Renal TransplantationRenal TransplantationByByMohamed Hassouna, MDMohamed Hassouna, MDProfessor of Urology, AlexandriaProfessor of Urology, AlexandriaUniversityUniversity
SELECTION FOR KIDNEY TRANSPLANTSELECTION FOR KIDNEY TRANSPLANT- Diagnose the- Diagnose the primary diseaseprimary disease and its risk ofand its risk ofrecurrence in the kidney graftrecurrence in the kidney graft- Rule out :- Rule out :-active invasive infection,-active invasive infection,- high probability of operative mortality- high probability of operative mortality- noncompliance,- noncompliance,- active malignancy,- active malignancy,
InfectionInfection Dental sepsis, pulmonary infectionDental sepsis, pulmonary infection UTI should be inactiveUTI should be inactive Tuberculin skin test , TB, CMV, herpes simplex virusTuberculin skin test , TB, CMV, herpes simplex virus
Active MalignancyActive Malignancy To reduce the risk of cancerTo reduce the risk of cancerrecurrence, a waiting time of 2 to 5recurrence, a waiting time of 2 to 5cancer-free years from the time of thecancer-free years from the time of thelast cancer treatmentlast cancer treatment
Perioperative Morbidity or MortalityPerioperative Morbidity or Mortality-- Heart disease is the main cause of death after renal TxHeart disease is the main cause of death after renal Tx- CVD, peptic ulcer, and pulmonary disease must be detected- CVD, peptic ulcer, and pulmonary disease must be detected
Technical DifficultiesTechnical Difficulties- to determine the suitability of the Bladderto determine the suitability of the Bladderfor Ureteric anastomosisfor Ureteric anastomosis- to determine the necessity forto determine the necessity forpretransplantation nephrectomy:pretransplantation nephrectomy:Polycystic, Pyonephrosis, uncontrolledPolycystic, Pyonephrosis, uncontrolledUTI, Uncontrolled RenoVascular HTNUTI, Uncontrolled RenoVascular HTN- significant bladder residual urine- significant bladder residual urine
DONOR SELECTIONDONOR SELECTION-Absence of renal disease-Absence of renal disease- Absence of active infectionAbsence of active infection- Absence of transmissible malignancy.Absence of transmissible malignancy.- Histocompatibility and ABO typingHistocompatibility and ABO typingthe living donor will havethe living donor will have nearly normalnearly normalrenal function after nephrectomy.renal function after nephrectomy.
Living DONOR SELECTIONLiving DONOR SELECTIONCT angiographyCT angiography with IV contrast :with IV contrast :- Satisfactorily excludes stone disease- Satisfactorily excludes stone disease- Demonstrates renal and vascular anatomy- Demonstrates renal and vascular anatomy- Defines the urinary collecting system- Defines the urinary collecting system- With minimal donor morbidity- With minimal donor morbidity- Reasonable expense- Reasonable expense
Donor surgeryDonor surgery- Two teams at two close theaters- Two teams at two close theaters- Warm ischemia time is limited to 30-40- Warm ischemia time is limited to 30-40minutes during surgery.minutes during surgery.- Cut as long as possible renal artery andCut as long as possible renal artery andvein for better anastomosis.vein for better anastomosis.- Keep the ureter as long as possible.Keep the ureter as long as possible.
Simple Cold Storage of KidneysSimple Cold Storage of Kidneys Cellular energy requirements areCellular energy requirements aresignificantly reduced bysignificantly reduced byhypothermiahypothermiaThis is done by surface cooling orThis is done by surface cooling orflushing with an ice cold solutionflushing with an ice cold solutionfollowed by cold storage.followed by cold storage.
RECIPIENT OPERATIONRECIPIENT OPERATION In adults and children (moreIn adults and children (morethan 20 kg)than 20 kg) the kidney graft is usuallythe kidney graft is usuallyplaced extraperitoneally in theplaced extraperitoneally in theiliac fossa by way of a Gibsoniliac fossa by way of a Gibsonincisionincision
RECIPIENT OPERATIONRECIPIENT OPERATIONVascular anastomosisVascular anastomosis In adults:In adults:Renal A. to Internal iliac A. or External Iliac A.Renal A. to Internal iliac A. or External Iliac A.Renal V. toRenal V. to External Iliac V.External Iliac V. In children:In children:Renal A. to aortaRenal A. to aortaRenal V. to IVCRenal V. to IVC- Ureteral anastomosis to the bladder- Ureteral anastomosis to the bladder
Post-operative managementPost-operative management Immunosuppressent drugs for lifeImmunosuppressent drugs for life Very ExpensiveVery Expensive Any infection is life threateningAny infection is life threatening Only 10% would live for 10 years.Only 10% would live for 10 years.