 \200 Referral to liaison psychiatry May be necessary: \200 Trauma/post-traumatic stress disorder (PTSD) Traumatic experiences (e.g. severe life-threat ening compli- cations, emergency treatments) may give rise to symptoms of PTSD. Past psycho logical trauma may be recalled and impact on a patient \200\231s ability to cope with treat ment. Typical reactions to trauma include: Re-experiencing the traumatic event: \200 \200 \200 if the patient is psychotic, severely depressed, is at a sig- ni \201 cant risk of self-ha rm, or has suicidal ideation; if level of distress is suf \201 cient to require medication (e.g. antidepressants or anxiolytics \200\223 see Royal College of Psychiatrists guidelin es). Further reading Stein A, Wild J. Kidney failure explained. London: Class Publishing; 2007. \202 ashbacks; intrusive memories; distressing dreams and nightmares. White CA. Cognitive behavior therapy for chronic medical problems: a guide to assessment an d treatment in practice. Chichester: Wiley; 2001. Arousal reactions: \200 \200 \200 \200 \200 \200 Internet resources British Association for Behavioral and Cognitive Psychotherapies (BABCP) : sleep disturbance; irritability and/or anger; impaired concentration and memory; hyperalert ness; exaggerated startle response; physiological response such as anxiety and panic attack s. Avoidance (e.g. of situations connected with trauma) and emotional numbing. http://www.babcp.org.uk National Institute for Health and Clinical Excellence (NICE): http://www.nice.org.uk National Institute of Mental Health: http://www.nimh.nih.gov National Phobics Society: Treatment/interventions It is recommended that the following treatments should be provided to people who have been diagnosed with PTSD: \200 \200 http://www.phobics-society.org.uk Royal College of Psychiatrists: trauma-focused CBT; eye movement desensitization and reprocessing (EMDR) therapy. http://www.rcpsych.ac.uk/mentalhealthinforma- tion.aspx Sleep disorders Research has demonstrated that many hemodialysis patients experience a slee p disorder, including delayed sleep onset and/or night-time waking. Restless leg symptoms h ave also been described in patients experiencing insomnia. See also Neuropyschiatric disorders in CKD, p. 454 Sexual disorders in CKD, p. 402 Dialysis strategies, p. 480 This page intentionally left blank 543 Chapter 14 Renal transplantation Chapter contents Selection and preparation of the recipient 544 Assessment of live renal donors 548 Transpla nt surgery and surgical complications 552 Early management of transplant recipients 556 Imm unosuppression for renal transplantation 560 Long-term medical complications of renal trans plantation 566 Recurrent and de novo disease post renal transplantation 572 Outcome of rena l transplantation 576 C. NEWSTEAD 544 Selection and preparation of the recipient Introduction Overall renal transplantation both increases survival and greatly improves the quality of life of recipients. Most ben- e \201 t is seen when the patient is transplante d either just before or shortly after initiating dialysis. Because of the imbalance between the numbers of those who could bene \201 t from renal transplantation and the supply of o rgans it is sensible to exclude potential recipi- ents who can be predicted to have a poor outcome. Recommendations in this chapter are based on guidelines published by the American Society of Transplantation and the American Society of Transplant Surgeons as well as the E uropean Best Practice Guidelines for Renal Transplantation published on behalf of the Europ ean Renal Association \200\223 European Dialysis and Transplant Association. Cancer How long to delay transplantation in a potential recipient who has been previously t reated for cancer and potentially cured is a common clinical issue. The key consideration i s to minimize the risk of relapse of occult metastatic disease which may be accelerated by immunosuppression. Transplant registries have demonstrated that in general recurrence rates of cancer are less the longer the waiting time, with: \200 \200 \200 53% recurring within 2 years; 34% between 2 and 5 years; remaining 13% recurring after 5 ye ars. Because of the survival advantage of transplantation compared to dialysis, a reasonable com promise is to wait 2 years after successful treatment for most cancers prior to transplant listing. Current guidelines are summarized in Table 14.1.1. Cardiovascular disease Cardiovascular disease is the major contributor to prema- ture death in renal transplant recipients. An algorithm for the workup of cardiovascular disease in p otential recipi- ents is shown in Fig. 14.1.1. Breast cancer It is dif \201 cult to know how best to manage patients with treated cancer of the breast as the majority of relapses occur after 3 years. Many cancers are heterogeneo us conditions, with the prognosis