Kidney Transplantation

  • Mohammad Ayaz Hossain
  • Radhika Chadha
  • Atul Bagul
  • Reza MotallebzadehEmail author
Part of the In Clinical Practice book series (ICP)


Renal transplantation remains the optimal treatment for end stage renal disease. Compared with dialysis, it is associated with increased patient survival and better quality of life, and is cost effective. Kidney transplantation requires a multi-disciplinary approach in the pre-operative assessment and work-up of donors and recipients, and subsequent post-operative care. The classical surgical procedure for renal transplantation has changed little from the original pelvic operation originally described in 1951, but the surgical complexity however has been magnified by the increasing age of recipients, frequently with other comorbidities, and impetus to utilise kidneys from extended criteria donors, either as single or dual transplants. There have also been tremendous advances in the technical aspects of live-donation. This chapter details the surgical aspects of kidney donation and transplantation, including preparation of the graft, vessel reconstruction, urinary drainage and identification and management of post-donation and transplantation complications. It is hoped the reader is provided with a comprehensive account of the technical aspects of renal transplantation, with a description of variation in procedure based on anatomical aberrations. An overview of current practise with a look to the future is provided.


Renal artery anastomosis Venous anastomosis Ureteric implantation techniques Implantation Carrel patch Update 


  1. 1.
    Klein AA, Lewis CJ, Madsen JC. Organ transplantation; a clinical guide: Cambridge University Press; 2011.Google Scholar
  2. 2.
    Libby P, Pober JS. Chronic rejection. Immunity. 2001;14(4):387–97.PubMedCrossRefGoogle Scholar
  3. 3.
    Pascual M, Theruvath T, Kawai T, Tolkoff-Rubin N, Cosimi AB. Strategies to improve long-term outcomes after renal transplantation. N Engl J Med. 2002;346(8):580–90.PubMedCrossRefGoogle Scholar
  4. 4.
    Heaphy EL, Poggio ED, Flechner SM, Goldfarb DA, Askar M, Fatica R, et al. Risk factors for retransplant kidney recipients: relisting and outcomes from patients’ primary transplant. Am J Transplant. 2014;14(6):1356–67.PubMedCrossRefGoogle Scholar
  5. 5.
    Nankivell BJ, Borrows RJ, Fung CL, O’Connell PJ, Allen RD, Chapman JR. The natural history of chronic allograft nephropathy. N Engl J Med. 2003;349(24):2326–33.PubMedCrossRefGoogle Scholar
  6. 6.
    Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, et al. Risk of end-stage renal disease following live kidney donation. JAMA. 2014;311(6):579–86.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Mjoen G, Hallan S, Hartmann A, Foss A, Midtvedt K, Oyen O, et al. Long-term risks for kidney donors. Kidney Int. 2014;86(1):162–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Matas AJ, Wadstrom J, Ibrahim HN. Kidney donation and risk of ESRD. JAMA. 2014;312(1):92–3.PubMedCrossRefGoogle Scholar
  9. 9.
    Heimbach JK, Taler SJ, Prieto M, Cosio FG, Textor SC, Kudva YC, et al. Obesity in living kidney donors: clinical characteristics and outcomes in the era of laparoscopic donor nephrectomy. Am J Transplant. 2005;5(5):1057–64.PubMedCrossRefGoogle Scholar
  10. 10.
    Kalantar-Zadeh K, Kopple JD. Body mass index and risk for end-stage renal disease. Ann Intern Med. 2006;144(9):701; author reply 701–2.CrossRefGoogle Scholar
  11. 11.
    Vivante A, Golan E, Tzur D, Leiba A, Tirosh A, Skorecki K, et al. Body mass index in 1.2 million adolescents and risk for end-stage renal disease. Arch Intern Med. 2012;172(21):1644–50.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Yang A, Barman N, Chin E, Herron D, Arvelakis A, LaPointe Rudow D, et al. Robotic-assisted vs. laparoscopic donor nephrectomy: a retrospective comparison of perioperative course and postoperative outcome after 1 year. J Robot Surg. 2018;12(2):343–50.PubMedCrossRefGoogle Scholar
  13. 13.
