117 - Renal Transplant Complications

disease). Transplantation is recognized as the most effective form of renal replacement therapy for these patients. Specific disease entities that causing chronic kidney disease are outlined in Box 117.1. Diabetic nephropathy is the most common single disease process leading to renal transplantation. Most renal grafts now function for longer than 10 years. The 1-year survival rate of renal transplant recipients is 95% to 98%. Renal transplants are more effective than hemodialysis at prolonging the life of patients with chronic kidney disease. Previously, the highest surgical success rates were achieved with histologically matched donor kidneys from a living re cipient. Advances in immunosuppressive medication regimens have improved the success rate of cadaveric kidney transplantation, which now approaches that seen with living donors. Preoperative clearance for renal transplantation is extensive. For patients with cancer, the suggested disease-free interval before transplantation is 5 years. Infection with human immunodeficiency virus is considered a contraindication to renal transplantation in many institutions, although transplantation has been successful in many patients with wellmaintained CD4 T-cell counts. Cholecystectomy was previously performed in all patients undergoing renal transplantation. Currently, cholecystectomy is performed only in patients with evidence of cholelithiasis or cholecystitis. The surgical approach to renal transplantation varies with the age of the patient, as well as with the location of the kidney and the anastomosis. The recipient’s native kidneys and collecting system are generally left in place unless there is another indication for nephrectomy. The donor kidney is placed in one of the lower abdominal quadrants (more commonly the right), and the ureter is anastomosed to the bladder; arterial and venous anastomoses generally arise from the iliac vessels, aorta, or inferior vena cava. The transplanted kidney is usually palpable on abdominal examination. Immunosuppression is initiated after transplantation and is divided into two phases: induction and maintenance. Agents such as tacrolimus and monoclonal and polyclonal antibodies are often included in the induction and maintenance phases of treatment (Box 117.2). With the use of immunosuppressive medications, the 1-year incidence of acute rejection is 15% to 25%.