*3.1.1 Complications of donor nephrectomy*

Post-operative donor complications occur in 7.9–22% with bleeding in about 3%. Infectious, gastrointestinal, respiratory, cardiac and psychiatric complications may occur [78–80].

#### **3.2 Recipient surgery**

The harvested kidney is covered in ice slush, wrapped in gauze piece and preserved in ice container as organ perfusion machine is not readily available in the sub-region.

Kidneys with multiple arteries are avoided but if inevitable, arteries are anastomosed side to side, end to side, or separately onto the external iliac artery (**Figure 4**). The right external iliac vessels are more superficial than the left and this side is frequently preferred for the first renal engraftment.

Anti-reflux uretero-cystostomy is performed over a size 4Fg double J-ureteric stent (**Figure 5**).

### *3.2.1 Pitfall in recipients surgery*

**Sclerosed External Iliac Vein (EIV):** this results from repeated cannulation of EIV for hemodialysis. Recipient pre-operative EIV doppler ultrasound scan for patency is important. Major complications of recipient engraftment include bleeding, delayed graft function, hyperacute rejection and allograft renal vein thrombosis.

### **3.3 Peri and post-operative care of renal transplant recipient**

Immunosuppressive regimen is divided into induction and maintenance phases.

#### *3.3.1 Induction phase*

This is required to prevent acute rejection. Due to sensitization from blood transfusions, previous pregnancies (females) and increased susceptibility to graft rejection (in blacks) recipients undergo induction [81]. A combination of antithymocyte globulin (ATG) and methylprednisolone is often used. Prior to this, patients receive pretreatment with acetaminophen and antihistamines to prevent cytokine release syndrome associated with ATG.

Biologic agents (Alemtuzumab, Basiliximab, Daclizumab) may be used when available in less sensitized patients.

### *3.3.2 Maintenance regimen*

To prevent allograft rejection, maintenance immunosuppression is achieved with a combination of low dose corticosteroid (prednisolone is widely in available SSA), an antiproliferative agent (mycophenolate mofetil (MMF) or azathioprine)

*Organ Donation and Transplantation in Sub-Saharan Africa: Opportunities and Challenges DOI: http://dx.doi.org/10.5772/intechopen.94986*

**Figure 4.** *Donor angiogram with multiple left renal arteries.*

**Figure 5.** *End-to-side donor-recipient arterial anastomosis with kidney wrapped in gauze piece packed with saline ice slush.*

and a calcineurin inhibitor (CNI) (tacrolimus (TAC) or cyclosporine (CYP)). Tacrolimus has shown superiority over cyclosporine in improving graft survival and preventing acute rejection. Thus, TAC remains an integral part of the common posttransplant immunosuppressive combination [82]. The initiating dose is titrated to achieve a trough level of 8-10 ng/ml in the first three months post-transplant.

Prophylaxis against bacteria, fungi and viruses are commenced within this time.
