Transplantation Immunology.pdf - E-Lib FK UWKS

6 Callaghan and Bradley
kidney transplants from marginal donors has been reported to give similar results
to single kidney transplants from nonmarginal donors (23), and dual transplantation
does not appear to increase the rate of surgical complications (24). This
procedure is rarely undertaken in the United Kingdom, with only one dual transplant
performed in 2002–2003.
Objective methods of assessing donor kidney quality are necessary to enable
rational decision making about organ usage, but none are in widespread use.
Scoring systems using donor variables such as age, history of hypertension,
renal function, kidney biopsy findings, cause of death, and HLA mismatch
may provide a quantitative approach to identifying marginal kidneys (25,26).
Until scoring systems become widespread, careful consideration is required as
to how best to allocate these organs from marginal donors. It is also important
that potential recipients offered kidneys from marginal donors receive careful
counseling to enable informed consent to be given (27).
3.2. Living Donors
The outcome of kidney transplantation from living donors has been shown to
be superior to that of kidney transplantation from cadaveric donors (8). Although
they are usually poor matches for HLA, grafts from living unrelated donors
have 3-yr survival rates equivalent to those from living related organs (28).
Concerns surrounding living donor transplantation center on the potential risks
to the donor and on the possibility of coercion, which may be difficult to detect.
The peri-operative mortality rate for live donor nephrectomy is in the region
of 0.03% (29), and the peri-operative major complication rate is approx 2%.
There is no long-term increase in mortality after kidney donation, but donors
may develop asymptomatic proteinuria and hypertension more often than the
general population (30). In addition to a rigorous health screen, potential
donors must be carefully questioned by the transplant team about their
motives for donation and all attempts must be made to ensure that coercion
does not occur.
Medical evaluation of the prospective donor is extensive and can be divided
into different phases (31). ABO blood grouping and cross-match testing are
performed first to establish that living donor transplantation is feasible. This is
followed by a complete medical assessment, including assessment of renal
function, and radiological definition of the renal vascular anatomy. If both kidneys
have single renal arteries, the left kidney is usually selected for donation
because the longer left renal vein makes the recipient operation marginally
technically easier.
Removal of the donor’s kidney has traditionally been performed through a
15- to 20-cm-long flank incision (open-donor nephrectomy). Postoperative
wound pain, which may be chronic in around 5% of donors, and poor cosmesis