    Minnee RC, Bemelman WA, Maartense S, Bemelman FJ, Gouma DJ, Idu MM. Left or right kidney in hand-assisted donor nephrectomy? A randomized controlled trial. Transplantation. 2008;85(2):203–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Hsu TH, Su L, Ratner LE, Trock BJ, Kavoussi LR. Impact of renal artery multiplicity on outcomes of renal donors and recipients in laparoscopic donor nephrectomy. Urology. 2003;61(2):323–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Saidi R, Kawai T, Kennealey P, Tsouflas G, Elias N, Hertl M, et al. Living donor kidney transplantation with multiple arteries: recent increase in modern era of laparoscopic donor nephrectomy. Arch Surg. 2009;144(5):472–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Gerstenkorn C, Papalois VE, Thomusch O, Maxwell AP, Hakim N. Surgical management of multiple donor veins in renal transplantation. Int Surg. 2006;91(6):345–7.PubMedGoogle Scholar
  17. 17.
    Tran MH, Foster CE, Kalantar-Zadeh K, Ichii H. Kidney transplantation in obese patients. World J Transplant. 2016;6(1):135–43.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Rahul Koushik BK. Chapter 16: kidney transplantation-the recipient: Mc Graw Hill Medical; 2008.Google Scholar
  19. 19.
    Ratner LE, Ciseck LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR. Laparoscopic live donor nephrectomy. Transplantation. 1995;60(9):1047–9.PubMedGoogle Scholar
  20. 20.
    Giessing M. Laparoscopic living-donor nephrectomy. Nephrology Dialysis Transplant 2004;19:36–40.CrossRefGoogle Scholar
  21. 21.
    Kokkinos C, Nanidis T, Antcliffe D, Darzi AW, Tekkis P, Papalois V. Comparison of laparoscopic versus hand-assisted live donor nephrectomy. Transplantation. 2007;83(1):41–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Nanidis TG, Antcliffe D, Kokkinos C, Borysiewicz CA, Darzi AW, Tekkis PP, et al. Laparoscopic versus open live donor nephrectomy in renal transplantation: a meta-analysis. Ann Surg. 2008;247(1):58–70.PubMedCrossRefGoogle Scholar
  23. 23.
    Horgan S, Vanuno D, Sileri P, Cicalese L, Benedetti E. Robotic-assisted laparoscopic donor nephrectomy for kidney transplantation. Transplantation. 2002;73(9):1474–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Giacomoni A, Di Sandro S, Lauterio A, Concone G, Buscemi V, Rossetti O, et al. Robotic nephrectomy for living donation: surgical technique and literature systematic review. Am J Surg. 2016;211(6):1135–42.PubMedCrossRefGoogle Scholar
  25. 25.
    Segev DL, Muzaale AD, Caffo BS, Mehta SH, Singer AL, Taranto SE, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA. 2010;303(10):959–66.PubMedCrossRefGoogle Scholar
  26. 26.
    Patel S, Cassuto J, Orloff M, Tsoulfas G, Zand M, Kashyap R, et al. Minimizing morbidity of organ donation: analysis of factors for perioperative complications after living-donor nephrectomy in the United States. Transplantation. 2008;85(4):561–5.PubMedCrossRefGoogle Scholar
  27. 27.
    Mjoen G, Oyen O, Holdaas H, Midtvedt K, Line PD. Morbidity and mortality in 1022 consecutive living donor nephrectomies: benefits of a living donor registry. Transplantation. 2009;88(11):1273–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Hadjianastassiou VG, Johnson RJ, Rudge CJ, Mamode N. 2509 living donor nephrectomies, morbidity and mortality, including the UK introduction of laparoscopic donor surgery. Am J Transplant. 2007;7(11):2532–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H, et al. Long-term consequences of kidney donation. N Engl J Med. 2009;360(5):459–69.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Clemens KK, Thiessen-Philbrook H, Parikh CR, Yang RC, Karley ML, Boudville N, et al. Psychosocial health of living kidney donors: a systematic review. Am J Transplant. 2006;6(12):2965–77.PubMedCrossRefGoogle Scholar
  31. 31.
    Smith GC, Trauer T, Kerr PG, Chadban SJ. Prospective psychosocial monitoring of living kidney donors using the short Form-36 health survey: results at 12 months. Transplantation. 2004;78(9):1384–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Andersen MH, Mathisen L, Veenstra M, Oyen O, Edwin B, Digernes R, et al. Quality of life after randomization to laparoscopic versus open living donor nephrectomy: long-term follow-up. Transplantation. 2007;84(1):64–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Perry KT, Freedland SJ, Hu JC, Phelan MW, Kristo B, Gritsch AH, et al. Quality of life, pain and return to normal activities following laparoscopic donor nephrectomy versus open mini-incision donor nephrectomy. J Urol. 2003;169(6):2018–21.PubMedCrossRefGoogle Scholar
  34. 34.
