Kidney transplantation in adults: Overview of the surgery of deceased donor kidney transplantation

INTRODUCTION — Kidney transplantation is the most commonly performed vascularized solid organ transplant. Technically, it is perhaps the easiest transplant procedure to perform and has the added security of the ability to provide dialysis in patients who experience delayed allograft function [1-4]. However, it is unforgiving of technical error and can present specific challenges in the case of particular recipient or donor issues.

The basic elements of back-table preparation of the deceased-donor kidney and the features of implantation in adults and children will be discussed here. The complications associated with this procedure are presented separately.

BACK-TABLE PREPARATION — The anatomic structures that are transplanted during a deceased-donor kidney transplant usually consist of the kidney, with most of the perinephric fat removed, and the following anatomic structures:

●Renal artery(ies) usually with a cuff of the donor aorta

●Renal vein(s) usually with a cuff of the inferior vena cava for the left kidney or the entire inferior vena cava for the right kidney

●Ureter with a generous amount of periureteral tissue

The kidney is immersed in an iced saline or Ringer's Lactate solution while being prepared for implantation. The renal vein is dissected free, and its branches (on the left side, the adrenal, gonadal, and lumbar) are ligated. The artery is then dissected free. The excess perinephric fat is removed, and the remaining tissue is ligated. Relatively little dissection of the ureter is performed in order to minimize the risk of devascularization. To allow for efficient vascular anastomosis, the excess vena cava and aorta are trimmed.

With a right kidney, the short renal vein can be extended using the donor vena cava or iliac vein; this results in a longer vein for easier implantation, minimizing the disparity in length between the renal artery and vein. Therefore, the artery does not become kinked.

In the case of variations, such as multiple (or inadvertently transected) arteries, back-table reconstruction may be needed to facilitate implantation. There is no collateral arterial circulation to the kidney, so the entire arterial supply must be revascularized. By comparison, there is excellent collateral venous drainage, so a second renal vein can be ligated with impunity.

With a kidney from a living donor, recovered using the open technique, much of the preparation of the kidney has been done in situ, prior to the recovery of the organ; laparoscopically recovered living-donor kidneys are actually more similar to deceased-donor kidneys and require much more back-table preparation. The donor artery and vein will be shorter than with a deceased-donor kidney as the donor vena cava and aorta are obviously not available.

IMPLANTATION — In contrast to the transplanted heart, lung, and liver, which are transplanted orthotopically, the kidney is transplanted heterotopically, usually into the iliac fossa. The native kidneys are rarely removed.

A potential retroperitoneal space is created by making a right (or left) lower quadrant incision. The inferior epigastric vessels and lymphatics are ligated and divided, and, in women, the round ligament is divided; in men, the spermatic cord is usually preserved. The peritoneum is mobilized medially to expose the external iliac artery and vein, which are then dissected free.

The renal vein is usually anastomosed first, end-to-side to the external iliac vein, with a running 5-0 or 6-0 polypropylene suture. The renal artery is usually anastomosed end-to-side to the external iliac artery, again with a running 5-0 or 6-0 polypropylene suture.

During the exposure of the vessels, the recipient is hydrated; in addition, furosemide 1 mg/kg and mannitol (doses vary based on center experience from 12.5 to 25 g as a fixed dose to 1 g/kg [maximum dose 75 g]) are infused slowly, as the vessels are anastomosed. The kidney can be kept cold during the implantation by being wrapped in an ice blanket. The living-donor kidney is kept cool by topical irrigation with cold saline.

After reperfusion of the kidney, bleeding vessels are identified and ligated, oversewn, or cauterized. The ureter is then implanted into the bladder, usually with an extravesical technique, with a slowly absorbable suture, such as 6-0 polyglyconate (Maxon) or polydioxanone (PDS). Some surgeons prefer to stent the ureteroneocystostomy to minimize the risk of leak or stenosis. When a stent is used (a personal preference is six french 12 cm double J stent, but there are other options), it is generally left in place for four to six weeks and is removed cystoscopically. Others tie a suture to the stent and Foley catheter, and the stent and catheter are removed at discharge from the hospital.

There are a number of potential variations regarding the technical aspects of implantation, but the basic principles of venous, arterial, and ureteral anastomosis are common to any kidney transplantation.

In small pediatric recipients weighing <20 kg, the external iliac vessels are usually too small to allow for implantation. The important principle is to identify appropriately sized vessels; in the smallest recipients, this may require intraabdominal exposure and anastomosis to the recipient aorta and vena cava to allow adequate inflow and outflow. Of additional critical importance is the need to overhydrate the very small pediatric recipient to ensure adequate kidney perfusion as the transplanted kidney may take up a substantial percentage of the recipient's cardiac output. It is also important to either fix the kidney to the retroperitoneum and/or abdominal wall or put the kidney in at least a partially retroperitoneal position by draping the right colon over it, in order to minimize the risk of subsequent torsion.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Kidney transplantation".)

SUMMARY

●General principles – Kidney transplantation is the most commonly performed vascularized solid organ transplant. Although it is technically perhaps the easiest transplant procedure to perform, it is unforgiving of technical error and can present specific challenges in the case of particular recipient or donor issues. (See 'Introduction' above.)

●Back-table preparation – The anatomic structures that are transplanted during a deceased-donor kidney transplant consist of the kidney, with most of the perinephric fat removed; renal arteries; renal veins; and ureter. (See 'Back-table preparation' above.)

●Implantation – There are a number of potential variations regarding the technical aspects of implantation, but the basic principles of venous, arterial, and ureteral anastomosis are common to any kidney transplantation. (See 'Implantation' above.)