depending on staging. Therefore, it is important to adopt an individualized approach to this problem with close consultation with the oncology team. Breast cancer is twice as common in renal transplant recip- ients compared to the general population. Ischemic heart disease Criteria to select asymptomatic patients for further investigation m ay include: \200 \200 \200 \200 age >50 years; diabetes; smoked cigarettes in the past 5 years; resting ECG shows a rhythm disturbance or ST segment abnormalities. Screening for cancer The issue of screening for occult de novo cancer in poten- tial renal transplant recipients is contentious. It is reasona- ble to adopt an individualized approac h with cancer screening based on symptoms, signs or in the presence of conditions known to particularly predispose to cancer. Exercise tests have the most discriminating power but may not be practical due to poor exer cise tolerance. Pharmacologically driven cardiac stress testing is com- monly used as an al ternative. If there is signi \201 cant reversible ischemia, coronary angiog- raphy should be undertaken. If left ventricular function is adequate and symptoms are controlled then tr ansplant listing can be recommended. Gastrointestinal disease The rate of colonic perforation post renal transplantation is 1% and most commonly associated with diverticular disease. Screening of asymptomatic patients is not justi \201 ed, as one study found that none of the patients with signi \201 cant d iver- ticular disease had symptomatic disease post transplanta- tion. Patients with symptom atic disease should undergo imaging and consideration given to resection of extensive disea se. Screening of asymptomatic individuals for peptic ulcer disease is not recommended becau se of the low morbidity rate even in patients with past peptic ulcer disease. How best to m anage incidentally noted cholelithiasis is not straightforward, although a detailed decisio n analysis recommended expectant management as the preferred strategy for kidney transplant recipients with asympto- matic cholelithiasis. Cerebrovascular disease Screening asymptomatic potential renal transplant recipi- ents for cerebrovascular disease is not recommended. Patients with a completed stroke or a transient ischemic attack within the past 6 months should be referred for neu- rological assessment. Transplantation should be reconsid- ered after medical and surgical management has been op timized and the patient free of recurrent transient ischemic attacks for 6 months. Carotid ultrasound screening after the discovery of an asymptomatic bruit is routine but the result s of this and further investigations rarely alter the clinical decision. Peripheral vascular disease If patients are asymptomatic with good femoral pulses then only a plain X-ray is recommended to rule out extensive vascular calci \201 cation. Patients w ith symptoms or lack of palpable femoral pulses require vascular imaging and a surgical ass essment of whether it is technically possible to implant the graft and if the transplant wo uld be predicted to lead to steal and critical ischemia in the ipsilateral distal leg. Genitourinary disease Routine urological screening of potential transplant candi- dates is generally unnecessary. Investigations by urologists should be carried out in the pediatric population when congenital obstructive uropathy CHAPTER 14.1 Selection and preparation of the recipient 545 is suspected or in adult practice where bladder outlet obstruction or a neurogenic bladder resulting in high intravesical pressures is suggested by clinical history and examination. Native nephrectomy is rarely indicated prior to listing for transplantation. Removal of bot h kidneys may be indicated for persistent sepsis especially in the presence of nephro- lith iasis and/or pronounced re \202 ux. Uninephrectomy of a large polycystic kidney is occasio - nally required to make space for the allograft or if it is infected; there is no compelli ng evidence supporting whether the surgery should be pre-emptive or at the time of transpla nt. The removal of a failed allograft may be required prior to listing if it is the source of sepsis or causing systemic in \202 ammation from rejection or to allow space for a new allograft. Cardiovascular disease risk assessment Current symptoms or past history ischemic heart disease Yes Review past tests No Yes Noninvasive test of occult ischemia and assess LV function Age >50 years or diabetic or cigarette smoker in past 5 years or rhythm disturbance/ST segm ent elevation in resting ECG Reversible ischemia Normal or small area of non- reversible ischemia and adequate LV function Coronary imaging No TIA in past 6 months or past completed stroke Histocompatibility Blood group typing ABO typing is routine as an incompatible transplant c an result in immediate graft failure from