PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
World J Urol. Author manuscript; available in PMC 2010 December 8.
Published in final edited form as:
World J Urol. 1988 August; 6(2): 136–139.
doi:  10.1007/BF00326630
PMCID: PMC2999361
NIHMSID: NIHMS241498

Future aspects of renal transplantation*

Summary

New and exciting advances in renal transplantation are continuously being made, and the horizons for organ transplantation are bright and open. This article reviews only a few of the newer advances that will allow renal transplantation to become even more widespread and successful. The important and exciting implications for extrarenal organ transplantation are immediately evident.

Renal transplantation has excited both physicians and patients for more than 30 years. The role of transplantation in the treatment of renal failure was not firmly established until the early 1960s, after the introduction of the immunosuppressive agents azathioprine and prednisone [17] and, somewhat later, antilymphocyte globulin (ALG) preparations [18]. With the advent of cyclosporine in the late 1970s and early 1980s [2], renal transplantation expanded greatly. At present, 1-year patient survivals of > 90% and graft survivals of 80% for cadaveric allografts are not uncommon [14]. However, even with these improved results, some patients lose their grafts to rejection. Ideally, the goal is complete patient and graft survival with a very low incidence of morbidity. Many of the concerns of the early 1960s remain: donor organ preservation, immunosuppression, rejection, sensitization, infection, and issues related to organ supply and distribution. These problems are discussed, and some of the more recent developments and their implications for the clinical renal transplant surgeon are pointed out.

Organ preservation

Donor organ preservation has recently benefited from a major new advance. Historically, cold storage with relatively high osmotic preservation fluids (Le., modified Collin’s solution) has been the generally accepted mode of preservation [4]. The ultimate renal function of organs kept in this manner was as good as that of organs preserved with pulsatile perfusion storage, without the cost or inconvenience required for the latter [4]. The incidence of delayed graft function, primary non function, and graft failure increases exponentially with the duration of cold storage [21]. Belzer’s group at the University of Wisconsin (UW) has achieved a quantum improvement in static cold preservation of the kidneys and, especially, of the liver and pancreas (Table 1) [1]. The addition of lactobionate and hydroxyethyl starch has been shown to control intracellular fluid and electrolyte shifts in the donor organ [1]. The solution appears to stabilize cell membranes during cold storage and at the time of reperfusion [1]. The results of these authors in canine renal transplants suggest that cold storage for up to 5 days is possible [1].

Table 1
Composition of the UW cold-storage solution

Preservation injury is thought to have two components. The first is produced by ischemia, with which cellular energy reserves decay to the point that synthetic functions required for cellular integrity are no longer adequate. The second component of preservation injury is thought to occur during reperfusion, when the blood supply to the donor organ is reestablished. Evidence suggests that this type of injury is produced by oxygen free radicals [11]. These radicals are generated by the breakdown of ATP by xanthine oxidase during the initial promptly and prior to irreversible ischemic renal damage [9]. In such cases, the kidney is removed, flushed, and preserved extracorporeally with surface hypothermia while associated abdominal injuries are repaired. Following extracorporeal renal reconstruction, when the patient’s condition has stabilized, autotransplantation into the iliac fossa is then carried out in the usual fashion. Although such cases are uncommon and require early operative intervention for attempted renal salvage, it is appropriate to include them among the listed indications for renal autotransplantation.

Footnotes

*Supported by Research Grants from the Veterans Administration and Project Grant No. AM 29961 from the National Institutes of Health, Bethesda, Maryland.

