immunology allergic disorders
Kidney Transplantation
Procedure
Thedonor kidneyis removed during a standard or robotic-assisted laparoscopic (or rarely, an open) procedure, perfused with cooling solutions containing relatively large concentrations of poorly permeating substances (eg,mannitol,hetastarch) and electrolyte concentrations approximating intracellular levels, then stored in an iced solution. Kidneys preserved this way usually function well if transplanted within 24 hours. Although not commonly used, continuous pulsatile hypothermic perfusion with an oxygenated, plasma-based perfusate can extend ex vivo viability up to 48 hours. Forrecipients,dialysis may be required before transplantation to ensure a relatively normal metabolic state, but living-donor allografts appear to survive slightly better in recipients who have not begun long-term dialysis before transplantation. Recipient nephrectomy is usually not required unless native kidneys are infected. Whether transfusions are useful for patients who have anemia and are anticipating an allograft is unclear; the leading evidence suggests that transfusions can sensitize patients to alloantigens and thus should typically be avoided if possible. However, allografts may survive better in recipients who receive transfusions but do not become sensitized, possibly because transfusions induce some form of tolerance. The transplanted kidney is usually placed in the iliac fossa. Renal vessels are anastomosed to the iliac vessels, and the donor ureter is implanted into the bladder or anastomosed to the recipient ureter. Vesicoureteral reflux occurs in about 30% of recipients, but usually without adverse effects. vary (see table Immunosuppressants Used to Treat Transplant Rejection ). An induction agent (eg, 