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Technical Aspects of Renal Transplantation

Technical Aspects of Renal Transplantation

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12/26/2012

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1
Technical Aspects ofRenal Transplantation
R
enal transplantation is the preferred treatment method of end-stage renal disease (ESRD). It is more cost-effective than ismaintenance dialysis [1] and usually provides the patient witha better quality of life [2]. Adjusted mortality risk ratios indicate a sig-nificant reduction in mortality for kidney transplantation recipientswhen compared with that for patients receiving dialysis and patientsreceiving dialysis who are on a waiting list for renal transplantation(Fig. 14-1) [3].The indication for renal transplantation is irreversible renal failurethat requires or will soon require long-term dialytic therapy. The eval-uation of candidates for renal transplantation is discussed in Chapter12. Generally accepted contraindications are noncompliance, activemalignancy, active infection, high probability of operative mortality,and unsuitable anatomy for technical success [4]. The technicalaspects of kidney transplantation are discussed, primarily through theillustrations of kidney preparation and of a living donor renal trans-plantation.Kidneys from living donors require little preparation by the trans-plantation team because most of the dissection has already been doneduring the nephrectomy. Further separation of the renal artery orarteries from the renal vein(s) will allow separation of the arterial andvenous suture lines in the recipient and will prevent the technicalinconvenience of side-by-side anastomoses. The right kidney from aliving donor usually has a cuff of the inferior vena cava attached tothe renal vein. This provides the recipient team with maximum renalvein length and a wide lumen for anastomosis. The renal arteries in akidney graft from a living donor are not attached to aortic patches asthey usually are in the cadaveric kidney. The technical aspects of living-donor harvesting are not illustrated here.
John M. Barry 
C H A PT ER
 
14.2
Transplantation as Treatment of End-Stage Renal Disease
ADJUSTED MORTALITY RISK RATIOSFOR END-STAGERENAL DISEASE BY TREATMENT MODALITY
Treatment modality
All patients on dialysisPatients on dialysis who are on a waiting listCadaveric kidney transplantation recipientsLiving-donor related kidney transplantation recipients
 Data from
USRenal Data System [3].
Risk ratio
1.00.480.320.21
TECHNICAL CONSIDERATIONSFOR RECIPIENTSOF KIDNEY TRANSPLANTATION
Kidney graft
Right or leftGross appearance and sizeArterial anatomyVenous anatomyUreteral anatomy
Recipient
Abdominal wall anatomySizeArterial anatomyVenous anatomyUrinary tract anatomy and functionGender
FIGURE 14-1
The adjusted mortality risk ratio for patients on dialysis placed onthe renal transplantation waiting list is greater than that for kidneytransplantation recipients, suggesting transplantation itself resultsin a reduced mortality risk for patients with end-stage renal diseasewho are treated [3].
FIGURE 14-2
A number of factors concerning the kidney graft and recipientdetermine the technique of renal transplantation in each recipient.Placement of the kidney graft in the contralateral iliac fossa ispreferable because the renal pelvis becomes the most medial of thevital renal structures and thus readily available for future recon-struction if ureteral stenosis occurs. Areas of previous abdominalsurgery such as ileostomy, colostomy, renal transplantation, or aperitoneal dialysis exit site are avoided, if possible. A kidney toolarge for the recipient’s iliac fossa is usually placed in the rightretroperitoneal space and revascularized with the aorta or commoniliac artery and interior vena cava or common iliac vein. Pelvic vas-cular disease and previous renal transplantation determine whetherthe aorta or internal iliac, external iliac, common iliac, native renalor splenic artery will be selected for renal artery anastomosis. Theuse of both internal iliac arteries in serial renal transplantations inmen is avoided to prevent impotence [5]. The method of urinarytract reconstruction depends primarily on the status of the recipi-ent’s bladder, continent reservoir, or incontinent intestinal conduit.
Cadaveric Kidney Graft
FIGURE 14-3
Instrument setup for cadaveric kidney graft preparation. The towelprevents renal movement during dissection.
 
14.3
Technical Aspects of Renal Transplantation
FIGURE 14-4
Preparation of a leftcadaveric kidneygraft. The kidneyand its vital struc-tures are surround-ed by other tissues.The cadaverickidney graft canrequire an hour of preparation timebecause the specimenusually includes aportion of the inferiorvena cava, an aorticcuff, the adrenalgland, variableamounts of peri-nephric tissue,sometimes pieces of muscle, and occa-sionally damagedrenal vessels.
FIGURE 14-5
Renal vein dissection. The adrenal and gonadal veins have beenisolated. They will be divided between ligatures.
FIGURE 14-6
Renal artery dissection. In this posterior view, the aortic patch andmain renal artery have been separated from the surrounding tissues.
FIGURE 14-7
Left cadaver kidneygraft after prepara-tion. The adrenalgland and excessperinephric tissuehave been removed.Fibrofatty tissue isleft around the renalpelvis and ureter toensure blood supplyto the ureter. Theaortic patch, renalvein, and ureter willbe further modifiedto provide a “bestfit” in the recipient.

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