hyperacute rejection. If satisfactory No Yes HLA typing Recipients also undergo HLA typing in which, as a mini- mum, the HLA-A, HLA-B an d HLA-DR antigens of the major histocompatibility complex (MHC) are determined. The degree of HLA mismatching may help to identify recip- ient and donor combinations that would be ex pected to result in poor graft survival, as well as in \202 uence immuno- suppressive stra tegies. In cadaveric graft allocation the level of HLA mismatching between donor and recipi ent in \202 uences the allocation pro- tocol. In live donor transplantation the degree of mismatching has much less in \202 uence on outcome. Neurologic assessment of likelihood of perioperative stroke and prognosis Claudication or absent femoral pulses Risk judged acceptable and no TIA for 6 months No Yes Plain x-ray does not show extensive vascular calcification Vascular assessment as to risk distal limb ischemia and overall prognosis satisfactory Vascular imaging Proceed Anti-HLA antibodies Subjects undergoing transplantation are also tested for the presence of antibodies to HLA antigens. Antibodies may develop following: \200 \200 \200 Fig 14.1.1 Algorithm for the work-up of cardiovascular disease in the transplant recipient. ECG, electrocardiogram; LV, left ventricular; TIA, transient ischemic attack. Reproduced w ith permission from Newstead and Davis (2007). previous transplantation of (mismatched) organs; pregnancy; blood transfusions. Table 14.1.1 Outline guidelines for recommended delay to transplant listing following diagn osis of cancer On occasions there are no known risk factors. These HLA antibodies may lead to immediate gr aft rejec- tion or accelerated humoral rejection. The presence of antibodies is detected by \200\230crossmatch \200\231 tests. Current recommendations for detection and characteriza - tion of clinically relevant antibodies in solid organ trans- plantation have been summari zed by the British Society of Histocompatibility and British Transplantation Society (BTS). No waiting time Basal cell skin cancer Low-grade bladder cancer Asymptomatic renal cell car cinoma In situ carcinoma Focal neoplasm, with known very low rate of metastasis 2 years Most cancers Assessment of histocompatibility Formerly the presence of ABO incompatibility or of a posit ive crossmatch due to donor relevant HLA antibody would have precluded transplantation. In recent years several groups have published reports of successful transplants in this situat ion using combinations of intravenous immunoglobulin, plasma exchange and immunoabsorption columns as well as augmented immu- nosuppressive treatment. >2 years (5 years advised) Colorectal cancer Breast cancer Uterine cancer Malignant melanom a Modi \201 ed from Penn (1993) with permission. C. NEWSTEAD 546 Reviews of the largest experience of HLA antibody desen- sitization have been published fro m the USA and Japan, particularly related to ABO \200\230incompatible \200\231 live donor renal transplantation. Summary guidelines relating to \200\230Antibody Incompatible Transp lants \200\231 are available from the BTS. Practice with regard to screening for asymptomatic infection varies. CXR to look for inacti ve disease and a tuberculin skin (PPD) test is recommended in the USA. While a positive PPD correlates with past infection, a nega- tive skin test in the uremic patient may represent a false- negative result. In one study the PPD was positive in only 20 \200\22325% of pati ents before transplant who developed active tubercu- losis post transplant and many units c hose not to screen. Infectious complications The principal tests required for screening are shown in Table 14.1 .2. Geographic location determines screening requirements for some rare occult infections. Obesity Obese subjects have an increased risk for wound infections and perioperative compli cations. From an analysis of the USRDS data base, an advantage for transplantation for obes e subjects could be shown for live donors, whereas for deceased donors the survival bene \201 t was only shown if the recipient had a BMI <40 kg/m2. Transplantation of deceased don or kidneys into recipients with a BMI >40 kg/m2 is not recommended. Epstein \200\223Barr virus (EBV) and cytomegalovirus Recipients with negative EBV antibody titers who receive EBV antibody-positive renal transplants have an increased risk of develo ping post-transplant lymphoproliferative disorder. Recipient viral serology may therefore i n \202 uence postgraft immunosuppressive strategies. CMV serology at the time of grafting guides antiviral pro- phylactic strategies. Psychosocial issues A number of psychosocial variables can in \202 uence the transplant wo rk-up. If an adult has impaired capacity for consent, proxy arrangements need to be put in place. Another concern relates to issues around treatment adherence and concordance, or