Renal Transplant: Procedure, Anatomy and Physiology of Kidney, and Potential Complications

This essay discusses the issue and potential complications during the surgical journey of Mr. Holm and it will also depict how the implementation of guidelines supported in the delivery of this care. It also covers the anatomy and physiology of the kidney, the procedure of renal transplant, and potential complications. The document type is an essay and the type of assignment is not mentioned. The subject is Renal Transplant and the course code, course name, and college/university are not mentioned.

Running Head: RENAL TRANSPLANT
Renal Transplant
Name of the Student
Name of the University
Author Note

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Essay on Renal transplant
Kidney transplant is a type of surgical process for placing healthy kidney from a
deceased or living donor into the person having dis-functioning kidney. The kidneys are the
bean-shaped organs which are situated in the spine’s two sides below the rib cage. The size is
similar to a fist and it functions as filter for removing waste, fluid and minerals from the body
through producing urine (Hricik et al., 2015). When human kidneys lose the ability of filtering,
harmful fluid and the waste accumulate in the body raising the blood pressure. It results the
ability to renal failure. This is also called the end-stage renal diseases when the kidneys lose
almost 90 % of the strength to work normally. There are many reasons behind the end stage
kidney disease are uncontrolled high blood pressure, diabetes, chronic glomerulonephritis,
polycystic kidney disease. It is known that human can live without one kidney but then kidney
donation or transplant is not accepted in the United Kingdom (Colombo et al.,2017).. The study
showed that most of the donations were from the deceased people not the living ones.
When the case of Mr. Holm is taken, it is seen that he is a 68 years old man being
detected with the end-stage renal disease and hospitalized for the renal transplant surgery from
the deceased donor. Almost nine years ago, he had been diagnosed with hypertension and
diabetes . As per the AIHW or Australian Institute of Health and Welfare, kidney damage is the
result of hypertension and diabetes. The Australian College of Operative Room Nurses
( ACORN) , the Australian National Standards, the Organizational policies and the World Health
Organization ( WHO) have given proper guidelines for delivering quality care reducing the risk
at the time of surgery. This essay discusses the issue and potential complications during the
surgical journey of Mr. Holm and it will also depict how the implementation of guidelines
supported in the delivery of this care.

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The renal transplant is an extremely crucial in reducing the patient’s burden. Those
patients who underwent renal transplant do not necessarily undergo dialysis because it is a very
time-consuming process. There are many concerns related to the after effects of kidney
transplant. This is called the postoperative complications as delayed function in the transplanted
kidney, dysfunction due to refusal of taking foreign body organ by the patient’s body , the deep
vein thrombosis and many others. Thrush, infections, hypertension, diabetes mellitus and many
others can cause these complications (Naylor et al., 2016). The past health history of Mr Holm
reveals that he diabetes mellitus and hypertension has been diagnosed in his body in the year
2010. He also has a history of dyslipidaemia, hypertensive nephropathy, Hepatitis B infection
(HBV) and gout too. These diseases have cumulatively accentuated the possibility of the chronic
kidney and it rapid progression toward end stage renal disease and related complications.
The renal transplant is a long-term process because the number of deceased donor is
limited but in some cases, living donors are also found reducing the waiting time. The patient for
the renal transplant needs proper evaluation such as laboratory studies, social issues, infectious
profile, immunologic evaluation, diagnostic procedures for highlighting factors, which may
affect the surgical outcomes. The patients for renal transplant are required to be supported with
whole life immunosuppression. This helps to prohibit the organ rejection, infection and the drug
toxicity.
The renal transplant department confirmed Mr Holm that he is free from any infective
symptoms along with the fact that both his diabetes and blood pressure were under control. On
the other hand, the peripheral oedema was nil, the lung fields were also clear, and the abdomen
was perfect for the process. The department decided to give modified immune suppression to
avoid the risk of HBV re-activation. As a whole, Mr Holm was prepared for the operation and as

