Critical Care in Kidney Transplantation

Almost 30 years have passed since the first serious attempts at cadaveric renal transplantation, which is now a common occurrence. Bv 1984. more than 60.000 renal transplants ha~ been pertormed. Although the surgical technique is now standardized. methods of immunosuppression have continued to change from body irradiation in the beginning (1,2). to 6-mercaptopurine (3). then azathioprine alone (4) or together with steroids (5), and finally cydosporine (6) as a single agent (7) or in combination with steroids (8-11). Polyclonal and. recently. monoclonal antilymphocyte antibodies have been used to supplement, conventional therapy for treatment of severe acute rejection (12-14). Increased awareness within the medical profession and among the general public of the improved graft survival being o~ined with current methods of immunosuppression has mcreased the number of patients with end-stage renal ,disease seeking transplantation. Although organ donation has also mcreased. supply continues to fall short of need. F~h~rmore. there is an ever-increasing pool of patients With high levels of preformed cytotoxic antibody for. whom it is difficult to firld a suitable organ donor. This. more than any other factor today, determines whether or not-an organ transplant can be performed on an individual in a reasonable amount of time. The technical aspects of kidney transplant surgerY are such that the procedure can be safely performed by any well-trained surgeon. However, organ procurement surgery, particularly the ever more frequent multiple organ procurement. remains an area in which insufficient training, outdated technique. and inflexible personal habits can jeopardize the quality of renal allografts and, at the same time, the viability of other retrievable organs. Given the current demand for and success of extrarenal transplantations, every organ donor today must be considered for multiple organ donation and every transplant surgeon is obligated to become familiar with the requirements of successful multiple organ procurement. Similarly. nurses and physicians working in rcus must be alert to the possibility of organ donation and skilled in the care of the multiple organ donor. Surgical techniques have been developed for early in situ cooling and en bloc removal of the kidneys with minimal dissection in the brain-dead cadaver donor. These methods allow the safe removal of extrarenal organs without compromising the quality of the renal allografts (15-17).