CHAPTER 100: KIDNEY TRANSPLANT

INDICATIONS

This procedure is for patients with end-stage chronic kidney disease with a glomerular filtration rate ≤20 mL/min who possess adequate cardiopulmonary reserve to undergo surgery. In addition, the patient cannot have an active infection or malignancy that would be exacerbated after the transplant due to the necessity of ongoing immunosuppression therapy following engraftment.

PREOPERATIVE PREPARATION

Candidates are evaluated prior to transplantation for suitability based on the above indications as well as other psychosocial factors. Candidates found to have pre-existing comorbidities will receive additional evaluation and testing at this time as needed to aid in determining suitability. Once the candidate has been deemed suitable, the patient is ready for transplantation with a living donor kidney, if available, or listed for a deceased donor kidney.

Intravenous access is obtained prior to administration of general anesthesia and endotracheal intubation. Central venous access is preferable as it allows for intravascular volume assessment during the procedure. Antibiotics are administered intravenously within 1 hour prior to procedure commencement. Following intubation, a urinary catheter is placed and the bladder is irrigated with antibiotic-containing saline. If the patient is oliguric or anuric saline is left in the bladder after irrigation to distend it, aiding intraoperative identification. The Foley drainage bag is clamped to keep the bladder distended until the neoureterocystostomy is performed. An oral gastric tube is placed and kept on suction to evacuate and decompress the stomach. Deep venous thrombosis prophylaxis should be employed.

ANESTHESIA

General and endotracheal anesthesia is required.

POSITION

The patient is placed in the supine position. The legs are secured to the table with a strap with slight laxity. The lower extremities should be exposed enough to allow surgical access to the infrainguinal femoral vessels for the rare case where arterial reconstruction is necessary. If the patient has a peritoneal dialysis catheter every attempt should be made to position and drape it out of the surgical field. The ipsilateral femoral artery is palpated to verify iliac artery patency.

OPERATIVE PREPARATION

The hair overlying the surgical field is removed with hair clippers. The abdomen is prepped from the midaxillary line on the side chosen for implantation to well beyond the midline, or if desired to the opposite midaxillary line. Caudally the abdomen is prepped below the symphysis pubis, and includes the femoral region on the implantation side. The prep extends cephalad to at least 5 cm above the umbilicus.

INCISION AND EXPOSURE

The straight or curvilinear skin incision is made on the left or right side of the lower abdomen from the symphysis pubis at the midline laterally and cephalad far enough to provide adequate exposure of the external iliac vessels and to perform the vascular anastomoses (figure 1). The ...