General
Kidney transplantation:
Indication for a kidney transplantation and graft survival:
The most common cause of end-stage renal disease is diabetic nephropathy followed by hypertensive nephroangiosclerosis and various primary and secondary glomerulopathies. All patients with chronic renal failure should be considered for kidney transplantation. Patient survival one year after transplantation from a living-related donor is 95% and comparably high if the organ comes from a cadaveric donor. Graft survival ranges between 70-90% at 3-5 years.
Newly developed immunosuppressive drugs and immunologic monitoring have led to the expansion of recipient age from 5 months up to 75 years.
Donor selection and preservation:
Up to approximately 1/3 of kidney organs are realized from living, genetically (un-)related donors, possessing bilateral renal function, tissue histocompatibility and do not have other systemic diseases. Over 2/3 of kidney allocrafts are from cadaveric donors, excluding donors with vascular diseases, diabetes and malignancies. After established brain death, donors are kept in stable cardiovascular conditions and normal renal function. The kidneys are removed, flushed, cooled by perfusion and preserved in special iced solutions for transport. Kidneys have a maximum preservation time of about 30 hours. Successful transplantation after 30 hours can be achieved by using an ex-vivo continuous perfusion system based on oxygenated hypothermic plasma perfusate.
Transplant procedure:
The transplant procedure is a relative simple operation, taking approximately two hours. The patient has to be hemodialyzed and free of any infection. The kidney is transplanted retroperitoneally in the iliac fossa, vascular anastomosis connected to arteria and vena iliaca and the ureter is implanted in the bladder.
Complications:
The major complication after transplantation is rejection of the organ. For kidney transplantation most rejection episodes arise in the first 4 month after transplantation. In spite of primary immunosuppressive therapy, patients can suffer from multiple acute rejection episodes. Irreversible chronic graft rejection is envolved continuously and spans over several years. If treatment does not reverse the rejection, the recipient has to return to hemodialysis and wait for another chance. Other later complications are drug intoxicity especially nephrotoxicity of cyclosporine, infection, kidney related diseases and the incidence of malignancies. The risk of epithelial carcinoma and lymphoma rises to 30 times higher than normal population. Aggressive tumors and lymphomas are treated by reduction or interruption of the current immunosuppressive therapy.