the use of illicit drugs. Some individuals can be identi \201 ed prior to listing in whom add itional support post procedure can minimize the risk of premature graft failure due to inab ility to comply with management. Other individuals may demonstrate such poor adherence to m edical management advice that placing them on the transplant waiting list would be inapprop riate. It is usual in these circumstances to seek views from several of the health professi onals involved in the patient \200\231s care as well as from the patient and immediate fami ly members. Human immunode \201 ciency virus HIV infection is not an absolute exclusion for transplant a- tion, with reports of graft and patient survival that are comparable to non-HIV infected recipients, but the work- up and postprocedure management are complex. Guidelines have bee n produced in conjunction with the British HIV Association and are available on the BTS web site. Hepatitis B Carriers of hepatitis B surface antigen may receive a renal transplant provided there is neither evidence of active viral replication nor evidence of chronic active hepat itis or cirrhosis. Patients with active viral replication are recommended to undergo liver biopsy to stage the disease and to receive antiviral treatment prior to transplantation. Pa tients with cirrhosis and active viral replication have a poor prognosis, and immunosuppres sive therapy in these subjects can lead to worsening of the liver disease. Patients should be monitored for the increased risk of hepatocellular carcinoma with yearly serum -fetopr otein estimations and/or liver USS. Pulmonary disease Pulmonary function tests should be performed if the history or examinatio n suggest chronic lung disease. All patients who smoke cigarettes should be advised to stop since smokers have a \201 ve-fold increased risk of pul- monary complications compared w ith those who do not smoke. Patients with bronchiectasis require careful assessment as they carry signi \201 cant risk of serious septic complications post transplantation. Hepatitis C Candidates who have antibodies to hepatitis C virus (HCV) should be tested for HCV RNA and also undergo liver biopsy, since there is only a weak relationship between vira l RNA load, conventional liver function tests and liver histology. Subjects with mild liver disease and active infection should be treated with pegylated interferon while still on di alysis. In the event that infection is not cleared, subjects may undergo renal transplantat ion, for even though viremia may increase with the immunosuppression, the survival of trans planted HCV-positive patients are improved com- pared to those remaining on dialysis. For s ubjects with advanced liver disease on biopsy a simul- taneous liver-kidney transplant may be considered. Re-evaluation of patients on the waiting list Following placement on the list, some patient s wait years before receiving the offer of a transplant. It is logical that a re-evaluation of suitability is undertaken at intervals, but there are no data to help decide how often this should be. In Canada guidelines have been proposed which are signi \201 - cantly more rigorous than those recommended for initial evaluation in this Chapter and would, if follo wed, have very signi \201 cant resource implications. Regular assessment of hepatitis and HIV viral status should be undertaken and will generally occur as a part of routine dialysi s care. Tuberculosis Tuberculosis may reactivate following transplantation. CHAPTER 14.1 Selection and preparation of the recipient 547 Table 14.1.2 Screening tests for occult infection. Newstead CG, Davis CL. Evaluation and preoperative management of kidney transplant recipien t and donor. In: Feehally J, Floege J, Johnson RJ. Comprehensive Clinical Nephrology, 3rd e dn. Amsterdam: Elsevier; 2007. p. 1056. Routine Serology Where Indicated, Tests for Other Routine Investigations Penn I. The effect of immunosuppression on pre-existing cancers. Urine culture Chest radiograph Human herpesvirus 8 HTLV Strongyloides stercoralis Malaria Trypanosoma cruzi Schistosomiasi s Hepatitis B virus Hepatitis C virus HIV Cytomegalovirus Epstein-Barr virus Transplantation 1993; 55: 742 \200\223747. Internet resources British Society of Histocompatibility: http://www.bshi.org.uk/ British Transplantation Society: HIV, human immunode \201 ciency virus; HTLV, human T cell lymphotropic virus http://www.bts.org.uk/ American Society of Transplantation: Re-evaluation for progression of asymptomatic ischemic heart disease and atherosclerotic di sease is the area most likely to be of bene \201 t. However, no bene \201 t of cardiac su rveillance following wait-listing was shown in one obser- vational study. Nevertheless, in the absence of symptoms it seems reasonable that cardiac re-evaluation be performed every 4 years in nondiabetics