This tab covers the donor and recipient operations, early post-transplant complications (urinary and lymphatic leaks, vascular thrombosis, and rejection), allograft nephrectomy, and post-transplant fertility.
Transplant Operation
- Donation — most laparoscopic donor nephrectomies are left-sided (the longer left renal vein eases implantation). Mobilise the ureter only to the iliac-vessel crossing, leaving the gonadal vein and artery to the donor. Hem-o-lok clips are contraindicated on the aortic side of the donor renal artery (associated with living-donor deaths).
- Allograft preparation — ligate renal-vein branches (e.g. the left adrenal vein) and peri-hilar fatty/lymphatic tissue (to prevent lymphocele). The best preservation fluid is University of Wisconsin (UW) solution, and early graft function correlates directly with cold ischemia time.
- Recipient operation — the kidney is placed extraperitoneally in the iliac fossa (minimising ileus, keeping the ureter medial), anastomosed to the external iliac vessels. Keep CVP at 10–15 cmH₂O and MAP >80 mmHg, and avoid the genitofemoral nerve lateral to the external iliac artery. The venous anastomosis is done first (to limit leg ischemia), an IV furosemide + mannitol bolus is given before reperfusion, and urinary continuity is restored by an antireflux ureteroneocystostomy with a routine stent (which reduces ureteral complications).
Post-Transplant Care
The best predictor of immediate graft function after living-donor transplant is the donor kidney's urine output just before nephrectomy. The catheter is usually removed on POD3. Early complications include infection, bleeding, urinary leak, lymphocele, vascular thrombosis, and rejection.
- Urinary leak — presents with falling catheter output and rising drain output; replace the catheter immediately if it was already removed. Most heal with the stent and catheter drainage; non-healing leaks need a nephrostomy or open repair.
- Lymphocele — arises from the graft or peri-iliac lymphatics (reduced by a closed-suction drain removed when output is <50 mL/day). Large ones cause pain, infection, or graft compression; manage by a stepwise ladder of image-guided aspiration → closed-suction drain → sclerosant → peritoneal window.
- Vascular thrombosis — renal-artery thrombosis (within 3 days; from a hypercoagulable state or delayed graft function) presents with sudden cessation of urine output and no flow on Doppler; renal-vein thrombosis follows hypercoagulability, kinking/stenosis, rejection, or hypotension. For both, emergent thrombectomy/thrombolysis is attempted but rarely successful.
- Elevated resistive index (normal RI = 0.60–0.70) has many causes (mnemonic ARVOCAD): renal Artery stenosis, Rejection, renal Vein thrombosis, ureteric Obstruction, perinephric Collection, ATN, and Drug toxicity.
- Rejection:
- Hyperacute (humoral) — minutes after reperfusion; recipient cytotoxic antibodies and complement attack donor endothelium → thrombosis. Now rare thanks to sensitive crossmatching.
- Acute — classically ~5 days post-transplant (without immunosuppression); rising creatinine and falling urine output, with needle biopsy the diagnostic standard.
- Chronic — gradual decline with interstitial fibrosis, arteriolar sclerosis, and tubular atrophy that rarely improve with more immunosuppression.
Allograft Nephrectomy and Fertility
Allograft nephrectomy is technically challenging and reserved for specific situations; removing a graft that fails within the first year can lower anti-HLA antibodies and ease re-transplantation. Fertility usually recovers after successful transplant — FSH, LH, and testosterone normalise and spermatogenesis improves in men (with no increase in offspring abnormalities, though impregnation should be delayed ≥1 year), and fertility is restored in premenopausal women. Haemorrhagic cystitis in an immunosuppressed patient is most often due to adenovirus.