References

1. Adib K, Belzer FO. Renal autotransplantation in dissecting aortic aneurysm with renal artery involvement. Surgery. 1978;84:686–688. [PubMed]
2. Altebarmakin VK, Rabinowitz R, Linke C, Caldemone AA, Cockett ATK. Surgical treatment of renal vascular hypertension in children: the role of renal autotransplantation. J Urol. 1980;124:877–881. [PubMed]
3. Bodie B, Novick AC, Rose M, Straffon RA. Long-term results with renal autotransplantation for ureteral replacement. J Urol. 1986;136:1187–1189. [PubMed]
4. Boxer RJ, Fritzche P, Skinner DG, Kaufmann JJ, et al. Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients. J Urol. 1978;121:728–731. [PubMed]
5. Calne RY. Tumor in a single kidney; nephrectomy, excision and autotransplantation. Lancet. 1971;I:761–774. [PubMed]
6. Dean RH, Meacham PW, Weaver FA. Ex vivo renal artery reconstruction: indication and techniques. J Vasc Surg. 1986;4:546–552. [PubMed]
7. Dubernard JM, Martin X, Geleta A, Mongin D, Canton F, Tabib A. Renal autotransplantation vs bypass techniques for renal vascular hypertension. Surgery. 1985;97:529–534. [PubMed]
8. Dubernard JM, Martin X, Mongin D, Geleta A, Canton F. Extracorporeal replacement of the renal artery: techniques, indications and long-term results. J Urol. 1985;133:13–16. [PubMed]
9. Guttman RM, Homsy Y, Schmidt E. Avulsion injury to the renal pedicle: successful autotransplantation after bench surgery. J Trauma. 1978;18:469–471. [PubMed]
10. Hardy JD. High ureteral injuries: management by autotransplantation of the kidney. JAMA. 1963;184:97–101. [PubMed]
11. Hutchinson SMW, Doig A, Jenkins AM. Recurrence of loin pain hematuria syndrome after renal autotransplantation. Lancet. 1987:1501–1502. [PubMed]
12. Jordan ML, Novick AC, Cunningham RL. The role of renal autotransplantation in pediatrics and young adult patients with renal artery disease. J Vasc Surg. 1985;2:385–392. [PubMed]
13. Kaufman JJ. The middle aortic syndrome: report of a case treated by renal autotransplantation. J Urol. 1973;109:711–715. [PubMed]
14. Kent KC, Salvatierra O, Reilly L, Ehrenfeld WK, Goldstone J, Stoney RJ. Evolving strategies for the repair of complex renal vascular lesions. Ann Surg. 1987;206:272–278. [PubMed]
15. Kyriakides GK, Najarian JS. Renal vascular hypertension in childhood: successful treatment by renal autotransplantation. Surgery. 1979;85:611–616. [PubMed]
16. Little PJ, Sloper JS, deWardener HE. A syndrome of loin pain and hematuria associated with disease of peripheral renal arteries. Q J Med. 1967;36:253–259. [PubMed]
17. Munda R, Mendoza N, Alexander JW. Renal autotransplantation for retroperitoneal fibrosis. Arch Surg. 1982;117:1615. [PubMed]
18. Novick AC. Management of intrarenal branch arterial lesions with extracorporeal microvascular reconstruction and autotransplantation. J Urol. 1981;126:150–154. [PubMed]
19. Novick AC. Use of inferior epigastric artery for extracorporeal microvascular branch renal artery reconstruction. Surgery. 1981;89:513–517. [PubMed]
20. Novick AC. Microvascular reconstruction of complex branch renal artery disease. Urol Clin North Am. 1984;11:465. [PubMed]
21. Novick AC. Surgical management of branch renal artery disease: Value of in situ and extracorporeal technique. Nephron. (Suppl 1) 1986;44:40–43. [PubMed]
22. Novick AC. Partial nephrectomy for renal cell carcinoma. Urol Clin North Am. 1987;14:419–433. [PubMed]
23. Novick AC, Banowsky LHW, Stewart BH, Straffon RA. Renal revascularization in patients with severe artherosclerosis of the abdominal aorta or previous operation on the abdominal aorta. Surg Gynecol Obstet. 1977;144:211–218. [PubMed]
24. Novick AC, Straffon RA, Stewart BH. Surgical management of branch renal artery disease: in sito vs extracorporeal methods of repair. J Urol. 1980;123:311–316. [PubMed]
25. Novick AC, Stewart BH, Straffon RA. Extracorporeal renal surgery and autotransplantation: indications, techniques and results. J Urol. 1980;123:806–811. [PubMed]
26. Novick AC, Straffon RA, Stewart BH. Experience with extracorporeal renal operations and autotransplantation in the management of complicated urologic disorders. Surg Gynecol Obstet. 1981;153:10–18. [PubMed]
27. Novick AC, Streem SB, Montie JE, Straffon RA, Pontes JE, Siegel S, Montague DK, Goormastic M. Conservative surgery for renal cell carcinoma: a single-center experience with 100 patients. J Urol. in press. [PubMed]
28. Olsson CA, Idelson B. Renal autotransplantation for recurrent renal colic. J Urol. 1980;123:467–474. [PubMed]
29. Palleschi J, McAninch JW. Renal autotransplantation for retroperitoneal fibrosis. J Urol. 1981;125:408–411. [PubMed]
30. Peters PC, Sagalowski AI. Genitorurinary trauma. In: Walsh PC, Gittes RF, Perlmutter AD, Stanley TA, editors. Campbell’s urology. 5th edn. vol 1. Philadelphia: Saunders; 1986. p. 1192.
31. Pettersson S, Brywnger H, Henriksson C, Johansson S, Nilson A, Ranch T. Treatment of urothelial tumors of the upper urinary tract by nephroureterectomy, renal autotransplantation and pyelocystostomy. Cancer. 1984;54:379–386. [PubMed]
32. Rose MC, Novick AC, Rybka SJ. Renal autotransplantation in patients with retroperitoneal fibrosis. Cleve Clin Q. 1984;51:357–363. [PubMed]
33. Sheil AGR, Thomas MAB, Ibels LS, Graham JC. Renal autotransplantation for severe loin pain hematuria syndrome. Lancet. 1985:1501–1502. [PubMed]
34. Sheil AGR, Ibels LS, Pollock C, Graham JC, Short J. Treatment of loin pain hematuria syndrome by renal autotransplantation. Lancet. 1987:907–908. [PubMed]
35. Salvatierra O, Olcott C, Stoney RJ. Ex vivo renal artery reconstruction using perfusion preservation. J Urol. 1978;119:16–19. [PubMed]
36. SelJi C, Masini GC, Carini M, Turini D. Ureteral motility after renal autotransplantation. Eur Urol. 1982;8:11–13. [PubMed]
37. Stanley JC. Renal vascular disease in renovascular hypertension in children. Urol Clin North Am. 1984;11:451–463. [PubMed]
38. Stewart BH, Hewitt CB, Banowsky LHW. Management of extensively destroyed ureter: special reference to renal autotransplantation. J Urol. 1976;115:257–263. [PubMed]
39. Whitsell JC, Goldsmith EI, Nakamura H. Renal autotransplantation without ureteral division: an experimental study and case report. J Urol. 1970;103:577–582. [PubMed]