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  1. Pretransplant native kidney nephrectomy/nephroureterectomy:
    1. Not a routine pretransplant procedure.
    2. The native kidneys are left in place because they still may produce significant volumes of urine, secrete erythropoietin, and activate vitamin D.
    3. Indication: large polycystic kidneys (Massive enlargement), significant proteinuria, and chronic reflux disease.
    4. Renal calculi, renal infection, hematuria
Pretransplant cholecystectomy: Symptomatic or asymptomatic gallstones.
Splenectomy: May be indicated as a protocol for ABO-incompatible kidney transplants.
Multiple random blood transfusions: Once, this was associated with improved, kidney transplant graft survival. Currently, there is no clinical benefit to transfusion, and the risk of sensitization is significant.

  1. Technique, Postoperative Management
    1. Gibson incision:
      1. A curvilinear incision in a lower quadrant of the abdomen (ie, Gibson incision), with division of the muscles of the abdominal wall and dissection of the preperitoneal space to expose the iliac vessels and the bladder.
      2. Then, the donor kidney’s renal vessels are connected to the iliac vessels, typically with end-to-side anastomoses of a fine (5-0 or 6-0) permanent vascular suture.       
    2. Ureteroneocystostomy
      1. The ureter is introduced into the bladder by creating a ureteroneocystostomy.
      2. This may involve bringing the ureter through a tunnel in the bladder submucosa (Leadbeder-Politano) or by creating an anastomosis between the tip of the ureter and the bladder mucosa, then partially covering this with bladder muscularis (Lich).
    3. Postoperative management
      1. Management of the operative procedure: 0.45% Saline in 0-5% Dextrose at a rate equal to hourly output (often in the 250-500 cc/h range) plus insensible loss.
      2. With improving renal function, fluid balance must be maintained, hypertension management may need modification, and electrolyte abnormalities may require correction.
      3. Immunosuppressive therapy: can be divided into 2 phases induction and maintenance.
      4. The induction immunosuppression should occur during and immediately following transplantation and again should be divided into antibody and nonantibody regimens.
      5. The typical antibody-based induction immunosuppression uses either monoclonal or polyclonal antibody preparations directed at T lymphocytes in combination calcineurin inhibitors (eg, cyclosporine, tacrolimus), antiproliferative agents (eg, azathioprine, mycophenolate), and steroids.
      6. Both nonantibody induction therapy and most forms of maintenance therapy dispense with the antibodies but use calcineurin inhibitors, antiproliferative agents, and steroids in various combinations.
      7. Drug Category: Antirejection induction agents -- Induction immunotherapy consists of a short course of intensive treatment with intravenous agents.
      8. Antilymphocyte antibody induction therapeutics are varied and include polyclonal antisera, mouse monoclonals, and so-called humanized monoclonals.
      9. Polyclonal antisera, such as antilymphocyte globulin (ALG), antilymphocyte serum (ALS), and antithymocyte globulin (ATG), are equine, goat, or rabbit antisera directed against human lymphoid cells. 
  1. Antithymocyte globulin, equine (ATGAM): Infection, leukopenia, and thrombocytopenia may occur; adverse reactions include fever, chills, malaise.
  2. Daclizumab: Humanized monoclonal antibody that specifically binds to and blocks IL-2 receptor on surface of activated T cells.
  3. Basiliximab: Chimeric monoclonal antibody that specifically binds to and blocks IL-2 receptor on the surface of activated T cells.
  4. Antithymocyte globulin, rabbit (Thymoglobulin) -- A purified immunoglobulin solution produced by the immunization of rabbits with human thymocytes.
  5. Infection, leukopenia, and thrombocytopenia may occur; adverse reactions include fever, chills, malaise, headache. Q
  6. Methylprednisolone: Steroids ameliorate delayed effects of immune reactions. Caution in active infection, diabetes, heart failure Q 
  1. Drug Category: Maintenance Immunosuppression:  Maintenance immunosuppressive agents are required for the patient's entire life.
    1. Prednisone: Immunosuppressant for treatment of autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
      1. Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use. 
    2. Azathioprine (Imuran)Q -- Active component of azathioprine is 6-mercaptopurine.
      1. Acts as purine analog that interacts with DNA and inhibits lymphocyte cell division.
      2. Risk of leukopenia and (rarely) liver dysfunction; caution with liver disease and renal impairment;hematologic toxicities may occur.
    3. Cyclosporine: Calcineurin inhibitors that diminish IL-2 production in activated T cells. Q
      1. These agents bind to the intracellular immunophilin cyclophilin, interfering with the action of calcineurin, which inhibits nuclear translocation of the NFAT.
      2. Evaluate renal and liver functions often; may increase risk of infection and lymphoma.
    4. Tacrolimus: Calcineurin inhibitor that diminishes IL-2 production in activated T cells.
      1. Binds to intracellular immunophilin and FKBP, interfering with the action of calcineurin, which inhibits nuclear translocation of the NFAT. Q
      2. Has nephrotoxic effects; tonic clonic seizures may occur.
    5. Sirolimus: Inhibits lymphocyte proliferation by interfering with signal transduction pathways
      1. Binds to immunophilin FKBP to block action of mTOR.
      2. May exacerbate hyperlipidemia and thrombocytopenia

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