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Guideline Summary
Guideline Title
Transplantation techniques. In: Guidelines on renal transplantation.
Bibliographic Source(s)
Transplantation techniques. In: Kälble T, Alcaraz A, Budde K, Humke U, Karam G, Lucan M, Nicita G, Süsal C. Guidelines on renal transplantation. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 43-52. [67 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

End-stage kidney disease requiring kidney transplantation

Guideline Category
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Nephrology
Pediatrics
Surgery
Urology
Intended Users
Advanced Practice Nurses
Hospitals
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To present current knowledge about renal transplantation
  • To provide recommendations for kidney transplantation techniques
Target Population

Kidney transplant recipients

Interventions and Practices Considered
  1. Preparation for kidney transplantation
  2. Kidney transplant techniques used in adults and children
    • Approach
    • Vascular anastomosis
    • Ureteral anastomosis
    • Special considerations in children
    • Vascular problems in the recipient
  3. Prevention and management of early and late complications
  4. Management of kidney transplantation in patients with an abnormal urogenital tract
Major Outcomes Considered
  • Incidence of early and late complications
  • Morbidity
  • Mortality

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A structured literature search is performed for all guidelines but this search is limited to randomised controlled trials and meta-analyses, covering at least the past three years, or up until the date of the latest text update if this exceeds the three-year period. Other excellent sources to include are other high-level evidence, Cochrane review and available high-quality guidelines produced by other expert groups or organizations. If there are no high-level data available, the only option is to include lower-level data. The choice of literature is guided by the expertise and knowledge of the Guidelines Working Group.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Level of Evidence

1a Evidence obtained from meta-analysis of randomised trials

1b Evidence obtained from at least one randomised trial

2a Evidence obtained from at least one well-designed controlled study without randomisation

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

General Methods Used to Formulate the Recommendations

  • The first step in the European Association of Urology (EAU) guidelines procedure is to define the main topic.
  • The second step is to establish a working group. The working groups comprise about 4 to 8 members, from several countries. Most of the working group members are academic urologists with a special interest in the topic. Specialists from other medical fields (radiotherapy, oncology, gynaecology, anaesthesiology, etc.) are included as full members of the working groups as needed. In general, general practitioners or patient representatives are not part of the working groups. Each member is appointed for a four-year period, renewable once. A chairman leads each group.
  • The third step is to collect and evaluate the underlying evidence from the published literature.
  • The fourth step is to structure and present the information. All main recommendations are summarised in boxes and the strength of the recommendation is clearly marked in three grades (A–C), depending on the evidence source upon which the recommendation is based. Every possible effort is made to make the linkage between the level of evidence and grade of recommendation as transparent as possible.

Specific Methods Used for This Guideline

As renal transplantation is very much an interdisciplinary field, the Guidelines Group contains not only urologists but also an immunologist and a nephrologist. Besides medical and technical aspects, the Guidelines Group has also considered ethical, social and political aspects. This was necessary because of the still-increasing gap between 'supply' and 'demand' for kidney transplants, and the large differences in organ donation rates between several European countries, suggesting European countries can learn from each other on how to increase organ donation rates.

There are few prospective randomised studies for most sections of the Guidelines, and sometimes none. Thus, the grades of recommendation, which are evidence-based, seldom exceed grade C. Instead, the Guidelines are well supported by a wealth of clinical experience based on several decades of work in renal transplantation, as in, for example, technical aspects of transplantation and explantation.

A level of evidence and/or grade of recommendation have been assigned where possible. The aim of grading recommendations is to provide transparency between the underlying evidence and the recommendation given.

Rating Scheme for the Strength of the Recommendations

Grade of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
  2. Based on well-conducted clinical studies, but without randomised clinical trials
  3. Made despite the absence of directly applicable clinical studies of good quality
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

There is no formal external review prior to publication.

The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used to analyse and assess a range of specific attributes contributing to the validity of a specific clinical guideline.