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psychological concern, the surgeon assured him along with the transplant co-ordinator. The
donor was also prepared by the transplant coordinator after brain death of the donor . The family
consent was also received for the donation of organ and the organ care was handed over to
procurement co-ordinator. They took all necessary measures to ensure that the organs adequately
perfused till the time of reaching the operation theatre.
ANATOMTY and PHYSIOLOGY OF RENAL SYSTEM (Kidney)
The renal system functions as filtering the blood and creating urine to be the waste by-
product. The organs in the urinary system consist of renal pelvis, kidneys, ureters, urethra and
bladder. The structure of kidney is such that it is divided into two of the principle regions. The
regions are the central medulla and peripheral rim of the cortex. The kidneys receive almost 25
% of the cardiac output. These are protected by the renal fat pad in the retroperitoneal space
which overlays the muscle and the ribs. At the renal hilum, the lymph vessels, ureters, blood
vessels and the nerves come and leave (Locke et al.,2015).The renal arteries rise from the aorta
and on the other hand, the renal veins directly drain into the vena cava. The kidney function is
extracted from the activities of almost 1.3 million nephrons in each kidney, which are called the
functional units.
The Bowman’s capsule captures the glomerulus, capillary bed and blood filters. There is
a portal system created when during the blood flow through second capillary bed covering the
proximal and distal convoluted tubules along with Henle loop. The solutes and water are
recovered by the second capillary bed. This is a particular filtration processed by collecting
ducts which drains into the minor calyces. The filtrate progresses towards the renal pelvis and
ureters lastly. Kidneys take the blood supply from the aorta through the renal arteries. Blood
returns to the vena cava through the renal veins. Urine is excreted from the kidneys and passes

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down the fibromuscular ureters to collect in the bladder (Haller et al., 2016).The bladder muscle
on the other hand can distend to accept the urine without increasing the inside pressure. At the
time of urine passing, the urethral sphincter relaxes in at the bladder base, the contraction of
detrusor occurs and urine is voided through the urethra.
The procedure
It is to be noted that the operative procedure can be segregated into five main parts such
as preparation, exposure, vascular anastomoses, the ureteral anastomosis and closing. At the
beginning, the sterile bag and the ice container protected the cadaver kidney throughout the way
to the operation theatre. The next responsibility was that of the vascular surgeon to prepare the
kidney donor for transplantation (Thomusch et al., 2016).The surgical team washed their hands
having worn the operation theatre attire and gloves as per the policies of the organization and its
standards. The operation theatre was designed in such a way that it reduced the risk of infection.
There is a sterile field too designed where there are sterile surgical personnel, the instruments,
the sterile draped equipment trolley and the draped patient. It is the team’s responsibility to
maintain the asepsis and reduce the possibility of risk of post-operative infection (Kulkarni et
al., 2017).When the sterile field is done properly, the nurses arrange the instruments and keep
them in the scheduled order of the surgeon’s suggestions. The scout nurses are given the
responsibility to check whatever items are introduced in the sterile circle (Pihlstrøm et
al.,2015).This is done for checking whether the equipment have sterile packaging, expiry or the
external indicators. All the accountable items for the surgery were checked again before
commencing the operation for ensuring the safety of the patients reducing risk of unintentionally
kept items. A mandatory documentation was also done beforehand.
For preparing the donor kidney, the tissues were dissected and extra vessels were ligated.

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When there is need, vessels are repaired and it is confirmed that kidneys were perfused for
transplant. When the dissection and evaluation was complete, the surgeon placed the prepared
kidney in the sterile basin on the aseptic field covered with ice. Next, Mr. Holm was transferred
to that particular operation theatre for the conduction of the procedure. Before beginning the
anaesthetic operation, the nurse did the ‘time out ‘which is designed for the creation of a specific
time (Whalen et al.,2017). This is to introduce the team members, review the consent, confirm
the identity of the patient, determine the allergic status, note antibiotic prophylaxis, ensure the
equipment sterility, consider the critical events and ask the patient whether he/she has any final
question. Lack of communication might lead to risk enhancement and erroneous work (Sawinski
et al., 2016). Next, a general anaesthetic was given to Mr. Holm as requested by the surgical
team. They also inserted a three –way Foley catheter into his bladder via an aseptic technique
that was linked to a cystoscopy tube set and three litres of solution bag. There are plenty of
advantages of catheterisation at the time of renal transplant. It helps in post-operative bladder
decompression and follow up of the urine output (Newell et al., 2017). It further allows the intra-
operative bladder irrigation. There is one drawback too that is it initiates the possibility of
nosocomial infections in the transplant population.
The assessment of the patient’ risk factors, the required position for the surgery and
expected surgical time was done by the surgical team (Potura et al., 2015). The assessment
consisted of the risk factors such as weight, age, skin condition, mobility, the basic anatomy and
physiology and privacy of the patient too. There has to be knowledge of ergonomic concepts of
safety, scientific evidence, devices and equipment should also be ensured to avoid any kind of
risk to the surgeon or the patient (Freeman et al., 2015). In the case of Mr Holm., he was
required to be in the supine position for gaining best access to the primary body cavities. Since

