The Transplant Operation

The contract between this chapter and the reader.

1. 1. Describe the placement and anastomoses of the transplant operation.
2. 2. Explain cold and warm ischemia times and their importance.
3. 3. Describe reperfusion and the on-table assessment.
4. 4. Manage immediate post-operative hemodynamics and perfusion.
5. 5. Interpret early urine output and replace fluids appropriately.
6. 6. Monitor early graft function, including Doppler ultrasound.
7. 7. Anticipate the early vascular and urologic complications.
8. 8. Assess the early non-functioning graft.

A sixty-second reading. Each bullet stands alone.

• The graft is placed heterotopically in the iliac fossa, extraperitoneally, with the native kidneys usually left in place.
• The donor renal artery and vein are anastomosed to the recipient iliac vessels, and the ureter to the bladder, usually over a stent.
• Cold ischemia time is minimised because a longer time increases delayed graft function.
• On reperfusion a healthy graft pinks up and often makes urine on the table.
• Immediate management maintains perfusion — adequate volume and blood pressure — because the graft depends on flow.
• Brisk early diuresis is a good sign; oliguria suggests delayed graft function or a complication.
• High early urine output is replaced to avoid hypovolemia, with attention to potassium and glucose.
• Graft function is monitored by a falling creatinine and by Doppler ultrasound of perfusion.
• A bladder catheter protects the ureteric anastomosis, and the ureteric stent is removed weeks later.
• Induction and maintenance immunosuppression are started peri-operatively.
• Early vascular complications include arterial or venous thrombosis and bleeding.
• Early urologic complications include urine leak and obstruction.
• Sudden anuria with graft pain suggests vascular thrombosis — a surgical emergency.

The medical core. An expert should agree the transplant operation and immediate course are fully covered here.

Why it matters at the bedside

The transplant operation is brief and standardised, but the hours after it decide a great deal. A graft that is well perfused and making urine on the table is off to the best possible start; one that is hypoperfused, thrombosing, or leaking needs to be recognised in minutes, not days. The early course is mostly about protecting flow and reading the signals.

The operation

• The kidney is placed heterotopically — not where the native kidneys sit, but in the iliac fossa, extraperitoneally — and the native kidneys are usually left in place. The donor renal artery is anastomosed to a recipient iliac artery, the donor renal vein to the external iliac vein, and the donor ureter is implanted into the bladder, usually over a temporary ureteric stent and with an antireflux tunnel.

Ischemia times

• Two clocks matter. Cold ischemia time runs from cold perfusion and storage to implantation, and a longer cold time increases the risk of delayed graft function — so it is kept as short as possible. Warm ischemia includes the anastomosis time on the bench and, in DCD donors, the warm period around circulatory death. Living-donor kidneys, with minimal cold time, typically function immediately.

Reperfusion and the on-table assessment

• When the clamps come off and blood enters the graft, a healthy kidney pinks up promptly, regains turgor, and often produces urine on the table — the best early sign. Poor or patchy reperfusion prompts an immediate check of the anastomoses and inflow before the patient leaves theatre.

Immediate hemodynamics and perfusion

• The single most important early principle is perfusion: the new kidney depends entirely on blood flow, so hypotension and hypovolemia are avoided and an adequate volume status and blood pressure are maintained, often guided by central venous pressure. Nephrotoxins are avoided in these early, vulnerable hours.

Urine output and fluid replacement

• Early urine output is read carefully. Brisk diuresis signals immediate function (typical of living-donor and low-cold-time grafts); oliguria signals delayed graft function or a complication. A high urine output is replaced — often volume-for-volume — to prevent hypovolemia, which would itself harm the graft, with close attention to potassium and glucose during early polyuria.

Monitoring graft function and Doppler

• Function is tracked by a falling creatinine and by Doppler ultrasound, which confirms arterial and venous perfusion and excludes collections or obstruction. An early Doppler is the quickest way to distinguish a perfused but sluggish graft (delayed function) from a vascular catastrophe.

Lines, catheters, and the stent

• A bladder catheter is kept to decompress the bladder and protect the fresh ureteric anastomosis, and is removed on schedule; the ureteric stent stays for some weeks and is removed cystoscopically later (it reduces leak and obstruction but must be removed to avoid encrustation and infection). Central access supports monitoring and fluids.

Starting immunosuppression

• Immunosuppression begins peri-operatively: induction (often a lymphocyte-depleting or interleukin-2-receptor antibody) plus the maintenance regimen, set by the recipient's immunologic risk. The detail belongs to the immunosuppression chapters, but it starts here, in the operating room and the first hours after.

Early complications to anticipate

• A handful of early problems must be on the radar from the first hour: vascular thrombosis (arterial or venous — sudden anuria and graft pain, a surgical emergency that usually loses the graft if not reversed), bleeding, urine leak, and obstruction. Delayed graft function (its own chapter) is common with long cold times and DCD grafts, and hyperacute rejection, though now rare because of the crossmatch, presents as immediate graft failure on the table.

Assessing the early non-functioning graft

• When the graft does not work — oliguria or a rising creatinine — the response is systematic: confirm perfusion and exclude obstruction with Doppler ultrasound, check the catheter and volume status, and, once vascular and urologic causes are excluded, attribute oliguria to delayed graft function or, if suspected, biopsy for rejection. The order matters: the treatable emergencies (thrombosis, leak, obstruction) are excluded first.

Five fully-built tables.

Table A — The operation

Table B — Ischemia times

Table C — Immediate post-operative priorities

Table D — Interpreting early urine output

Table E — Early complications

Visualise & Map

Numbered rules. These numbers are the cross-reference handle for the cases and flowcharts.

Clinical Reasoning

Four cases. Each stops you at a decision before it answers it.

Exhaustive. Every rule in the chapter is here.

Safety & Evidence

Panel A — Red flags

Panel B — NEVER DO

Anti-patterns clinicians fall into. Each becomes a Level 22 distractor.

The grade reflects strength of evidence, not importance.

Apply & Test

Copy-paste chart notes that map to the early course.

Template 1 — Immediate post-operative transplant note

• Donor type and ischemia: living/deceased (DBD/DCD); cold ischemia time ___.
• Anastomoses: arterial/venous (iliac) and ureteric (stent placed); reperfusion appearance ___.
• Urine on table: yes/no; early output ___; replacement plan ___.
• Perfusion: volume/blood-pressure targets; nephrotoxins avoided.
• Immunosuppression: induction ___ ; maintenance ___ . Catheter/stent: in situ, removal plan ___.

Template 2 — Early graft dysfunction assessment note

• Pattern: oliguria / anuria / rising creatinine; onset and graft pain ___.
• Catheter patency and volume status checked: ___.
• Doppler: arterial/venous flow; obstruction/collection ___.
• Working differential: thrombosis / leak / obstruction / DGF / rejection.
• Action: urgent surgery / support / biopsy; and outcome ___.

Pre-rounds compression. Rules only.

Active recall. At least one card per objective.

Micro-teaching for rounds. Two scenarios, five steps each.

Eight items, each anchored in this chapter. At least one per objective.