    Buell JF, Lee L, Martin JE, Dake NA, Cavanaugh TM, Hanaway MJ, et al. Laparoscopic donor nephrectomy vs. open live donor nephrectomy: a quality of life and functional study. Clin Transpl. 2005;19(1):102–9.CrossRefGoogle Scholar
  35. 35.
    Nicholson ML, Elwell R, Kaushik M, Bagul A, Hosgood SA. Health-related quality of life after living donor nephrectomy: a randomized controlled trial of laparoscopic versus open nephrectomy. Transplantation. 2011;91(4):457–61.PubMedGoogle Scholar
  36. 36.
    Morris PJ. Transplantation–a medical miracle of the 20th century. N Engl J Med. 2004;23(351(26)):2.Google Scholar
  37. 37.
    Cassini MF, de Andrade MF, Tucci S. Surgical Complications of Renal Transplantation.Google Scholar
  38. 38.
    Gittes RF, Waters WB. Sexual impotence: the overlooked complication of a second renal transplant. J Urol. 1979;121(6):719–20.PubMedCrossRefGoogle Scholar
  39. 39.
    Nanni G, Tondolo V, Citterio F, Romagnoli J, Borgetti M, Boldrini G, et al. Comparison of oblique versus hockey-stick surgical incision for kidney transplantation. Transplant Proc. 2005;37(6):2479–81.PubMedCrossRefGoogle Scholar
  40. 40.
    Khan T. Post kidney transplant lymphoceles: meticulous ligation of lymphatics reduces incidence. 2011.Google Scholar
  41. 41.
    Baston CHM, Preda A, Gener I, Manea I, Voinea S, et al. Comparative urologic complications of ureteroneocystostomy in kidney transplantation: transvesical Leadbetter-Politano versus extravesical lich-Gregoir technique. Transplant Proc. 2014;46(1):3.CrossRefGoogle Scholar
  42. 42.
    Zilinska ZCM, Trebaticky B, Breza J, Slobodnik L, Breza J, et al. Vascular complications after renal transplantation. Bratisl Lekárske Listy. 2010;111(11):3.Google Scholar
  43. 43.
    Mangus RSHB. Stented versus nonstented extravesical ureteroneocystostomy in renal transplantation: a metaanalysis. Am J Transplant. 2004;4(11):7.CrossRefGoogle Scholar
  44. 44.
    MT. BB. Modified extravesical ureteroneocystostomy in cadaveric kidney transplantation with completely duplicated ureters: a case report. J Transplant Technol Res. 2014;04(2).Google Scholar
  45. 45.
    NHSBT. Taking organ transplantation to 2020. In: England N, editor. Bristol: NHSBT; 2018.Google Scholar
  46. 46.
    Aubert O, Kamar N, Vernerey D, Viglietti D, Martinez F, Duong-Van-Huyen JP, et al. Long term outcomes of transplantation using kidneys from expanded criteria donors: prospective, population based cohort study. BMJ. 2015;351:h3557.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Lucarelli G, Bettocchi C, Battaglia M, Impedovo SV, Vavallo A, Grandaliano G, et al. Extended criteria donor kidney transplantation: comparative outcome analysis between single versus double kidney transplantation at 5 years. Transplant Proc. 2010;42(4):1104–7.PubMedCrossRefGoogle Scholar
  48. 48.
    Remuzzi G, Grinyo J, Ruggenenti P, Beatini M, Cole EH, Milford EL, et al. Early experience with dual kidney transplantation in adults using expanded donor criteria. Double kidney transplant group (DKG). J Am Soc Nephrol. 1999;10(12):2591–8.PubMedGoogle Scholar
  49. 49.
    Remuzzi G, Ruggenenti P. Renal transplantation: single or dual for donors aging > or =60 years? Transplantation. 2000;69(10):2000–1.PubMedCrossRefGoogle Scholar
  50. 50.
    Schaffer M, Schier R, Napirei M, Michalski S, Traska T, Viebahn R. Sirolimus impairs wound healing. Langenbeck’s Arch Surg. 2007;392(3):297–303.CrossRefGoogle Scholar
  51. 51.
    Kobayashi KCM, Rossman LL, Kyriakides PN, Kahan BD, Cohen AM. Interventional radiologic management of renal transplant dysfunction: indications, limitations, and technical considerations. Radiographics. 2007;27(4).PubMedCrossRefGoogle Scholar
  52. 52.
    Ghazanfar ATA, Augustine T, Pararajasingam R, Riad H, Chalmers N. Management of transplant renal artery stenosis and its impact on long-term allograft survival: a single-Centre experience. Nephrol Dial Transplant. 2011;26(1):7.CrossRefGoogle Scholar
  53. 53.