The AGREE instrument, to be used by two to four appraisers, was developed by the AGREE collaboration (www.agreecollaboration.org External Web Site Policy) using referenced sources for the evaluation of specific guidelines. (See the "Availability of Companion Documents" field for further methodology information.)

Recommendations

Major Recommendations

Note from the European Association of Urology (EAU) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of the publication date. However, because EAU updates their guidelines frequently, users may wish to consult the EAU Web site External Web Site Policy for the most current version available.

Levels of evidence (1a–4) and grades of recommendation (A–C) are defined at the end of the "Major Recommendations" field.

Transplant Preparation

Kidney

  • Place the kidney on a sterile iced bed.
  • Check for the absence of renal tumours.
  • Tie all that is cut near the hilus (lymphostasis).

Vein

  • The right kidney should be removed, together with the infra-renal vena cava for lengthening the renal vein on the back table.

Artery

  • Preserve the aortic patch and check the intima of the renal ostium.
  • In severe atheroma in the ostium, remove the aortic patch.
  • In multiple arteries, back table reconstruction could be necessary.

Ureter

  • Preserve peri-pyelic and proximal peri-ureteral fat in the 'golden triangle'.
  • Check for double ureter.

Transplant Biopsies

  • Use 16G or 18G automatic single-use needle.
  • Systematic in some centres because it can be very important to follow the long-term histological modifications of the transplant.

Transplant Technique

Transplant Technique in Adults

Approach

  • Extra-peritoneal approach of one iliac fossa.
  • Transplantation is possible either into the contralateral or ipsilateral iliac fossa.
  • Lymphostasis with clips or ligatures to avoid lymphocoele is mandatory.
  • Total mobilisation of the external iliac vein avoids traction on the venous anastomosis (sometimes ligation of the internal iliac vein is necessary particularly for right transplant with a short vein).
  • Minimal dissection of the iliac artery.

Vascular Anastomosis

  • Generally external iliac vessels are used; avoid atheromatous plaques.
  • Choose the sites of vascular anastomosis according to the length of each vessel to avoid plication or traction.
  • Both anastomoses are performed with two halves of running non-absorbable monofil 6x0 or 5x0 sutures.
  • The internal iliac artery should not be used except in specific situations.

Ureteral Anastomosis

  • Extravesical implantation at the antero-lateral surface of the bladder is the method of choice. Suture the ureter to the bladder mucosa using two halves of running absorbable 6x0 or 5x0 sutures. This technique gives better results than open implantation to the bladder.
  • A double J-stent may be placed to protect the anastomosis, particularly in cases of tricky anastomoses. Several transplant groups use a double J-stent routinely and remove it 2 to 4 weeks later. (Level of evidence: 2b)
  • The uretero-ureteral anastomosis is an alternative to a very short or poorly vascularised transplant ureter. It is also used for a third transplant or in children. A double J-stent is absolutely necessary in these cases. (Level of evidence: 3)

Special Considerations

Kidneys Taken from Children Weighing <15 kg

  • In adults, en-bloc transplantation should be performed, including the aorta and the inferior vena cava.
  • The two ureters are anastomosed in double pant using the extra-vesical technique.

Vascular Problems in the Recipient

  • If the iliac arteries do not allow clamping, endarterectomy or a simultaneous vascular prosthesis has to be performed.
  • If a prosthetic replacement has been previously carried out, implant the renal artery into the prosthesis using a punch perforator.
  • If the iliac vein and/or vena cava are thrombosed, the native renal vein or superior mesenteric vein can be used. However, in most cases, transplantation must be stopped.

