Chapter 30. Renal Transplantation

Donor Nephrectomy

• Appropriate volunteer to donate to a person with renal failure.

Renal Transplantation

• All causes of impending or established end-stage renal disease.

Donor Nephrectomy

Absolute

• Impaired renal function (generally considered to be a glomerular filtration rate < 80 mL/min per 1.73 m2).
• Active infection.
• Diabetes.
• Pregnancy.
• Age younger than 18 years.
• Poorly controlled psychosis.

Relative (Open or Laparoscopic)

• Proteinuria or hematuria.
• History of malignancy.
• Kidney stones.
• Disorder requiring anticoagulation.
• Active substance abuse.
• Cardiovascular disease.
• Chronic illness.
• Hypertension.
• Abnormal urologic anatomy.
• Family history of diabetes.
• History of kidney stones.
• Obesity.

Relative (Laparoscopic)

• Previous laparotomies.
• History of pyelonephritis.
• Horseshoe kidney.
• Short right renal vein.
• Multiple renal arteries.

Renal Transplantation

Absolute

• Untreated ongoing infection.
• Active malignancy with short life expectancy.
• Chronic illness (with life expectancy < 1 year).
• Poorly controlled psychosis.

Relative

• Cardiovascular disease.
• Infection.
• Active substance abuse.
• Cerebrovascular disease.
• Obesity.
• Proven habitual noncompliance with medical recommendations.

Donor Nephrectomy

• This procedure is unique in that it involves operating on a patient who has no chance for medical benefit from surgical intervention. For this reason, an extensive psychosocial evaluation is required prior to surgery.
• The motivation of the volunteer must be established as genuinely altruistic and the patient must be aware that he or she can opt out at any time.
• Postoperative pain, transient urinary retention, and superficial surgical site infections are common minor complications.
• Compared with an open approach, laparoscopic donor nephrectomy is associated with a quicker convalescence.
• Operative mortality and major complications are infrequent, but not nonexistent.
  • Major complications include systemic complications of major surgery (pulmonary emboli, cardiovascular events, pneumonia, sepsis, infection, and bleeding).
  • Other risks include pancreatitis; injury to bowel, spleen, or adrenal gland; small bowel obstruction; and conversion to an open procedure when a laparoscopic approach is planned.
• Importantly, there is no increased risk of renal failure after donor nephrectomy.

Renal Transplantation

Expected Benefits

• For most patients with end-stage renal disease, renal transplantation is superior to dialysis in terms of long-term mortality risk. Therefore, candidates commonly undergo transplantation once a suitable donor is identified and appropriately allocated.

Potential Risks

• Systemic complications associated with any major surgery (cardiovascular events, pneumonia, pulmonary emboli, and venous thromboemboli).
• Other operative risks include:
  • Acute rejection.
  • Arterial or venous thrombosis.
  • Post-transplantation renal dysfunction.
  • Urine leaks.
  • Ureteral obstruction.
  • Wound infection.
  • Abscess.
  • Seroma.
  • Allograft fracture.
  • Lymphocele and hemorrhage.
• Late complications include:
  • Acute or chronic rejection episodes.
  • Renal artery stenosis.
  • Infection.
  • Malignancy.

Donor Nephrectomy