and every 2 years in diabetic trans- plant wait-listed candidates us ing similar work-ups as in the initial evaluation. http://www.a-s-t.org/ American Society of Transplant Surgeons: http://www.asts.org/ Index of clinical trials including those in transplantation: http://www.clinicaltrials.gov/ See also Assessment of live renal donors 548 Medical management of dialysis patients 528 Ps ychological aspects of treatment for renal failure 538 Further reading Berthoux F, Abramowicz D, Bradley B, et al. European best practice guidelin es for renal transplantation (Part 1). Nephrol Dial Transplant 2000; 15(Suppl 7). Kasiske BL, Cangro CB, Hariharan S, et al. The evaluation of renal transplant candidates: c linical practice guidelines. Am J Transplant 2001; 1(Suppl 2). C. NEWSTEAD 548 Assessment of live renal donors Introduction Recipients who receive a kidney from a live donor have on average better graft function and survival than those receiving a kidney from a cadaveric donor. In some countr ies receiving a live donor renal transplant is the only practical way of providing long-ter m treatment for ESRD. Live donor surgery is elective and easier to organize prior to starti ng dialysis than when the renal donor is a cadaver. Exchange schemes and strategies to over come recipient antibodies to allow previously \200\230incompatible \200\231 transplants me an that there are increased opportunities for individuals to donate to assist their relativ e. The advent of laparoscopic live donor nephrectomy has contributed to the acceptance of t he procedure as it is seen as less traumatic for the donor. The advantages to the recipient as well as the imbalance between the size of the waiting list and number of grafts perform ed have all contributed to a signi \201 cant increase in live donor retrieval. Living dono rs may be: \200 \200\230blood relatives \200\231; \200 not related (e.g. spouses); \200 altruistic; \200 part of an exchange scheme. An individual with known or occult myocardial dysfunction or coronary ischemia should not d onate. Absolute contraindications to donation also include symp- tomatic valvular disease a nd severe valvular disease even if this asymptomatic. Donor hypertension If elevated blood pressure is detected the following should be performed looking for end-organ damage: \200 \200 \200 \200 CXR; ECG; echocardiogram; ophthalmic examination. Donation from hypertensive individuals may be acceptable if: \200 \200 \200 \200 there is no evidence of end-organ damage; BP is subsequently controlled; GFR is normal; no proteinuria. Pulmonary disease Pulmonary function testing, echocardiogram and/or sleep studies should be performed, if indicated by the history and examination. Contraindications to donation incl ude chronic lung diseases that signi \201 cantly increase the anesthetic risk. In all case s, donors should cease smoking for \211 4 \200\2238 weeks before surgery to minimize the r isk of pneumonia. Practices vary from country to country. Following successful donation there is usually an i mproved relationship with the recipient and self-image. Donor obesity Obesity increases the risk of: \200 \200 \200 \200 perioperative complications; nephrolithiasis; renal cell cancer; ESRD. Risks of living donation The undoubted advantage for the recipient of receiving a kidney fr om a live donor is balanced by the morbidity of the procedure for the donor. The perioperat ive mortality risk is estimated at 1 in 3000. Most deaths are related to occult ischemic he art disease or pulmonary thromboembolism. Data from Scandinavia show an improved life expec tancy for individuals who have been live renal donors with less risk than the general popul ation of ESRD, but it is possible that this is falsely reassuring. Acceptance of donors wit h medical morbidity that in the past would have precluded donation, or donors from cer- tai n ethnic groups, may result in unexpected late morbidity that only long-term follow-up will reveal. An arbitrary limit beyond which donation is absolutely contraindicated is dif \201 cult to de \201 ne. In practice, other signi \201 cant comorbidity in the presence of marked obe sity usually rules out donation. Diabetes mellitus The following should undergo an oral glucose tolerance test: \200 \200 obese prospective donors; nonobese subjects with a first-degree relative with diabetes; don ors with a history of gestational diabetes. An abnormal glucose tolerance is a contraindication to donation. The medical assessment of the donor Medical evaluation of the living donor has been discuss ed at large consensus conferences with comprehensive guidelines available from several sour ces including the British Transplant Society (BTS) and UK Renal Association. An outline sch eme for donor evaluation is shown in Table 14.2.1. Renal function Use of an age-related threshold GFR is sensible so