RENAL TRANSPLANTATION: AN UPDATE FOR THE GENERAL NEPHROLOGIST

Kidney transplants have become common surgical procedures, with thousands performed yearly around the world. The surgical techniques for the transplant are well established and the procedure is associated with high success rates. The complication rate associated with the procedure is low, especially when compared to other abdominal organ transplants such as liver and pancreas transplants. Nonetheless, the detection, accurate diagnosis, and timely management of surgical complications occurring after kidney transplant are important tasks of the team managing these patients. A delay in the diagnosis or management of these complications can result in significant morbidity to the recipient, with risk of graft loss and mortality. Most surgical complications involve either the wound or one of the three anastomoses (renal artery, renal vein, or ureter). Examples include wound infection, renal artery or vein thrombosis, and urine leak. Most of these complications will require surgical or radiologic intervention for appropriate management. Refinements in surgical technique have resulted in significant decreases in the incidence of surgical complications after kidney transplants. The surgical procedure is now routinely performed across the world with very low morbidity rates. As compared with liver and pancreas transplants, the incidence of technical problems associated with kidney transplants is significantly lower. While the incidence of surgical complications has decreased, so too has the incidence of medical and immunologic problems. With modern immunosuppression, rates of acute rejection are very low, with many centers reporting less than 20% incidence of acute rejection at 1 year posttransplant. The incidence of graft loss due to acute rejection is now less than 1%, and the incidence of graft loss due to chronic rejection is decreasing. Therefore, somewhat ironically, surgical complications remain an important cause of graft loss after kidney transplants. The initial presentation of surgical problems may be very similar to and must be differentiated from nonsurgical problems such as rejection or drug toxicity. Even if surgical complications do not affect graft function, they may still cause significant morbidity in the recipient, or may even result in death. For all of these reasons, it is crucial that all persons involved in the postoperative care of kidney transplant recipients be aware of the potential surgical complications that may occur, thus allowing for rapid diagnosis and treatment. Operative Procedure A detailed description of the operative procedure for kidney transplants is not the purpose of this article. However, a basic understanding of the procedure and of the regional anatomy is necessary to better understand the possible complications. The surgical technique for kidney transplants has changed very little from the original pelvic operation described in 1951 by Kuss et al. The most common approach today is the standard pelvic operation, with extraperitoneal placement of the kidney graft, allowing easy access for percutaneous biopsy. Usually the right iliac fossa is chosen because of the more superficial location of the iliac vein on this side. However, the left iliac fossa may be used when the recipient is a candidate for a future pancreas transplant, or when there is a previous transplant or significant arterial disease on the right side. Another option is to place the kidney in an intra-abdominal position through a midline incision. This option is useful when a pancreas transplant is being performed simultaneously or when a recipient has previously undergone operations on both the left and the right iliac veins. With the standard pelvic operation, the dissection is extraperitoneal. The iliac vessels are identified and assessed regarding suitability for anastomosis. The internal iliac artery can be used as the inflow vessel, with an end-to-end anastomosis, or the external iliac artery can be used, with an end-to-side anastomosis. The latter is the more commonly used procedure today. To minimize the risk of lymphocele formation, only a modest length of artery is dissected free and the lymphatics overlying the artery are ligated. The donor renal vein is anastomosed end-to-side to the external iliac vein.