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Kidney transplantation is performed to prolong and improve the lives of those with end-stage renal disease. Open and laparoscopic surgery are the two approaches for both procurement and transplantation. The main surgical indication is end-stage renal disease. This activity reviews the evaluation and treatment of end-stage renal disease and highlights the role of the interprofessional team in evaluating and treating this condition. Objectives: Describe the epidemiology of kidney transplantation. Review the evaluation of kidney transplantation. Outline the management options available for end-stage renal disease. Summarize some interprofessional team strategies that can be employed to ensure optimal outcomes for patients who need kidney transplantation. Access free multiple choice questions on this topic.

Kidney transplantation is often the preferred treatment for those with end-stage renal disease.[1] The discipline of kidney transplantation has grown tremendously over the past 50 years.  Patients with end-stage renal disease have better long-term survival if they are placed on the waiting list and eventually undergo kidney transplantation than those who stay on dialysis.[2] Furthermore, those who undergo transplantation often experience a better quality of life and a projected survival benefit of 10 years over those who remain on dialysis.[2] Since kidney transplantation was first successfully performed by Dr. Joseph Murray in 1954, there have been major developments in transplantation and immunology, allowing for a wider selection of acceptable donors and recipients.

Hemorrhage – As with any vascular surgery, hemorrhage is always possible, both on-the-table and in the early postoperative period. Classical signs of bleeding may not be seen. Patients may not demonstrate classical tachycardia in response to hypovolemia as they are often on beta-blockers. Additionally, they can be hypertensive rather than hypotensive as a result of parenchymal compression. They often will complain of new-onset acute flank pain, and there may be a palpable mass or bulge near the incision. High clinical suspicion should be maintained and may warrant a return to the operating room. It’s important to remember that bleeding may be tamponaded by the kidney’s compartmentalized space in the retroperitoneum, an effect that would not be expected following intra-peritoneal placement of the allograft. Thrombosis – Renal vein thrombosis is fortunately rare but is associated with a high risk of graft loss. This phenomenon may manifest in the early postoperative period with new-onset hematuria, sudden-onset oliguria/anuria, and/or graft dysfunction. Arterial thrombosis is rarer still but is often equally devastating and may manifest similarly in the recipient. Ultrasound is often diagnostic and should be ordered in the event of a precipitous decline in UOP in a previously functioning allograft. High suspicion for vascular complications should be maintained in the early postoperative period due to technical errors and/or clamp injury. Infection – Infections are common as patients are placed on immunosuppression immediately postoperatively. They are most heavily immune-suppressed in the first 3-6 months post-operatively, putting them at heightened risk of infection during that window. Conventional nosocomial and bacterial infections are seen most commonly in the first month post-transplant and include UTIs and surgical site infections (SSI). High suspicion must be maintained for unconventional or opportunistic pathogens, particularly in the months that follow. Commonly tested viral pathogens include cytomegalovirus, Epstein-Barr virus, and polyomavirus (BK-type). Patients are often placed on prophylactic antivirals and antibiotics to decrease the risk of infection in the first 3-6 months – most commonly Bactrim for PCP, Valcyte for CMV, as well as some form of anti-fungal coverage.

Infection – Infections are common as patients are placed on immunosuppression immediately postoperatively. They are most heavily immune-suppressed in the first 3-6 months post-operatively, putting them at heightened risk of infection during that window. Conventional nosocomial and bacterial infections are seen most commonly in the first month post-transplant and include UTIs and surgical site infections (SSI). High suspicion must be maintained for unconventional or opportunistic pathogens, particularly in the months that follow. Commonly tested viral pathogens include cytomegalovirus, Epstein-Barr virus, and polyomavirus (BK-type). Patients are often placed on prophylactic antivirals and antibiotics to decrease the risk of infection in the first 3-6 months – most commonly Bactrim for PCP, Valcyte for CMV, as well as some form of anti-fungal coverage. Arterial Stenosis – This is a late complication and is often asymptomatic. Its discovery is often prompted by ultrasound examination in the setting of diminished graft function (elevated serum creatinine). Angiography is both diagnostic and therapeutic, and transluminal angioplasty may be attempted. Lymphocele – This complication occurs due to the disruption of associated lymphatics during the exposure of the iliac vessels. Careful ligation of lymphatic tissue should thus be performed where possible during this dissection.  Patients may present with pain and bulging overlying the transplanted kidney. Alternatively, the collection can become infected or cause graft compression and diminished function. The treatment for symptomatic lymphoceles is percutaneous drainage. Drain aspirate should also be checked for fluid creatinine to rule out a urine leak.  Persistent lymphocele may be surgically treated with peritoneal window drainage.

Lymphocele – This complication occurs due to the disruption of associated lymphatics during the exposure of the iliac vessels. Careful ligation of lymphatic tissue should thus be performed where possible during this dissection.  Patients may present with pain and bulging overlying the transplanted kidney. Alternatively, the collection can become infected or cause graft compression and diminished function. The treatment for symptomatic lymphoceles is percutaneous drainage. Drain aspirate should also be checked for fluid creatinine to rule out a urine leak.  Persistent lymphocele may be surgically treated with peritoneal window drainage. Urinoma – Usually occurs within the first week of transplantation. Like lymphocele, patients may present with pain and swelling at the incision, compromised graft function as a result of compression, or infection. An elevated creatinine level typically confirms the diagnosis in the fluid aspirate. Many centers preemptively place a ureteral stent at the time of anastomosis to guard against this complication as well as the delayed complication of ureteral stenosis. In the event of a urine leak, bladder decompression with Foley catheter placement is typically all that is needed. However, surgical intervention and revision of the ureteroneocystostomy may be necessary.

Transplant is a multidisciplinary practice. Their nephrologists and hepatologists initially see the patients before referral to a transplant surgeon. Once a referral is made, and the patient is placed on a transplant list, there are many more steps before an organ is allocated. When an organ becomes available, the transplant coordinators help with matching and allocating. The patient is then admitted for surgery, which involves the surgeons, anesthesiologists, operating room technicians, and afterward, the intensive care unit doctors, nurses, pharmacists, and social workers. This large team of healthcare professionals, each specialized in their field, working together, and communicating effectively is the only way transplantation is a reality.