General Principles

• Renal transplantation offers patients an improved quality of life and survival as compared to other renal replacement modalities.
• Pretransplant evaluation focuses on cardiopulmonary status, vascular sufficiency, and human lymphocyte antigen typing. Structural abnormalities of the urinary tract need to be addressed. Contraindications include many malignancies, active infection, or significant cardiopulmonary disease.
• In adult recipients, the renal allograft is placed in the extraperitoneal space, in the anterior lower abdomen. Vascular anastomosis is typically to the iliac vessels, whereas the ureter is attached to the bladder through a muscular tunnel to approximate sphincter function.
• Immunosuppression protocols vary among institutions. A typical regimen would include prednisone along with a combination of a calcineurin inhibitor (cyclosporine or tacrolimus) and an antimetabolite (mycophenolate derivative, azathioprine, or rapamycin).
• Evaluation of allograft dysfunction frequently requires kidney biopsy. Current laboratory and radiologic tests cannot reliably distinguish acute rejection from drug toxicity, the two most common causes of a rising Cr in the transplant population. Posttransplant lymphoproliferative disease, interstitial nephritis, and infections such as CMV, Polyomavirus (BK virus), and pyelonephritis may present similarly to acute allograft dysfunction and should be excluded.
• Complications and long-term management of transplant recipients are discussed further in Chapter 17, Solid Organ Transplant Medicine.