    Voiculescu ASM, Hollenbeck M, Braasch S, Luther B, Sandmann W, Jung G, Mödder U, Grabensee B. Management of arterial stenosis affecting kidney graft perfusion: a single-centre study in 53 patients. Am J Transplant. 2005;5(7):7.CrossRefGoogle Scholar
  54. 54.
    Leertouwer TCGE, Bosch JL, van Jaarsveld BC, van Dijk LC, Deinum J, Man In ’t Veld AJ. Stent placement for renal arterial stenosis: where do we stand? A meta-analysis. Radiology. 2000;216(1):7.CrossRefGoogle Scholar
  55. 55.
    Baig MA, Khan T, Mousa D. Post transplant ureteric stenosis causing allograft hydronephrosis and calyceal rupture: salvage side to side ureteroneocystostomy. Saudi J Kidney Dis Transpl. 2010;21(3):504–6.PubMedGoogle Scholar
  56. 56.
    Keller H, Noldge G, Wilms H, Kirste G. Incidence, diagnosis, and treatment of ureteric stenosis in 1298 renal transplant patients. Transpl Int. 1994;7(4):253–7.PubMedCrossRefGoogle Scholar
  57. 57.
    Golriz M, Klauss M, Zeier M, Mehrabi A. Prevention and management of lymphocele formation following kidney transplantation. Transplant Rev (Orlando). 2017;31(2):100–5.CrossRefGoogle Scholar
  58. 58.
    Lucewicz A, Wong G, Lam VW, Hawthorne WJ, Allen R, Craig JC, et al. Management of primary symptomatic lymphocele after kidney transplantation: a systematic review. Transplantation. 2011;92(6):663–73.PubMedCrossRefGoogle Scholar
  59. 59.
    Wagenaar S, Nederhoed JH, Hoksbergen AWJ, Bonjer HJ, Wisselink W, van Ramshorst GH. Minimally invasive, laparoscopic, and robotic-assisted techniques versus open techniques for kidney transplant recipients: a systematic review. Eur Urol. 2017;72(2):205–17.PubMedCrossRefGoogle Scholar
  60. 60.
    Hosgood SA, Yang B, Bagul A, Mohamed IH, Nicholson ML. A comparison of hypothermic machine perfusion versus static cold storage in an experimental model of renal ischemia reperfusion injury. Transplantation. 2010;89(7):830–7.PubMedCrossRefGoogle Scholar
  61. 61.
    Jochmans I, O’Callaghan JM, Pirenne J, Ploeg RJ. Hypothermic machine perfusion of kidneys retrieved from standard and high-risk donors. Transplant international: official journal of the European society for. Organ Transplantation. 2015;28(6):665–76.Google Scholar
  62. 62.
    Hosgood SA, Barlow AD, Hunter JP, Nicholson ML. Ex vivo normothermic perfusion for quality assessment of marginal donor kidney transplants. Br J Surg. 2015;102(11):1433–40.PubMedCrossRefGoogle Scholar
  63. 63.
    Chadha R, Hossain MA, Bagul A. Optimising organs for transplantation: is normothermic machine perfusion the answer? Expert Rev Med Devices. 2016;13(3):221–3.PubMedCrossRefGoogle Scholar
  64. 64.
    Doizi S, Kamphuis G, Giusti G, Palmero JL, Patterson JM, Proietti S, Straub M, De La Rosette J, Traxer O. First clinical evaluation of a new single-use flexible cystoscope dedicated to double-J stent removal (Isiris™): a European prospective multicenter study. World J Urol. 2017;35(8):1269–75.PubMedCrossRefGoogle Scholar
  65. 65.
    Rassweiler MC, Michel MS, Ritter M, Honeck P. Magnetic ureteral stent removal without cystoscopy: a randomized controlled trial. J Endourol. 2017;31(8):762–6.PubMedCrossRefGoogle Scholar
  66. 66.
    Mallon DH, Riddiough GE, Summers DM, Butler AJ, Callaghan CJ, Bradbury LL, Bardsley V, Broecker V, Saeb-Parsy K, Torpey N, Bradley JA, Pettigrew GJ. Successful transplantation of kidneys from elderly circulatory death donors by using microscopic and macroscopic characteristics to guide single or dual implantation. Am J Transplant. 2015;15(11):2931–9.PubMedCrossRefGoogle Scholar
  67. 67.
