Deceased and living donor renal allograft recovery
- Ron Shapiro, MD
Ron Shapiro, MD
- Professor of Surgery
- Surgical Director, Kidney/Pancreas Transplant Program
- Mount Sinai Hospital - Recanati Miller Transplantation Institute
Until totally implantable bioartificial or laboratory-grown kidneys become available, transplant surgeons must retrieve kidneys from deceased or living donors. An enormous part of the success of renal transplantation is predicated on the technically perfect recovery of the kidney [1-3]. The technical aspects of deceased- and living-donor renal allograft recovery will be discussed here.
Most of the time, a number of different organs will be recovered from a single deceased donor, potentially including the heart, lungs, liver, pancreas, kidneys, and intestine [4,5]. The kidneys can be reliably predicted to be the last organs to be removed.
Technique — The deceased donor will have been given heparin and possibly phentolamine (to promote vasodilatation) prior to aortic cross clamping. Donor pretreatment with dopamine may decrease the requirement for dialysis after kidney transplantation . In a randomized, prospective study, for example, the administration of low-dose dopamine (4 mcg/kg per minute) for a median period of 344 minutes resulted in a decreased need for multiple dialyses posttransplant (25 versus 35 percent, 95% CI 0.35-0.83) . Thus, with respect to donor management, a low threshold should exist to initiate low-dose dopamine early in the donor transplant management.
Via a cannula placed in the distal aorta, the kidneys are kept cold by an in-situ flush with an intracellular type of preservation solution. In the United States, the most popular is the University of Wisconsin (UW; Viaspan) solution; however, there has been an increase over the past several years in the utilization of histidine-tryptophan-ketoglutarate (HTK) solution as an alternative. There is some evidence that the HTK and UW solutions provide similar patient and allograft survival rates . The kidneys are usually not seen or mobilized prior to aortic cross clamping as such manipulation can adversely affect the liver.
Once the thoracic and upper abdominal organs have been removed, the right colon and distal small bowel are mobilized medially and superiorly, and the right kidney is exposed. The right kidney is then mobilized medially, with Gerota's fascia, from the retroperitoneum. The left colon is then mobilized medially and superiorly, and the lower splanchnic nerves are divided. The left kidney, again with Gerota's fascia, is mobilized medially.
- Asolati M, Matas AJ. Risks versus benefits of living kidney donation. Curr Opin Organ Transplant 2003; 8:155.
- Wood KE, Becker BN, McCartney JG, et al. Care of the potential organ donor. N Engl J Med 2004; 351:2730.
- Humar A, Matas AJ. Surgical complications after kidney transplantation. Semin Dial 2005; 18:505.
- Shapiro R, Simmons RL. Renal transplantation. In: Atlas of Organ Transplantation, Starzl TE, Shapiro R, Simmons RL (Eds), Gower Medical Publishing, New York 1992.
- Scantlebury V. Cadaveric and living donation. In: Renal Transplantation, Shapiro R, Simmons R, Starzl TE (Eds), Appleton & Lange, 1997.
- Schnuelle P, Gottmann U, Hoeger S, et al. Effects of donor pretreatment with dopamine on graft function after kidney transplantation: a randomized controlled trial. JAMA 2009; 302:1067.
- Lynch RJ, Kubus J, Chenault RH, et al. Comparison of histidine-tryptophan-ketoglutarate and University of Wisconsin preservation in renal transplantation. Am J Transplant 2008; 8:567.
- Moers C, Smits JM, Maathuis MH, et al. Machine perfusion or cold storage in deceased-donor kidney transplantation. N Engl J Med 2009; 360:7.
- Moers C, Pirenne J, Paul A, et al. Machine perfusion or cold storage in deceased-donor kidney transplantation. N Engl J Med 2012; 366:770.
- O'Callaghan JM, Morgan RD, Knight SR, Morris PJ. Systematic review and meta-analysis of hypothermic machine perfusion versus static cold storage of kidney allografts on transplant outcomes. Br J Surg 2013; 100:991.
- Gill J, Dong J, Eng M, et al. Pulsatile perfusion reduces the risk of delayed graft function in deceased donor kidney transplants, irrespective of donor type and cold ischemic time. Transplantation 2014; 97:668.
- Niemann CU, Feiner J, Swain S, et al. Therapeutic Hypothermia in Deceased Organ Donors and Kidney-Graft Function. N Engl J Med 2015; 373:405.
- Jochmans I, Watson CJ. Taking the Heat Out of Organ Donation. N Engl J Med 2015; 373:477.
- Yanaga K, Podesta LG, Broznick B, et al. Multiple organ recovery for transplantation. In: Atlas of Organ Transplantation, Starzl TE, Shapiro R, Simmons RL (Eds), Gower Medical Publishing, New York 1992.
- Ratner LE, Kavoussi LR, Sroka M, et al. Laparoscopic assisted live donor nephrectomy--a comparison with the open approach. Transplantation 1997; 63:229.
- Flowers JL, Jacobs S, Cho E, et al. Comparison of open and laparoscopic live donor nephrectomy. Ann Surg 1997; 226:483.
- Philosophe B, Kuo PC, Schweitzer EJ, et al. Laparoscopic versus open donor nephrectomy: comparing ureteral complications in the recipients and improving the laparoscopic technique. Transplantation 1999; 68:497.
- Chan DY, Fabrizio MD, Ratner LE, Kavoussi LR. Complications of laparoscopic live donor nephrectomy: the first 175 cases. Transplant Proc 2000; 32:778.
- Ratner LE, Buell JF, Kuo PC. Laparoscopic donor nephrectomy: pro. Transplantation 2000; 70:1544.
- Buell JF, Abreu SC, Hanaway MJ, et al. Right donor nephrectomy: a comparison of hand-assisted transperitoneal and retroperitoneal laparoscopic approaches. Transplantation 2004; 77:521.