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Mr. Holm had long term illness and medical conditions , the team prepared an intra-operative
care plan for him (Halloran et al., 2015).
The team covered all the intravenous bungs with pads for avoiding any type of pressure
sore. Since the fragile skin of Mr. Holm enhanced the risk of pressure sores, quick mobilisation
post operatively was required for avoiding the risk. The armboards were also placed for
preventing damage to the brachial plexus. It was also ensured before starting the surgery that Mr.
Holm was not in contact with any of the metal surfaces as the contact could have led to burns.
They also placed a megadyne under the patient to be used in the intra operative diathermy
(Crepin et al., 2015). The team further placed an intermittent pneumatic compression instrument
on the legs of the patient. This pneumatic compression device is effective for decreasing the
deep vein thrombosis whist it is pre-operatively applied.
As the patient was ready for the surgery, the team prepped the site with alcoholic
chlorhexidine and waited till the skin got dry and it was free from pooling of the surgical prep.
Having covered the patient with sterile drapes, the arrangement of other necessary equipment
was required and made. They provided extra attention to the hand held diathermies that were
kept in a dry, clean and nonconductive receptacle (Robertsen et al., 2015). The surgeon made a
slight incision in the right lower part of the abdomen. Usually, the transplanting kidney is located
in the right iliac fossa for getting easy access to the vessels along with the bladder. The team
prepared a retroperitoneal working space after proper tissue dissection. After this, a self-retaining
retractor was also placed in the prepared working space. In the previous years, surgeons used to
prefer the internal iliac artery but nowadays maximum of surgeons use the external iliac artery
since it is easy and quite safe to dissect. Due to the diabetic nature of Mr. Holm, there is high
chance that internal iliac artery could be damaged (Ranghino et al., 2015).

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During the vascular anastomosis process, then team need to ensure that kidneys are
properly kept chilled and topical ice is there to cover the kidney. After dissecting the vessels, the
surgical team brought the kidney to the operating area. The patient’ external iliac vein got
anastomosed with the renal vein of the donor’s kidney. After the process, they placed a small
clamp on the renal vein and from the iliac vein the clam was removed. This was done for letting
the vein release the venous congestion. After the anastomosis of the vessels, they released the
clamps and re-perfused it (Mallat et al, 2017). Then they checked the surgical site for bleeding.
After finishing the anastomosis, the urology surgeons began the next step which is ureter
anastomosis. The scout nurses unclamped the saline bag and clamped the urinary catheter for
filling the bladder. Then they passed the ureter through bladder wall and tunnelled it
suburothelially for 2- 2.5 cm. The implantation of the ureter into the bladder took place by the
surgeons. They passed a 4.8 F ureteric stent through a ureteroneocystostomy which could be
removed after 36 to 48 hours. The surgeon was quite satisfied that the anastomoses were not
leaking, the catheter was unclamped and bladder was fully empty (Thomusch et al, 2016). In this
way, they achieved Haemostasis and the catheter was connected properly to the urometer for
measuring post-operative urine output. As per the surgeon’s expectation, the urine output should
be 100 cc/hr after few hours of the transplantation.
The nurses performed a count prior to the cavity was stictched. They reported the
accomplishment and verification of the correct count and conveyed it verbally too which got
acknowledged by the surgical team (Sawinski et al, 2016). They do not close the wound until
the first count is made. They counted all the accountable items and documented them too on the
count sheet and the surgeon was reported about it. Prior to the skin closure, the final count was
done and surgical team were properly communicated about the correct count of the instruments.

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They removed all the sharp materials from trolley discarding them to the sharp’s box (Trillini et
al, 2015). They used water proof dressing which they removed replacing the gown of the patient
too. The patient Mr. Holm was then wrapped with a warm blanket.
After the operation, Mr. Holm was relocated to his bed and they conducted a post-
operative assessment. They checked the pressure fields, the integrity of skin and also inspected
the diathermy site for any adverse results. They handed the patient over to the anaesthetic nurse
along with the ureteric stent and catheter (Casiraghi et al, 2016). In the surgical journey of Mr.
Holm, pre-procedural planning, brilliant group-work supported a lot. Their support also reduced
the possibility of complications in all aspects. In the language of medical science, renal
transplant can be segregated into frequent and late complications. The patient’s body starts
showing signs of rejection in the first 2-3 days of transplant. There are other potential
complications such as urinary tract infection, thrombosis, stenosis in renal artery, oliguria, leak
in the ureter anastomosis, haematoma, malignancy and hypertension. For this reason , the
transplant should be on the long term immunosuppressant therapy leading to malignancy and
infection (Pihlstrøm et al, 2015).
The kidney transplant has given the patients chance to live independently and the success
rates have improved through the last decade. They are allowed to leave the hospital after few
days of the operation. Another considerable issue is in the post-transplant patient’s mental
condition. The surgical journey can be extremely complex. Therefore, there has to be proper
evidence based assessment and planning required for ensuring that care is delivered throughout
the surgical pathway.

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