    Ekser B, Furian L, Broggiato A, Silvestre C, Pierobon ES, Baldan N, Rigotti P. Technical aspects of unilateral dual kidney transplantation from expanded criteria donors: experience of 100 patients. Am J Transplant. 2010;10(9):2000–7.PubMedCrossRefGoogle Scholar
  68. 68.
    Ayorinde JO, Summers DM, Pankhurst L, Laing E, Deary AJ, Hemming K, Wilson ECF, Bardsley V, Neil DA, Pettigrew GJ. PreImplantation Trial of Histopathology In renal Allografts (PITHIA): a stepped-wedge cluster randomised controlled trial protocol. BMJ Open. 2019;9(1):e026166.PubMedPubMedCentralCrossRefGoogle Scholar
  69. 69.
    Snanoudj R, Timsit MO, Rabant M, Tinel C, Lazareth H, Lamhaut L, Martinez F, Legendre C. Dual kidney transplantation: is it worth it? Transplantation. 2017;101(3):488–97.PubMedCrossRefGoogle Scholar
  70. 70.
    van den Berg TAJ, Minnee RC, Nieuwenhuijs-Moeke GJ, Bakker SJL, Pol RA. The effect of perioperative antiplatelet/anticoagulant therapy on the incidence of early postoperative thromboembolic complications and bleeding in kidney transplantation. - a dual center retrospective cohort study of 2000 kidney transplant recipients. Transplantation. 2018;102:S186.CrossRefGoogle Scholar
  71. 71.
    Eng M, Brock G, Li X, Chen Y, Ravindra KV, Buell JF, Marvin MR. Perioperative anticoagulation and antiplatelet therapy in renal transplant: is there an increase in bleeding complication? Clin Transpl. 2011;25(2):292–6.PubMedCrossRefGoogle Scholar
  72. 72.
    Breda A, Territo A, Gausa L, Tuğcu V, Alcaraz A, Musquera M, Decaestecker K, Desender L, Stockle M, Janssen M, Fornara P, Mohammed N, Siena G, Serni S, Guirado L, Facundo C, Doumerc N. Robot-assisted kidney transplantation: the European experience. Eur Urol. 2018;73(2):273–81.PubMedCrossRefGoogle Scholar
  73. 73.
    Sood A, Ghosh P, Menon M, Jeong W, Bhandari M, Ahlawat R. Robotic renal transplantation: current status. J Minim Access Surg. 2015;11(1):35.PubMedPubMedCentralCrossRefGoogle Scholar
  74. 74.
    Peng P, Ding Z, He Y, Zhang J, Wang X, Yang Z. Hypothermic machine perfusion versus static cold storage in deceased donor kidney transplantation: a systematic review and meta-analysis of randomized controlled trials. Artif Organs. 2018;43(5):478–89.PubMedCrossRefGoogle Scholar
  75. 75.
    Hosgood SA, Saeb-Parsy K, Wilson C, Callaghan C, Collett D, Nicholson ML. Protocol of a randomised controlled, open-label trial of ex vivo normothermic perfusion versus static cold storage in donation after circulatory death renal transplantation. BMJ Open. 2017;7(1):e012237.PubMedPubMedCentralCrossRefGoogle Scholar
  76. 76.
    Bahmani B, Uehara M, Jiang L, Ordikhani F, Banouni N, Ichimura T, Solhjou Z, Furtmüller GJ, Brandacher G, Alvarez D, von Andrian UH, Uchimura K, Xu Q, Vohra I, Yilmam OA, Haik Y, Azzi J, Kasinath V, Bromberg JS, McGrath MM, Abdi R. Targeted delivery of immune therapeutics to lymph nodes prolongs cardiac allograft survival. J Clin Investig. 2018;128(11):4770–86.PubMedCrossRefGoogle Scholar
  77. 77.
    Hosgood SA, Thompson E, Moore T, Wilson CH, Nicholson ML. Normothermic machine perfusion for the assessment and transplantation of declined human kidneys from donation after circulatory death donors. Br J Surg. 2018;105(4):388–94.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Mohammad Ayaz Hossain
    • 1
  • Radhika Chadha
    • 2
  • Atul Bagul
    • 3
  • Reza Motallebzadeh
    • 1
    • 4
    Email author
  1. 1.Department of Nephrology and TransplantationRoyal Free HospitalLondonUK
  2. 2.Department of Academic SurgeryOxford University HospitalOxfordUK
  3. 3.Department of Renal TransplantationLeicester General HospitalLeicesterUK
  4. 4.Division of Surgery and Interventional Sciences; Centre for Transplantation, Department of Renal Medicine; and Institute of Immunity and TransplantationUniversity College LondonLondonUK

Personalised recommendations