Kidney Transplant II: Surgical Procedure

Preoperative management optimizes the recipient's metabolic state through diet adjustments, necessary dialysis, and tailored medical treatment. Both donor and recipient undergo comprehensive evaluations including blood typing, tissue typing, and antibody screening for compatibility. Infection screening and patient education about the surgical procedure and postoperative care are also essential to improve outcomes and adherence.

Psychosocial assessments identify coping mechanisms, social support, financial readiness, and psychiatric history in recipients, since immunosuppressive therapy including corticosteroids can worsen pre-existing mental health conditions. For donors, these evaluations confirm informed consent, autonomy, and psychological readiness, ensuring they are well-prepared and free from coercion before surgery.

Laparoscopic nephrectomy is minimally invasive and reduces blood loss, postoperative pain, recovery time, and hospital stay for living donors. In rare cases, an open nephrectomy may be required, necessitating a lateral positioning and an incision near the eleventh rib for optimal kidney access. The kidney is carefully removed, flushed with chilled sterile electrolyte solution, and prepared for transplantation.

The donated kidney is placed extraperitoneally in the iliac fossa, typically on the right side, to facilitate surgical access. The donor's renal artery and vein are anastomosed to the recipient's internal or external iliac artery and external iliac vein. The ureter is connected to the recipient's bladder using ureteroneocystostomy, where it is tunneled into the bladder submucosa to minimize infection risk.

Acute rejection arises within three to fourteen days post-transplant and may manifest as elevated serum creatinine, fever, tenderness, malaise, and oliguria. It is managed with prompt immunosuppressive therapy, including agents such as tacrolimus, corticosteroids, or belatacept. Hyperacute rejection occurs within 24 hours due to immediate antibody-mediated response and often requires kidney removal.

Prophylactic medications such as H2-blockers like famotidine or proton pump inhibitors like omeprazole are prescribed to prevent gastrointestinal complications associated with corticosteroid use. Since immunosuppressive regimens heighten infection risk, prophylactic antifungal therapy may be administered when clinically indicated to prevent gastrointestinal and urinary tract fungal infections.

Once blood flow is restored, the transplanted kidney should regain a healthy pink color and firm texture. The kidney often begins producing urine almost immediately, indicating successful revascularization and early graft function. The entire transplant procedure typically lasts between three and four hours, with rapid revascularization essential to minimize ischemic injury.