With the patient under general anesthesia, the surgeon makes a curvilinear incision in the right or left lower quadrant, extending from the symphysis pubis to the anterior superior iliac spine and up to just below the thoracic cage. He exposes the iliac fossa with a self-retaining retractor, then performs segmental separation, ligature, and division of perivascular tissue. Next, he clamps the iliac vein and artery in preparation for anastomosis to the donor kidney’s renal vein and artery.

Meanwhile, the donor kidney is prepared for transplantation. If a cadaver kidney is being used, it’s removed from cold storage or a perfusion preparation machine. Kidneys can be stored for 72 hours, although most transplantations are done within 48 hours.

If the kidney is from a living donor, it’s harvested in an adjacent operating room via nephrectomy and placed in cold lactated Ringer’s solution. Before transplantation, the donor kidney’s renal artery is flushed with cold heparinized lactated Ringer’s solution to prevent clogging. Then, the surgeon positions the kidney in a sling over the implantation site.

The surgeon then implants the kidney in the retroperitoneal area of the iliac fossa, where it’s protected by the hip bone. If a donor’s left kidney is being used, the surgeon implants it in the recipient’s right side; conversely, he implants a donor’s right kidney in the recipient’s left side. Doing so permits the renal pelvis to rest anteriorly and allows the new kidney’s ureter to rest in front of the iliac artery, where the ureter is more accessible.

When the kidney is in place, the surgeon anastomoses its renal vein to the recipient’s iliac vein and the renal artery to the recipient’s internal iliac artery. (See Understanding kidney transplant.) He then removes the venous and arterial clamps and checks for patency of the anastomoses. Next, he attaches the donor kidney’s ureter to the recipient’s bladder, taking care to ensure a watertight closure. When the transplantation is complete, the surgeon sutures the incision and sends the patient to the recovery room.

The major impediment to transplantation is rejection of the donated organ. However, careful tissue matching between donor and recipient decreases this risk. (See Managing transplant rejection, page 508.)

Kidney transplantation may also be associated with vascular complications—such as stenosis of the renal artery, vascular

leakage, and thrombosis at the surgical site—or genitourinary tract complications—such as ureteral leakage, ureteral fistula, ureteral obstruction, calculus formation, bladder neck contracture, scrotal swelling, and graft rupture. Cardiovascular complications include hypertension, arrhythmias, heart failure, and increased plasma erythropoietin level. Respiratory complications include pneumonia, pulmonary edema, pulmonary emboli, and reactivated tuberculosis. Hepatitis B, cirrhosis (associated with azathioprine therapy), peptic ulcers, and increased histamine levels can occur. Other potential complications include infection, hematomas, abscesses, lymphoceles, steroid-induced diabetes mellitus, osteoporosis, myopathy, aseptic bone necrosis, cataracts, glaucoma, and retinitis.