Transplantation

The first wholly successful human transplant took place on December 23, 1954, in Boston, Massachusetts. Surgeon Joseph Murray performed a kidney transplant between identical twin brothers. Although this and subsequent twin transplants did little to solve the problem of rejection, these procedures contributed to proving the value of the procedure and to the solution of many technical problems.

In 1963, the introduction of azathioprine and steroid combination therapy produced encouraging results and became the mainstay of immunosuppression until the introduction of cyclosporine in 1983. Cyclosporine, in turn, substantially improved outcomes of cadaver kidney transplants. Further innovations include anti–T-cell antibodies, both monoclonal and polyclonal, and other agents (eg, tacrolimus, mycophenolate, sirolimus).

If you have advanced and permanent kidney failure, kidney transplantation may be the treatment option that allows you to live much like you lived before your kidneys failed. Since the 1950s, when the first kidney transplants were performed, much has been learned about how to prevent rejection and minimize the side effects of medicines.
But transplantation is not a cure; it’s an ongoing treatment that requires you to take medicines for the rest of your life. And the wait for a donated kidney can be years long.

A successful transplant takes a coordinated effort from your whole health care team, including your nephrologist, transplant surgeon, transplant coordinator, pharmacist, dietitian, and social worker. But the most important members of your health care team are you and your family. By learning about your treatment, you can work with your health care team to give yourself the best possible results, and you can lead a full, active life.

A successful kidney transplant offers enhanced quality and duration of life and is more effective (medically and economically) than chronic dialysis therapy. Transplantation is the renal replacement modality of choice for patients with diabetic nephropathy and pediatric patients.

Candidates for renal transplantation undergo an extensive evaluation to identify factors that may have an adverse effect on outcome. Virtually all transplant programs have a formal committee that meets regularly to discuss the results of evaluation and select medically suitable candidates to place on the waiting list. Most programs perform the evaluation in the outpatient setting and possess a relatively uniform approach to the diagnosis and treatment of the pertinent medical and psychosocial issues affecting candidacy.

• Preexisting morbidities of the transplant candidate with renal disease
  • Hematologic abnormalities, such as anemia and platelet-hemostatic dysfunction
  • Upper and lower gastrointestinal track abnormalities, such as gastritis, peptic ulcer disease, diverticulosis, diverticulitis, spontaneous colonic perforation, and prolonged adynamic ileus (pseudoobstruction)
  • Hepatic abnormalities, such as viral hepatitis B and C
  • The cardiovascular system is profoundly affected in patients with chronic or end-stage renal failure. The increased mortality is related to hypertension, atherosclerotic heart disease with myocardial infarction, congestive heart failure, and left ventricular hypertrophy.
  • Bone and joint disease is common because of low calcium levels, high phosphorus concentrations, and elevated serum parathyroid hormone (PTH) levels.

Causes

• A diverse array of diseases destroys renal function in all age groups. The most common etiologies of renal disease leading to kidney transplantation are the following:
  • Diabetes – 31%
  • Chronic glomerulonephritis – 28%
  • Polycystic kidney disease – 12%
  • Nephrosclerosis (hypertensive) – 9%
  • Systemic lupus erythematosus (SLE) – 3%
  • Interstitial nephritis – 3%
• Understanding the etiology of renal disease is important because the primary renal pathology may influence the outcome based on the propensity for recurrence of disease and the association of comorbidities.

In carefully selected patients, virtually all causes of chronic renal failure can be treated with transplantation. Some conditions are likely to recur in the transplanted kidney, including immunoglobulin A (IgA) nephropathy, certain glomerulonephritis, oxalosis, and diabetes. Generally, the rate of recurrence is slow enough to justify transplantation.

Contraindications to Renal Transplant

Contraindications to surgery

• Cardiopulmonary insufficiency
• Morbid obesity
• Peripheral and cerebrovascular disease
• Tobacco abuse
• Hepatic insufficiency
• Other factors that increase the risk associated with a major surgical procedure

Infection and malignancy are the primary medical conditions. Acute infections should be fully resolved at the time of transplantation. In general, one should wait approximately 5 years following successful treatment of breast cancer, colorectal cancer, melanoma, diffuse bladder carcinoma, and non–in situ ovarian cancer. This is estimated to reduce the risk of recurrence from about 50% if the transplant is performed within 2 years to about 35% if performed between 2 and 5 years and to about 10% if performed after 5 years. Some tumors may require shorter waiting times. One year is reasonable for isolated nodules of prostatic carcinoma and focal bladder carcinoma. Two years is adequate for in situ uterine carcinoma, some renal tumors (eg, clear cell, Wilms, urothelioma), and basal or squamous cell skin carcinoma.

Kidney transplantation at UNRC was started in 1987 and nowadays is pioneer in Iran. More than 2500 kidney transplantation was performed at UNRC that is one of greatest clinical volume in Iran.

Kidney transplantation fellowships that graduated from this center has introduced transplantation in many other hospitals and universities allover the country. Laparoscopic donor nephrectomy as minimal invasive procedure is performed routinely in our center. There are many advantages for laparoscopic donor nephrectomy  in comparison to open surgery such as earlier discharge from hospital , less post operative pain and more cosmetic.