that a prospective donor \200\231s predicted GFR post nephrectomy at age 80 years should be \211 50 mL/min/1.73 m2. This age-related threshold has been adopted in BTS/Renal Association guidelines and is sho wn in Fig. 14.2.1. Cardiac disease If the history, physical examination or a resting ECG sug- gests cardiac is chemia or valvular disease then an exercise or pharmacologic stress test and/or echocardiog ram should be performed. Nephrolithiasis Patients with a history of bilateral or recurrent stones and those with sys temic conditions associated with recurrent stone disease should not donate. CHAPTER 14.2 Assessment of live renal donors 549 Table 14.2.1 Live donor evaluation checklist. CMV, cytomegalovirus; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunode \201 ciency virus; HSV, herpes simples virus. 160 140 Mean + 2SD ) 2 m 3 7 1 / n m 120 Live donor evaluation checklist . Mean GFR 100 i History (look for/ask about) Hypertension Diabetes Nonsteroidal anti-in \202 ammatory inhi bitors/medications/herbs Family history 86 ml/min/1.73 m2 / l 77 m 80 ( R F G 68 Mean \200\223 2SD 59 60 50 40 Intravenus drug abuse Infections 20 30 40 50 Age (years) 60 70 80 Vascular Vocation/avocation Willingness to donate Fig. 14.2.1 Minimum acceptable age-associated GFR in living donor candidates. Black solid l ine shows the variation with age of mean GFR. The outer dashed lines show the 2 populatio n standard deviation limits. GFR is constant up to the age of 40 years and then declines at the rate of 9 mL/min/1.73 m2 per decade. The gray line shows the safety limit of 86 mL/min /1.73 m2 for young adults declining to 50 mL/min/1.73 m2 at age 80 years. For transplant do nors with preoperative GFR values above the gray line the GFR of the remaining kidney will still be >37.5 mL/min/ 1.73 m2 at age 80 years. Physical Exam (evaluate/look for) Blood pressure Weight/height Arthritis Autoimmunity Cance r Prostate Breast Colorectal Lymph node Skin \200 chemical analysis of the stone if available; a helical CT scan of the kidneys. Malignancy A past history of the following malignancies precludes live kidney donation: \200 \200 \200 \200 \200 \200 \200 \200 Cardiovascular disease Laboratory Urinalysis Electrolytes, liver panel Fasting blood glucose and lipid pro \201 l e Complete blood count with platelets, coagulation screen 24-hour urine, creatinine clearan ce, protein excretion or glomerular \201 ltration rate measurement (iothalamate clearance ), and protein determination bronchial cancer; testicular cancer; renal cell carcinoma; choriocarcinoma; hematological m alignancy; breast cancer; melanoma; monoclonal gammopathy. Antiviral screening: HCV, HBV, HIV, EBV, CMV, HSV Puri \201 ed protein derivative test (PP D; controversial in nonendemic areas), rapid plasmin reagin tests A previous history of malignancy may not always preclude donation if the speci \201 c canc er is curable and the risk of transmission of the cancer thought to be acceptably low. A do nor with a successfully treated malignancy should only be accepted for donation if prior tr eatment did not decrease renal reserve or place the donor at increased risk for ESRD nor in crease the risk of nephrectomy. Electrocardiogram, chest radiograph PAP smear, prostate examination Age/family history dete rmined Exercise tolerance test, echocardiography Colonoscopy, ultrasonography Mammography/prostate -speci \201 c antigen Anatomic Evaluation per the Local Expertise Computed tomography angiography Magnetic resona nce imaging angiography Arteriography Uncontrolled Infections A living donor should not be accepted when: \200 \200 \200 there is a transmissible untreatable active infection; nephrotoxic treatment is required; t he donor is at risk of developing renal disease from either the infection or the treatment. Reproduced with permission from: Newstead and Davis (2007). The work-up for a prospective donor with a prior episode of nephrolithiasis should include: \200 \200 \200 \200 \200 \200 \200 \200 Venous thromboembolism Previous thromboembolism is a relative contraindication to live dona tion, and requires an assessment of the likeli- hood of recurrence. Oral contraceptives and hormone replacement therapy increase the risk for postoperative venous thrombosis and shou ld be withheld for at least 1 month prior to surgery. serum calcium; serum creatinine; serum albumin; serum parathyroid hormone; urinalysis; urin e culture; spot urine for cystine; 24 h urine for oxalate and creatinine; Renovascular disease Fibromuscular dysplasia where severe and diffuse pre- cludes donation. C. NEWSTEAD 550 Further reading Delmonico FL. A report of the Amsterdam forum on the care of the live kidne y donor: data and medical guidelines. Transplantation 2005; 79: S53 \200\22366. If present the donor must be normotensive, have normal renal function and have only unilate ral