**1. Introduction**

First successful kidney transplantation was done over 60 years ago and now because of major advances in immunosuppressive medicine, this represents the treatment of choice for patients with end-stage renal disease (ESRD). The kidney was the first organ to be transplanted regularly, and it remains the most common organ transplanted today but the surgical technique has changed very little from the original pelvic operation during this long period.

In most cases kidney is placed retroperitoneally and the iliac arteries and veins are used for perfusion of this organ and the ureter is transplanted directly to the bladder. But the sophis‐ ticated intensive care units and advanced perioperative anesthetic techniques lead to the use of more marginal donors for more complicated recipients. Now using a kidney graft from a donor after cardiac death or proceeding to kidney transplantation as a part of multivisceral or other abdominal organ transplantation is a routine procedure in the major transplant centers of the world. In such conditions the kidney grafts are not harvested in an optimized preoper‐ ative planning and may be damaged during the surgery. Then we may confront with a graft with 2 or more delicate or very short arteries or veins, ruptured capsule or transected ureter. We may use grafts with congenital anomalies such as horseshoe kidneys or duplicated ureteral system. Also the recipient procedure may be her or his second, third or more transplantation surgery and no more iliac vessels remained for anastomosis and the bladder may be so damaged that makes the anastomosis of the ureter to the bladder impossible. The transplant surgeon should always be ready to conquer such challenges. Using an intraperitoneal space, using the aorta or inferior vena cava or other major arteries and veins such as splenic vessels, and the native ureters for reconstruction of the urine outflow should be an in-hand procedure for every transplant surgeon.

© 2013 Kakaei et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In this chapter we will review basic steps of the standard approach to recipient's procedure from preparing the graft, then the skin incision till the skin closure with special attention to basic vascular and urinary tract re-establishment techniques and also intraoperative care of the patient. Then we proceed to the special and unusual situations including: complex vascular and ureteral reconstruction techniques, using kidneys with congenital and other anatomical anomalies, en bloc double kidney transplantation, using other vasculature for transplanting the kidney in different intraperitoneal spaces, and kidney transplantation conjoint with other abdominal organs.

**Name Composition Claimed advantages**

Allows for kidney preservation time up to 48 hours Allows for liver preservation time up to 24 hours Allows for pancreas preservation time up to 24

Kidney Transplantation Techniques http://dx.doi.org/10.5772/54829 169

Provides enough time to admit patients from

Provides enough time to improve recipient

Provides enough time to operate in a semi-

Rapid homogenous cooling due to low viscosity

Simple perfusion technique (ready-to-use, no

prevention of calcium overload with adequate

Better for heart and lung transplantation (as depicted by its manufacturer, Genzyme)

An out of date solution in most US and European

hours

matching

buffer

centers

When possible, the donor team should report the detailed graft anatomy (including number of arteries, veins and ureters and any anatomical anomaly or inadvertent injury to the graft during the donor operation) to the recipient team, especially when the graft is transferred from another hospital locally or regionally. It is very important to prevent any more injury to the graft and its capsule, vessels or ureter during the back table procedure, especially in case of deceased donor grafts which usually accompanied with other abdominal organs or at least covered by the peritoneum or peri-renal fats or other non-important tissues. Direct contact of the ice with the graft should be prevented by inserting the graft in a separate basin or organ

bag filled with a cold solution and then inserting this bag in another iced filled basin.

First of all, for irrigation of the living donor graft, the surgeon should find the artery and canulate it with an atraumatic olive-headed heparin irrigation needle as shown in figure 1. Using other devices such as Angiocath©, Baranule© or any types of intravenous needles for

distant locations

elective situation

Superior recovery of function Excellent ischemic tolerance Virtual absence of side effects

additives or preparation)

low potassium comparing with UW prevention of tissue edema prevention of free radical damage

Preserves the kidney up to 48 hours

Potassium lactobionate: 100 mmol/l

KH2PO4: 25 mmol/l MgSO4: 5 mmol/l Raffinose: 30 mmol/l Adenosine: 5 mmol/l Glutathione: 3 mmol/l Allopurinol: 1 mmol/l Hydroxyethyl starch: 50 g/l

Sodium chloride: 15 mmol/l Potassium chloride: 9 mmol/l

Magnesium chloride: 4 mmol/l Histidine · HCl:18.0 mmol/l Histidine: 180 mmol/l Tryptophan: 2 mmol/l Mannitol: 30 mmol/l Calcium chloride: 0.015 mmol/l

Lactobionic Acid 80 mmol/l Glutamtic Acid 20 mmol/l Histidine 30 mmol/l Calcium Chloride 0.25 mmol/l Potassium Chloride 15 mmol/l Magnesium Chloride 13 mmol/l Sodium Hydroxide 100 mmol/l Reduced Glutathione 3 mmol/l

Potassium phosphate 42.5 mmol.l Potassium chloride 15 mmol/l Sodium bicarbonate 10 mmol/l Anhydrous glucose 35 g/l Mannitol 31.7 mmol/l Raffinose 3.5 mmol/l

**Table 1.** Composition of the more common organ preservation solutions.

**Celsior** Mannitol 60 mmol/l

Potassium hydrogen 2-Ketoglutarate: 1mmol/l

**Belzer UW solution (Viaspan® )**

**Histidine-Tryptophan-Ketoglutarate (Custodiol® )**

**Euro-Collins (Renograf® )**
