Kidney transplant from living donor
When is this procedure indicated?
Stage V acute renal failure (GFR less than 15 ml/min).
How is it performed?
Kidney transplantation is classified as single or double. The surgery is performed under general anesthesia. In almost all cases, the kidney(s) are placed in a different site from the native kidney (heterotopic transplantation). In the case of single kidney transplantation, an incision is made at the flank (right or left, depending on the choice of laterality that is made on a case-by-case basis, depending on the anatomical condition of the recipient). Once access to the retroperitoneal space is obtained, isolation of the external iliac artery and vein is performed, which are then first loaded and then anastomosed to renal organ artery and vein. Next, the anastomosis between the ureter of the donated kidney and the recipient's bladder is packaged. This suture may or may not be protected for a period of time by the placement of a catheter called double J, which is then removed in an outpatient procedure without the need for anesthesia.
Upon awakening, the patient will have a venous catheter, central or peripheral, required for the administration of intravenous therapy and for hydration by drip. A bladder catheter will be placed in the operating room, which will be removed as soon as possible, and, at surgical discretion, an abdominal drain, if indicated. It will remain connected to a cardiac monitor for a few days, which will assist medical and nursing staff in monitoring vital parameters. Due to delayed functional recovery of the transplanted kidney, some postoperative dialysis sessions may be necessary (20% of cases). However, this does not compromise the final successful outcome of the transplantation. From the time of discharge, the patient will have outpatient follow-ups. Success in recovering and maintaining the function of the transplanted organ depends on a careful balance of medicines, which include immunosuppressive drugs (to prevent rejection), antibiotics and other prophylactic treatments (to prevent infection), as well as anti-ulcer drugs or other medicines that counteract the side effects related to anti-rejection drugs.
Patients start therapy during hospitalization and continue taking most of these drugs after discharge and for the rest of their lives. Doses will be progressively reduced to adjust the dosage for each patient.
In the short term potential risks of the operation include surgical complications and infections. The main problems that may occur are: blood or urinary collections at the transplantation site, stenosis, partial or total closure of the ureter, thrombosis of arterial or venous vessels, fistulas. Their onset is usually very early (1st week) and rarely late. Most of them do not jeopardize transplantation if recognized and treated promptly. Another common complication of this type of transplantation is lymphocele, which is the collection of lymphatic fluid at the site of vessel preparation. Such collection in most cases has a tendency to spontaneously exhaust itself, while in a limited number of cases it requires keeping surgical drainage in place for a longer time or, even more rarely, surgery with a minimally invasive technique to drain it.
By late surgical complications after kidney transplantation we define those with onset after three months after surgery. They include:
- Vascular complications: renal artery stenosis.
- Urinary complications: ureteral stenosis, recurrent urinary reflux pyelonephritis, stone formation in the transplanted kidney.
- Abdominal wall complications: laparocele.
The most common complications following kidney transplantation include: infections, rejection reactions, hemorrhage, thrombosis, delayed functional recovery, onset of diabetes, psychological changes. The recipient's immune system tries to reject the new organ, as it does not recognize it as its own. For this reason, transplant patients start immunosuppressive therapy from the day of surgery and continue taking it for the rest of their lives. Transplant patients should immediately notify physicians of the appearance of signs of rejection. If rejection is early diagnosed and treated, it is usually reversible. More insidious and difficult to treat, on the other hand, is chronic rejection, which appears at later stages. In addition, occasionally, a kidney transplant patient may develop diabetes after transplantation. This complication is related to the use of anti-rejection drugs, which are required after implantation of the new organ, and is facilitated by the patient's predisposition. This type of diabetes is usually, but not always, temporary and resolves when therapy is reduced. Some patients require the use of oral medications or insulin injections to correct high blood sugar.