disease. Atherosclerotic renal vascular disease is a strong relative contraindication f or living donation. Careful investigation for occult coronary disease and peripheral vascul ar disease should be undertaken given their association with renal vascular disease. Fehrman-Ekholm I, Elinder CG, Stenbeck M, Tyden G, Groth CG. Kidney donors live longer. Transplantation 1997; 64: 976 \200\223978. Jordan JC, Sann U, Janton A, et al. Living kidney donors \200\231 long-term psychological s tatus and health behavior after nephrectomy \200\223 a retrospective study. J Nephrol 2004 ; 17: 728 \200\223735. Isolated hematuria Isolated hematuria in a prospective donor is a relatively common problem . The differential diagnosis includes: \200 \200 \200 \200 \200 \200 Koushik R, Garvey C, Manivel JC, Matas AJ, Kasiske BL. Persistent, asymptomatic, microscopi c hematuria in prospective kidney donors. Transplantation 2005; 80: 1425 \200\2231429. Newstead CG, Davis CL. Evaluation and preoperative management of kidney transplant recipien t and donor. In: Feehally J, Floege J, Johnson RJ (eds), Comprehensive clinical nephrology, 3rd edn. Amsterdam: Elsevier; 2007. p. 1056. thin basement membrane nephropathy; IgA nephropathy; other glomerulonephritis; urinary trac t infection; malignancy; nephrolithiasis. Internet resources British Transplantation Society: http://www.bts.org American Society of Transplantation: A diagnosis needs to be established in the usual way. Prospective donors with hematuria and thin basement membrane disease should only be considered when aged >50 years with a normal GFR. IgA nephropathy is a contraindication to live donation. Isolated mesangial IgA deposi tion without proteinuria or impaired GFR may be not be a contraindication to dona- tion. An y decision should be decided upon in the context of family history, GFR, the presence of in terstitial disease, and age. In a small numbers of caes despite full investigation no cause for isolated haematuria is found. Most units would accept such individuals for donation. http://www.a-s-t.org/ American Society of Transplant Surgeons: http://www.asts.org/ See also Selection and preparation of recipients, p. 544 This page intentionally left blank A. BARLOW AND M. NICHOLSON 552 Transplant surgery and surgical complications Introduction Renal transplantation is well-established as the best treatment for restoring quality and quantity of life to patients with ESRD. Although essentially comprising three a nastomoses, the surgery can be challenging, particularly in the case of obese patients and complex graft anatomy. The inherently poor premorbid state of the recipients and the need f or postoperative immunosuppression increases the risk of infection and bleeding. Although m ostly rare, clinicians should be aware of the potential immediate complications of renal tr ansplant surgery. A number require a high index of suspicion to identify and may result in graft loss if the diagnosis is delayed or missed. Easier control of major bleeding than LDN. Disadvantages \200 As for LDN. \200 Increased cost of consumables compared to LDN. Retroperitoneoscopic donor nephrectomy This technique involves approaching the kidney via t he retroperitoneal space. The dissection is performed via laparoscopic ports and the kidney removed through a small \202 ank incision. It can also be performed using a hand-assiste d technique. Advantages \200 \200 \200 As for LDN. Shorter operating times than LDN. The peritoneal cavity is not entered, reducin g the risk of bowel injury and adhesion formation compared to LDN. Living donor nephrectomy Over recent years, living donor renal transplantation has increasi ngly been used to offset the shortage of cadaveric kidneys. The safety of the procedure for the donor has been con \201 rmed, and the improved outcome for the recipient over cadaver ic grafts proven. However, controversy still remains about the optimal technique for removi ng the kidney. The options are as follows: \200 \200 Disadvantages \200 Technically challenging procedure with a steep learning curve. Increased warm ischemic time compared to MODN and ODN. Increased operating time compared to MODN and ODN. Smaller worki ng space than LDN. Total laparoscopic donor nephrectomy (LDN); Hand-assisted laparoscopic donor nephrectomy (H ALDN); Retroperitoneoscopic donor nephrectomy (RDN); Mini-incision open donor nephrectomy ( MODN); Open donor nephrectomy (ODN). \200 \200 Mini-incision open donor nephrectomy This is similar to the traditional open procedure, but is performed through a smaller \202 ank incision without rib resection. Total laparoscopic donor nephrectomy This involves dissection via 4 \200\2235 laparoscopic ports and removal of the kidney through a 6 cm Pfannansteil or lower midline incision. Advantages \200 \200 \200 Less painful than ODN. Better cosmesis than ODN. Shorter