1. Renal Transplantation
Nalaka Gunawansa

2. THE HISTORY OF TRANSPLANTATION AS DEPICTED IN ART
The possibility to transplant limbs and organs predates the modern technology of organ transplantation.
The legend of the “Miracle of the Black Leg” describes two surgeon brothers – 15th century
The legend relates their miraculous removal of the diseased leg of a Caucasian Roman named Justinian and its replacement with the leg of a recently deceased black African.
The Miracle of Cosmas & Damian (15th c.)

3. History of Kidney Transplantation
The first successful experimental kidney transplants IN ANIMALS – Austria
The first kidney transplant experiments were performed in humans in France using animal kidneys.
The first human-to-human kidney transplant REJECTION
1940’s - Sir Peter Medawar at the University of London experimented with the immunologic basis of organ rejection.
Early 1950’s - Cortisone-like medications were used to suppress the human immune system

4. Kidney Transplantation Surgical Milestones
Ulman, 1902 – kidney to neck vessels
Carrel, 1912 – vascular techniques
Kolff, 1940’s – dialysis machine
Hume, 1947 – kidney to arm vessels
Murray, 1956 – identical twin transplant
into the iliac fossa

5. Alexis carrel
Alexis Carrel 1912

6. Hume, 1950’s – kidney to femoral vessels

7. History of Kidney Transplantation
1954- First successful kidney transplant
Total body irradiation for immunosuppression
Steroids
Now
Multiple immunosuppressants
Monoclonal antibodies
Plasmapharesis

8. Nobel Prize in Physiology or Medicine 1990
Joseph E. Murray (1/2)
Discoveries concerning organ transplantation in the treatment of human disease
In 1954, the first successful human kidney transplant was performed between twins in Boston.
Transplants were possible in unrelated people if drugs were taken to suppress the body's immune reaction
Great events in history of transplantation
2006-7year
Immunology

9. Murray, 1956 – current transplant position

10. Current status Live donor renal transplants
Deceased donor – brain dead/ cardiac death
HLA, anti HLA antibodies, T-B Cell cross match, PRAs, DSAs
ABO incompatible transplants
Xenotransplant / Tolerance

11. Kidney transplantation is the most effective therapy for ESRD Ojo, J Am Soc Neph, 2001;12:589

12. Medical Safety of Living Kidney Donation
Living kidney donation - removal of one kidney does not impair survival or long-term kidney function.
Extensively screened – HEALTHY
Life long follow up

13. Anatomy of Renal Transplantation

14. Heterotropic transplant
Orthotropic transplant – liver/ lung
Heterotropic transplant – kidney
Native kidney – only specific indications for removal
Infection
Space issues

15. The transplant renal a is anastomosed to the ipsilateral internal or external iliac a, the renal v to internal or external iliac v and the transplant ureter to the bladder.

16. Factors Determining Transplantation Outcomes
Type of donor (cadaveric vs. living)
Matching and sensitization
Racial Differences
Recipient Age
Donor Age
Ischaemia times
Delayed graft function
Acute rejection, chronic rejection
Years on dialysis
Underlying disease leading to ESRD

17. Waitlist and Transplant Activity for Kidneys, 1999-2008

18. One Year Unadjusted Graft Survival by Year, Living and Deceased Donor Kidney Transplants

19. complete follow up data
415 LDRT
18 Lost to follow up
397 (95%)
complete follow up data
32 (8%) Graft Failures
365 (92%) Graft survival
8 SGF
24 PGF
5 re-transplanted
19 dead
5 re-transplanted or
3 on waiting list
337 (85%)
overall patient survival at 5 yrs

20. Waiting List/ Deceased Donor Kidney Disparity
Am J Transplantation, 2(10): cover, 2002

21. Paired Donor Exchange Pair #1 Pair #2 Recipient = A Recipient = B
Donor = B Donor = A
Blood-type incompatible Recip/Donor pairs
exchange blood-type compatible kidneys

24. Organ Preservation Time
Heart: 4-6 hours
Lungs: 4-6 hours
Liver: 12 hours
Pancreas: hours
Kidneys: 72 hours

31. The Surgical Procedure
Many pitfalls and Technical glitches

32. Renal transplant:
Venous anastomosis

33. Renal transplant:
Arterial anastomosis

34. Surgical Complications
Graft thrombosis:
Caused by thrombosis of donor renal A or V.
Usually happens in first week.
Diagnosed by ultrasound with doppler studies.
Almost always requires explant of kidney.
Urine leak: Major ureteric complications
Urine leak/ hydronephrosis
May or may not have abdominal pain.
Diagnose with nuclear medicine scans (DTPA or MAG3).
Surgical repair and/or relief of obstruction.

35. Renal A / vein thrombosis

36. Renal Artery Stenosis

38. Delayed Graft Function
Need for dialysis in the first week after transplantation.
Causes:
ATN from prolonged cold ischemia.
Acute rejection.
Recurrent disease.
Usually requires biopsy for diagnosis and management.

39. Late Ureteral stenosis (5%)
Reflux (30-80%) and acute pyelonephritis (10%)
Kidney stones (1%)
Tx Renal artery stenosis (10%)
AVF & pseudo-aneurysm after renal biopsy (10%)
Lymphocele (1-20%)

40. 2. Urinary Leak
First transplant month. (2-5%)
Presents with urine extravasation and ARF, fever, pain and distended abdomen.
Diagnosis is via U/S which demonstrates a peritransplant fluid collection or via radioisotope scanning.
Treatment is foley catheter insertion and surgery.

41. Urinary Leak

43. 3. Obstructive Uropathy
Occurs in early post transplant period (3-6%). The commonest causes are extrinsic compression of the ureter by a lymphocoele or due to a technical problem with the ureteric anastomosis to the bladder.
Diagnosis is best achieved via U/S demonstrating hydronephrosis.
Treatment is surgical.

45. Routine intraoperative ureteric stenting for kidney transplant
recipients (Protocol) Wilson CH, Bhatti AB, Manas DM

47. Perigraft Fluid Collections
Seroma & Hematoma
Urinoma
Lymphocele

48. 4. Lymphocoele
- Occurs within the first 3 post transplant months and is due to lymph leaking from severed lymphatics (5-15%).
- Largely self limiting
- Rarely cause pressure on the ureter
- Percutaneous aspiration, open evacuation

49. Pseudoaneurysm / AV fistula

51. Live donor Healthy donors Selecting the kidney – DTPA, CTA
Better kidney for the donor
Preferentially left
Reconstruction if needed (multiple arteries)
Open / Robotic/ Total Laparoscopic/ hand assisted laparoscopy

55. Recipient Antibiotics Fluid management
Pressure control and renal perfusion
Reperfusion
Post-op mobilization/ DVT prophylaxis

56. Renal transplant: Reperfusion
Documented pressure drop >20% of starting SBP sustained for > 5 mins

57. Imaging Post-transplant
Allograft doppler
Can diagnose vascular complications, ureteric stenosis
Preliminary diagnosis of rejection, pyelonephritis
Aid in guided biopsy, stenting if required

63. Summary The science and art of transplantation in ever evolving
Better understanding of immune modulation
The demand highly exceeds the demand for organs
Embark on deceased donors, cardiac death, extended criteria donors, ABO incompatible
Surgically- quick and safe transplant
Post transplant vigilance

64. Thank you