Paediatric Recipient

  • Large kidneys must be placed in a higher position towards the lumbar fossa, using the aorta or the right common iliac artery and the inferior vena cava.
  • The iliac fossa is an option for young recipients. (Level of evidence: 3)

Recommendations

  • It is essential not to neglect transplant preparation. This is a crucial step in the transplantation process. (Grade of recommendation: C)
  • Take care with lymphostasis into the recipient and during the graft preparation. (Grade of recommendation: C)
  • Vascular anastomosis sites should take into account the differences in vessel length. (Grade of recommendation: C)
  • Double J-stent may be used routinely. (Grade of recommendation: C)
  • Check the arterial and venous status before transplant. (Grade of recommendation: C)
  • The iliac fossa may be an alternative in children less than 20 kg provided the graft is small enough. (Grade of recommendation: C)

Early Complications

Urinary Fistulae

  • Use a short ureter and keep the peri-ureteral fat around the hilus. (Grade of recommendation: C)
  • Avoid ligature of the polar artery because of the risk of parenchymal and ureteral necrosis. (Grade of recommendation: C)
  • Prophylactic use of double J-stent remains controversial. (Grade of recommendation: C)

Arterial Thrombosis

  • Importance of procurement technique quality. (Grade of recommendation: C)
  • Preserve when possible the aortic patch; otherwise, use a punch perforator to create a large arterial opening. (Grade of recommendation: C)
  • Look for a possible intimal rupture before performing anastomosis. (Grade of recommendation: C)
  • Avoid plication of the artery. (Grade of recommendation: C)

Venous Thrombosis

  • Lengthen the right renal vein with the infra-renal vena cava. (Grade of recommendation: C)
  • Carry out a large venous anastomosis. (G-ade of recommendation: C)
  • Avoid post-operative drop in blood pressure. (Grade of recommendation: C)
  • Check for hypercoagulation or Leiden factor V mutation if there is a history of thrombosis. (Grade of recommendation: C)

Late Complications

Ureteral Stenosis

  • Use a short and well-vascularised ureter, surrounded by peri-ureteral fat.
  • Do not narrow the anastomosis and the antireflux tunnel.
  • Use of a double J-stent remains controversial.
  • Yearly routine echography.

Reflux and Acute Pyelonephritis

  • The anti-reflux tunnel for the uretero-vesical anastomosis should be 3 to 4 cm long.
  • Avoid lower urinary tract infections.

Kidney Stones

  • Treat hyperparathyroidism in the recipient.
  • Use absorbable threads for the urinary anastomosis.
  • Treat urinary obstructions and infections.
  • Check calciuria.

Renal Artery Stenosis

  • Use aortic patch from the donor.
  • Examine the artery intima, fix it or re-cut the artery when necessary.
  • Keep a long left renal vein, and lengthen the right one with the vena cava.
  • Avoid too tight anastomoses.
  • Use punch perforator when aortic patch is absent.

Arteriovenous Fistulae and Pseudo Aneurysms after Renal Biopsy

  • Avoid very deep biopsy reaching the renal hilum. (Grade of recommendation: C)

Lymphocoele

  • Strict lymphostasis should be maintained by clips or ligatures of the lymphatic vessels of the transplant and during dissection of the iliac vessels. (Grade of recommendation: C)

Kidney Transplantation in Abnormal Urogenital Tract

The following points should be considered when performing kidney transplantation in the abnormal urogenital tract:

  • The technique used to implant transplant ureters in augmentations or conduits is the same as the method used with a patient's own ureter, e.g., following cystectomy for bladder cancer (Bricker, Wallace).
  • In bladder augmentations or continent pouches, ureters are implanted by tunnel technique (Goodwin-Hohenfellner), or extravesically (favoured in most patients), e.g., using Lich Gregoir or Leadbetter methods.
  • In ureterocystoplasty, it is feasible to perform uretero-ureterostomy with one of the patient's own ureters.
  • In patients with continent ileocoecal pouches with umbilical stoma or ileocystoplasties/ileal neobladders, transplant kidneys must be placed on the contralateral left side with the transplant ureters, crossing the abdomen subsigmoidally. (Level of evidence: 3-4)

Definitions:

