Allogeneic transplantation is one of the biggest medical breakthroughs of the 20th century. It has saved many patients’ lives and dramatically improved more. Rapidly developing progress in this area will undoubtedly improve safety and long-term results. Along with its success, transplantation offers more questions than answers in the area of medical ethics.
Kidneys for transplantation may come from live or deceased donors, and in the UK a third of kidneys come from live donors. Each type of kidney has different peri-operative considerations.
Live donor kidneys
Live donor kidney transplants may be conducted in parallel, with the donor in an adjacent theatre, or in tandem with the recipient procedure following the donor procedure. When in parallel there is often a period of time when the recipient is anaesthetised and ready to receive the donor kidney, and the donor kidney has yet to become available. In this case it is important to maintain muscle relaxation and anaesthesia, since the surgeons may have left the operative field while preparing the donor kidney.
ABO incompatible live donor kidneys
While it is usual to transplant blood group compatible kidneys, it is possible to pre-treat the recipient with plasmapheresis or antibody absorption columns to remove anti-blood group antibodies. This has two consequences. First, any blood products (e.g. fresh frozen plasma) need to be of donor type, and not recipient type. Second, plasmapheresis often removes clotting factors and it is common for patients to be depleted of fibrinogen. It is important to check fibrinogen and clotting before surgery since deficiency is readily treated by cryoprecipitate.