warm ischemic times than LDH, HALD N and RDN. Advantages \200 Reduced post-operative pain and analgesia requirements compared to MODN and ODN. Quicker re sumption of normal activities compared to MODN and ODN. Better cosmesis compared to MODN an d ODN (Fig. 14.3.1). Better post-operative respiratory function compared to MODN and ODN. Disadvantages \200 More painful and slower recovery than LDN, HALDN and RDN. Dif \201 cult access compared to ODN. May not be feasible in patients with higher BMI. \200 Disadvantages \200 Open donor nephrectomy This is performed through a \202 ank incision, with or without res ection of the 12th rib. The dissection is performed in the retroperitoneal space. Technically challenging procedure with a steep learning curve. Increased warm ischemic time compared to MODN and ODN. Increased operating time compared to MODN and ODN. Potentially i ncreased risk of bowel injury and intra- abdominal adhesions compared to retroperitoneal ap proaches. Advantages \200 \200 \200 \200 Least technically demanding of the various approaches. Allows easier control of major bleed ing. No breach of the peritoneal cavity. Shortest warm ischemic time. Disadvantages \200 Hand-assisted laparoscopic donor nephrectomy This is similar to LDN, but one port is a hand port, allowing placement of a hand within the peritoneal cavity. This allows tactile feedb ack and manual assistance with retraction and control of bleeding. More post-operative pain and analgesia requirements than other techniques. Slower return to normal activities than other techniques. Risk of signi \201 cant wound bulge due to paral ysis of \202 ank muscles. \200 Advantages \200 \200 As for LDN. Shorter learning curve than LDN. CHAPTER 14.3 Transplant surgery and surgical complications 553 Fig. 14.3.1 Comparison of incisions for open donor nephrectomy and total laparoscopic donor nephrectomy. If \202 uid is removed, the patient should be maintained above their target weight to fac ilitate adequate postoperative \202 uid \201 lling. Consideration should be made of the likelihood of primary graft function, as this may affect the decision to dialyse. Immunosu ppression is commonly commenced preopera- tively, usually in the form of an IL-2 receptor a ntibody. Complications Regardless of the surgical approach there are a number of potential complicat ions of donor nephrectomy that clinicians should be aware of. These include: \200 major post-operative bleeding, usually from the renal vessel stumps; deep vein thrombosis a nd/or pulmonary embolism; renal impairment; atelectasis and/or pneumonia. \200 \200 Incision An oblique or curvilinear incision is made from above the symphysis pubis towards the anterior superior iliac spine. The decision concerning which groin is used varies betwe en transplant centers. Arguments for the choice of groin are: \200 Post-operative management is tailored to reduce the risk of these complications and include s: \200 low molecular weight heparin; \200 IV \202 uid to maintain urine output >50 m L/h; \200 close monitoring of FBC and renal function; \200 early mobilization. a left kidney is placed in the right groin and vise versa as this places the renal pelvis a nd ureter anteriorly and facilitates the ureteric anastomosis; all kidneys are placed in th e right groin as the right iliac vessels are more accessible and convenient for anasto- mos is than the left. Follow-up Donors should be seen 4 \200\2236 weeks post-surgery for wound review and assessm ent of blood pressure and proteinuria. Some centers also repeat an isotope GFR at this stag e, but this is not mandatory. All being well, follow-up should then be on a yearly basis. T his should include measurement of blood pressure, renal func- tion and urine dipstick, part icularly looking for proteinuria. In the patient with a previous failed transplant in situ, the kidney is placed in the contr alateral groin. The muscles of the anterior abdominal wall are divided and the retroperiton eal space developed to expose the iliac vessels. Long-term sequelae Following the initial decline in GFR, the rate of loss of renal function in kidney donors is no faster than expected with normal aging. Overall, the risk of ESRD i s 0.2 \200\223-0.5%. Kidney donation does result in a small increase in urinary protein ex cretion secondary to hyperfiltration in the remaining kidney. There is an increased risk of hypertension, with a mean increase of 5 mmHg compared with control groups. The overall ris k of long-term mortality among kidney donors is infact lower than the predicted age- and se x-matched mortality. Vascular anastomoses Renal vein The renal vein is anastomosed end-to-side to the external i liac vein. If the renal vein is short this anastomosis may be facilitated by dividing the i nternal iliac vein, increasing the mobility of the external iliac vein Renal artery