Levels of Evidence

1a Evidence obtained from meta-analysis of randomised trials

1b Evidence obtained from at least one randomised trial

2a Evidence obtained from at least one well-designed controlled study without randomisation

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Grades of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
  2. Based on well-conducted clinical studies, but without randomised clinical trials
  3. Made despite the absence of directly applicable clinical studies of good quality
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Use of appropriate transplant preparation and techniques in kidney transplant recipients

Potential Harms

Early Complications of Kidney Transplantation

  • Wall abscesses
  • Haemorrhage
  • Haematuria
  • Incisional hernia
  • Urinary fistula
  • Arterial thrombosis
  • Venous thrombosis

Late Complications of Kidney Transplantation

  • Ureteral stenosis
  • Reflux and acute pyelonephritis
  • Kidney stones
  • Renal artery stenosis
  • Arteriovenous fistula and pseudo aneurysms after renal biopsy
  • Lymphocoele

Qualifying Statements

Qualifying Statements

As attitudes and practice to renal transplantation vary significantly, these guidelines provide general guidance only.

Implementation of the Guideline

Description of Implementation Strategy

The European Association of Urology (EAU) Guidelines long version (containing all 19 guidelines) is reprinted annually in one book. Each text is dated. This means that if the latest edition of the book is read, one will know that this is the most updated version available. The same text is also made available on a CD (with hyperlinks to PubMed for most references) and posted on the EAU websites Uroweb and Urosource (http://www.uroweb.org/guidelines/online-guidelines/ External Web Site Policy and http://www.urosource.com/diseases/ External Web Site Policy).

Condensed pocket versions, containing mainly flow-charts and summaries, are also printed annually. All these publications are distributed free of charge to all (more than 10,000) members of the association. Abridged versions of the guidelines are published in European Urology as original papers. Furthermore, many important websites list links to the relevant EAU guidelines sections on the association websites and all, or individual, guidelines have been translated to some 15 languages.

Implementation Tools
Foreign Language Translations
Pocket Guide/Reference Cards
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Transplantation techniques. In: Kälble T, Alcaraz A, Budde K, Humke U, Karam G, Lucan M, Nicita G, Süsal C. Guidelines on renal transplantation. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 43-52. [67 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Mar
Guideline Developer(s)
European Association of Urology - Medical Specialty Society
Source(s) of Funding

European Association of Urology

Guideline Committee

Renal Transplantation Guidelines Writing Panel

Composition of Group That Authored the Guideline

Primary Authors: T. Kälble; A. Alcaraz; K. Budde; U. Humke; G. Karam; M. Lucan; G. Nicita; C. Süsal

Financial Disclosures/Conflicts of Interest

All members of the Renal Transplantation Guidelines writing panel have provided disclosure statements on all relationships that they have and that might be perceived to be a potential source of conflict of interest. This information is kept on file in the European Association of Urology (EAU) Central Office database. This guidelines document was developed with the financial support of the EAU. No external sources of funding and support have been involved. The EAU is a non-profit organisation and funding is limited to administrative assistance and travel and meeting expenses. No honoraria or other reimbursements have been provided.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the European Association of Urology Web site External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Availability of Companion Documents

The following are available:

  • EAU guidelines office template. Arnhem, The Netherlands: European Association of Urology; 2007. 4 p.
  • The European Association of Urology (EAU) guidelines methodology: a critical evaluation. Arnhem, The Netherlands: European Association of Urology; 18 p.

The following is also available:

  • Guidelines on renal transplantation. 2009, Pocket guidelines. Arnhem, The Netherlands: European Association of Urology; 2009 Mar. 12 p. Electronic copies: Available in Portable Document Format (PDF) in English External Web Site Policy and Russian External Web Site Policy from the European Association of Urology Web site. Also available as an e-book from the EAU Web site External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on April 16, 2010. The information was verified by the guideline developer on May 21, 2010.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Downloads are restricted to one download and print per user, no commercial usage or dissemination by third parties is allowed.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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