Mastering Kidney Transplantation Surgery

Sources Of Kidney For Transplantation

Split into Two Parts. 

1. Living Donor- Related; Unrelated; 
2. Decreased Donor- Donation after brain death, Most common, Better than donation after cardiac death, Organs are still being perfused when they are being extracted for transplantation.

Donation After Brain Death

Function of brain stem death, Acceptable as a donor for transplantation,  Cannulate the aorta and IVC, Perfume organ with cold preservative, Reduce warm ischemia. The interval of time between the cardiac arrest and the cold solution perfusion to the kidney. There is an accumulation of blood in the kidney, it must be removed and the organ must be perfused with cold solutions. Blood flow to the kidney is interrupted.

The heart is the first organ removed. Warm ischemia time may worsen if the blood stagnates in the kidney. The IVC and aorta are cannulated to prevent this. Cold perfusion of fluid is carried out. Lung, liver, pancreas, and kidneys come next. Aorta patch, Carr's patch, renal vein, and the first 10-15 cm of the ureter are removed together with the kidneys. Cold perfusion fluid is utilized to perfuse the kidneys.

Also Read: Alport Syndrome and Familial Glomerular Disorders

Donation After Cardiac Death

Brain stem death function- Can be accepted as a donor for transplantation. While the heart is beating- Cannulate IVC and aorta, Perfume organ with cold preservative, Minimise warm ischemia, Time between the cardiac arrest and the time that the kidney is perfused with a cold solution.Blood flow to the kidney is stopped. Blood is accumulated in the kidney. It has to be retrieved, the organ has to be perfused with cold solutions.

First organ retrieved is Heart. The blood will stagnate in the kidney and warm ischemia time will be worsen. To avoid this they cannulate the IVC and aorta. Cold perfusion of fluid is done. First organ to be removed is the heart. Followed with lung, liver, pancreas, and kidney. Kidneys are removed with a patch of aorta patch. Carrel’s patch-Renal vein, 10-15cm of the ureter are removed along with kidney. Kidneys are perfused with cold perfusion fluid.

Also Read: Metabolic Syndrome- NEET SS Medicine

Maastricht Classification

Uncontrolled

Unexpected cardiac arrest, Prolonged warm ischemia times Surgical team is not prepared to extract the organ, Maastricht category 1.

Maastricht category 2

Controlled 

Expected cardiac arrest, Warm ischemia time can be reduced, Warm ischemia time >60, Marginal organ, Significantly delayed graft function 

DCD Protocol

Medical ethics approved; doctors outside the transplant team diagnosed the patient's death; the 5-minute rule was followed; the patient was to be left alone for five minutes without any further action; in situ cooling was used; and standard surgical techniques were used to retrieve the organ. 

Also Read: Diuretics And Its Action

Donation After Cardiac Death

• Uncontrolled 
  • Failed resuscitation 
  • Confirm cardiac death
  • 5-minute rule
  • Ventilation with 100% oxygen
  • In situ renal cooling 
• Controlled 
  • Awaiting cardiac arrest 
  • Confirmation of death
  • 5-minute rule 

In Situ Renal Perfusion

One balloon is located at the level of the iliac vessel; another is above the renal vessel;  The cannula is fixed in place; Cold fluid is supplied to the kidneys;  Return is coming through the venous vent;  A large bore cannula is inserted into the aorta via the presence of ice-cold perfusion fluid.

Also Read: Rapid Acquisition Of Key Nephrology Concepts

Living Kidney Donors

Advantage

Preoperative imaging, MRA and CTA, laparoscopic donor nephrectomy, and more. Benefits include: less severe and prolonged postoperative pain; shorter hospital stay; quicker return to work and regular activities; better cosmetic outcome than open donor nephrectomy; higher chance of donation; 

Disadvantage

Extended duration of warm ischemia;  Injury to the renal parenchyma and arteries.

Also Read: Special Considerations in Diabetes Mellitus

Approaches For Donor Nephrectomy                           

• Transperitoneal Laparoscopic donor nephrectomy 
  • Pneumoperitoneum is created
  • Through 4 ports 
  • Kidney taken out through Pfannenstiel incision
• Hand-assisted laparoscopic 
  • Tactile sensation can be used
  • Less operator expertise
• Retro peritoneoscopic approach 
  • Minimal operative field 
  • Full-length vessels can be isolated.
  • Renal artery or the renal vein

Effect Of Pneumoperitoneum

Vasoconstrictors: increased intracranial pressure, transient intraoperative oliguria, compromised early allograft function, decreased cardiac output, compression of the renal vein, urethral blockage, compression of the renal parenchyma, and renal vein.

Systemic Hormonal Effects 

RAAS system

Sympathetic nervous system 

Also Read: Immunosuppression In Transplantation

Factors Going To Lead To Reduced Urine Production 

There could be a release of hormones from the kidney or throughout the body, which would result in constriction of the ureter or renal arteries and no urine production, reduces GFR or cardiac output in and of itself.

Technical Issues

The laparoscopy operation is performed; ureteric ischemia may occur; the distal ureter's blood supply may be stopped; incorrect artery excision may occur; the left kidney is selected over the right; and the renal vein is not long enough.

Post-OP Recovery

Discharge - 2 to 4 days 

Returning to work in 3-6 weeks

Renal Preservation

HTK solution versus UW solution; cold storage versus pulsatile perfusion operated by a machine; aerobic function enabled by machine perfusion; oxygen and waste products eliminated; Normothermic perfusion in ex vivo.

Renal Transplantation Procedure

 End-to-side anastomosis; Heterotrophic position in the iliac fossa;  Right iliac fossa;  Extra peritoneal placement;  Vascular anastomosis;  Renal vein;  Extra iliac vein; Diverted internal iliac artery;  End-to-end; Observed in living donor.

Also Read: Haemodialysis Apparatus : Dialysis System, Dialysis Machine

End To Side With Carrels Patch

Cadaveric

End-side arterial anastomosis, End-end arterial anastomosis 

The renal vein experiences end-side anastomosis with the external iliac vein, and the renal artery experiences end-side anastomosis with the external iliac artery. This process is end-end, and it occurs in situations where the carrel patch is unknown. The internal iliac artery is divided and anastomosis to the renal artery occurs. No carrel patch is present, and the external iliac artery persists. End-end arterial anastomosis is observed in living donors; end-side is observed with deceased donors; renal vessels shouldn't be kinked; multiple renal vessels; no. Anastomosis should be minimized.

Also Read: High-Yield NEET SS Medicine Nephrology Questions

Urinary Drainage 

Politano- Leadbetter Technique 

Transvesical ureteroneocystostomy with submucosal antireflux tunnel. Goes through the bladder. New ureter is anastomosed to the recipient’s bladder. Tunnel is created to prevent reflex 

Extravesical Ureteroneocystostomy

Only technique, Shorter ureter, Muscle fibers used for forming anti-reflex mechanisms.

Temporary DJ Stent

Reduced urinary leak, Removal in 4-6 weeks

Forgotten DJ Stent 

Recurrent UTI

Alternative Techniques Of Urinary Reconstruction

• Abnormal bladders
• Urinary diversion with ileal conduit 
• Conduit - 6 weeks before transplant 

Drainage And Wound Closure

In certain centers, if there is delayed graft function, they will wait until creatinine stabilizes. Induction is given before or after the transplant when there are multiple doses. Serosanguineous and lymph around the kidney. Skin - Subcuticular absorbable suture. Postoperative. Removal of the drain five hours after surgery. Commencing maintenance immunosuppression.

Hope you found this blog helpful for your NEET SS Nephrology Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.