glomerular filtration and tubular

filtration.
• Needle biopsy of the kidney graft is sometimes necessary for confirm the diagnosis of acute rejection.
• The typical histologic findings of acute renal allograft rejection are mononuclear cellular infiltration tubulitis and vasculitis
3.chronic rejection
• It is characterized by gradual decline in renal function associated with interstitial fibrosis, vascular changes and minimal mononuclear cell

infiltration.




1.
HLA Tissue Typing :
a. Human leukocyte antigen present in short arm of chromosome 6
b. It is divided into two classes.
HLA –Class l
Class ll
c. Autosomal class l antigens are known as HLA-A, HLA-B, HLA-C antigens and they are present on nearly all nucleated cells
d. They are detected by tissue typing T-lymphocytes, usually with a DNA polymerize chain reaction amplification technique
e. HLA-DR, HLA-DQ and HLA-DP antigens are class ll antigens present in the B lymphocytes activated by T lymphocytes, monocytes, macrophages, dendistic

cells and some endothelial cells.
f. HLA-DR antigens are detected by tissue typing B lymphocytes testing for HLA-DQ, HLA-DP are not routinely used.



Post operative care:
A .Fluid and electrolyte balance:
• 0.45% saline in 5% dextrose to replace estimated insensible losses
• 0.45% saline in 0% dextrose is given at 0 rate equal to the previous hours urinary output.
B.management of tubes and drains:
Catheter is removed within a week after a negative a culture repor
Closed suction drains are removed when the output is less than 50ml / 24hrs or in 3 weeks.



Complications:
1. .Early Graft dysfunction: It may due to
• Infection
• Renal allograft rejection
• Urinary obstruction
• Vascular obstruction
• Nephrotoxicity
• Hyperglycemia
• Dehydration
2 .Vascular complication:
• Kinking of the kidney grafts artery or vein
• Suture line stenosis
• Thrombosis
• Thrombophilia
3 Lymphocele
4. Haematuria
5. Ureteric leak
6. UTI
7. Vesicoureteral reflux
8 . Erectile dysfunction
9. Pulmnory infection –pneumonia
10.Obstructive and stones
11.Cancer due to immunosuppressant
12.New Diabetes Mellitus