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donor kidney transplants have higher survival rates (11- 1 5 years) than

the cadaveric transplant (7-8 years).' The higher success rate of the

recipients of living donor transplants can be attributed to the

following7•23:

• The renal allograft from a living donor can be more thoroughly

evaluated before transplantation than the cadaveric allograft. This

results in closer genetic matches between the donor and recipient.

• There is a lower chance of damage to the donor organ during

preservation and transport.

• The incidence of acute tubular necrosis (ATN) in the postOperative period is 30-40% when a cadaveric donor is used but is infrequent with a living donor.

• Recipients of living donor transplants require less immunosuppressive medications and may have less risk of subsequent infection or malignancy.

• Living donor transplanr recipients undergo transplamation as

an elective procedure and may be healthier when they receive their

transplant.

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AClITE CARE HANDBOOK FOR PHYSICAL TI-IE.RAPISTS

Renal Transplant Procedure

The renal allograft is not placed in the same location as the native kidney. It is placed extra peritOneally in the iliac fossa through an oblique lower abdominal incision.'4.25 The renal artery and vein of the donated

kidney are attached to the iliac artery and vein of the recipient. The ureter of the donated kidney is sutured to the bladder. The recipient's native kidney is not removed unless it is a source of infection or uncontrolled hypertension. The residual function may be helpful if the transplant fails and the recipient requires hemodialysis.25,2.

The advantages of renal allograft placement in the iliac fossa versus placement in the correct anaromic position include the following27:

• A decrease in the posroperative pain, because the peritoneal cavity is not entered

• Easier access to the graft postoperatively for biopsy or any reoperative procedure

• Ease of palpation and auscultation of the superficial kidney to

help diagnose postoperative complications

• The facilitation of vascular and ureteral anastomoses, because it

is close to blood vessels and the bladder

Indication of Renal

Post Trmlsplallt

RestOration of renal function is characrerized by immediate production

of urine, massive diuresis, and declining levels of BUN and serum creatinine. Excellent renal function is characterized by a urine output of 800-1,000 ml per hourY However, there is a 20-30% chance that the

kidney will nOt function immediately, and dialysis will be required for

the first few weeks.2S Dialysis is discontinued once urine output

increases and serum creatinine and BUN begin to normalize. With rime,

normal kidney function is restOred, and the dependence on dialysis and

the dietary restrictions associated with diabetes are eliminared.2S

Postoperative Care and Complications

Volume status is strictly assessed. Intake and output records arc precisely recorded. Daily weights should be measured at the same time

ORGAN TRANSPLANTATION

711

using the same scale. When urine volumes are extremely high, intravenous fluids may be titrated. Other volume assessment parameters include inspection of neck veins for distention, skin turgor and

mucous membranes for dehydration, and extremities for edema. Auscultation of the chest is performed to determine the presence of adventitious breath sounds, such as crackles, which indicate the presence of excess volume.'2

The most common signs of rejection specific to the kidney are an

increase in BUN and serum creatinine, decrease in urine Output,

increase in blood pressure, weight gain greater than 1 kg in a 24-hour

period, and ankle edema.7.12.25 A percutaneous renal biopsy under

ultrasound guidance is the most definitive test for acute rejection.25

Sometimes, ATN occurs post transplantation. Twenty percent to 30%

of patients receiving cadaveric kidneys preserved for longer than 24

hours experience delayed graft function.25 This ischemic damage from

prolonged preservation results in ATN. The delayed kidney function

may last from a few days to 3 weeks. Therefore, dialysis is required

until the kidney starts to function7

Ureteral obstruction may occur owing to compression of the ureter

by a fluid collection or by blockage from a blood clot in the ureter. The

obstruction can cause hydronephrosis (dilation of the renal pelvis and

calyces with urine), which can be seen by ultrasound.25 The placement

of a nephrostomy tube or surgery may be required to repair the obstruction and prevent irreversible damage to the allograftH

Urine leaks may occur at the level of the bladder, ureter, or renal

calyx. They usually occur within the first few days of transplantation.25