Renal procurement from the deceased donor

Multi-organ procurement technique, preservation, and preparation of the kidney graft.

1. Introduction

Renal procurement is a critical stage of the transplantation process.

The success of kidney transplantation does not depend solely on the recipient's operation, but also on donor selection, prior hemodynamic stability, the procurement technique, perfusion, preservation, and preparation of the graft.

A technically deficient procurement can cause vascular injuries, ureteral damage, or inadequate preservation that compromises the later function of the organ.

Multi-organ procurement requires a coordinated, systematic procedure agreed upon by the different surgical teams.

2. Donor evaluation and planning

Before starting the procedure, the clinical and anatomical characteristics of the donor must be known.

The reference presentation highlights:

• ABO blood group compatibility.
• Characteristics of the donor and the recipient.
• History of hemodynamic instability.
• Episodes of cardiorespiratory arrest.
• Use of vasoactive drugs.
• History of infections.
• Age and comorbidities.
• Length of hospital stay.

The use of expanded-criteria donors makes it especially important to optimize procurement and preservation.

Question for the resident: why can two kidneys obtained with an apparently correct technique have different functional outcomes?

See discussion

Damage before procurement, ischemia, donor conditions, and preservation all influence the outcome of the graft.

3. Organization of multi-organ procurement

The transplant coordination plays a central role in organizing the procedure.

Before surgery, the following must be established:

• Participating teams and those in charge.
• Organs to be procured.
• Sequence of procurement.
• Cannulation and perfusion strategy.
• Availability of preservation solutions.
• Instruments and materials for bench surgery.
• Communication with the recipient centers.

4. Relevant surgical anatomy

Abdominal aorta

The aorta is the main arterial access for perfusion of the abdominal organs.

During procurement it is essential to recognize:

• Infrarenal aorta.
• Origin of the renal arteries.
• Superior mesenteric artery.
• Celiac trunk.
• Supraceliac aortic segment.

Inferior vena cava

The vena cava is a fundamental reference for venous drainage and renal procurement.

Its relationships with the renal veins and the retroperitoneal structures must be identified.

Renal pedicles

Renal vascular anatomy can show variants. Among the most relevant:

• Multiple renal arteries.
• Polar arteries.
• Variations in venous length.
• Particularities of the right and left renal veins.

Variants must be identified and preserved so that they can be reconstructed during bench surgery or implantation.

Ureter

Preservation of the ureter is especially important.

During dissection, extensive skeletonization that compromises its blood supply must be avoided.

The ureter must be procured with sufficient periureteral tissue, especially in its proximal and middle segments, preserving the vascular connections that contribute to its blood supply.

5. Multi-organ procurement techniques

The presentation describes three main modalities.

A. Classic technique

It is characterized by:

1. Anatomical dissection with intact circulation.
2. Preparation of the vessels for cannulation.
3. In situ perfusion and cooling.
4. Subsequent removal of the organs.
5. Preparation in bench surgery.

It allows the vascular structures to be recognized before circulation is interrupted.

Its use depends on the stability of the donor and on the strategy agreed upon by the teams.

B. Rapid technique

It is characterized by a limited initial dissection aimed at establishing vascular access and starting cold perfusion.

Once perfusion has been carried out and cooling obtained, the dissection of the organs is completed.

It is a particularly relevant strategy when it is necessary to reduce the handling time before perfusion.

C. En bloc procurement

It consists of obtaining several abdominal organs as a single anatomical unit, in order to separate and prepare them later on the bench.

Its characteristics include:

• Limited initial dissection.
• Abdominal perfusion.
• Joint removal of organs.
• Subsequent separation during bench surgery.

Its limitations include greater handling during later preparation and a potentially higher consumption of preservation solution.

Comparison

6. Phases of multi-organ procurement

Phase I. Preparation with maintained circulation

During this stage, abdominal exploration and evaluation of the organs are carried out.

Possible lesions, tumors, or malformations that might change the strategy are identified.

The vascular accesses needed for perfusion are also prepared.

The presentation emphasizes exposure of the great retroperitoneal vessels and preparation of the infrarenal aorta and of the site of proximal aortic control.

Phase II. Cannulation and in situ cooling

Once the accesses are prepared, cannulation is performed according to the protocol and the agreed procurement strategy.

Before starting perfusion, the following must be checked:

• Position and patency of the cannulas.
• Availability of preservation solution.
• Venous drainage system.
• Preparation of topical cooling.
• Coordination with the thoracic team when applicable.

Cold perfusion reduces cellular metabolism and limits ischemic damage during procurement.

Phase III. Removal of the organs

The sequence is established according to the organs procured and the agreed plan.

The presentation describes the removal of the thoracic organs, liver, pancreas, and then the kidneys.

The resident must understand that renal procurement is part of a shared operation and that preserving the pedicles of other organs determines certain maneuvers.

7. Renal procurement technique: surgical principles

Once perfusion has been carried out and adequate cooling reached, the kidneys are released.

Identification of the retroperitoneum

The anatomical relationships among the kidneys, aorta, vena cava, ureters, and iliac vessels are recognized.

The dissection must maintain clear landmarks to avoid vascular injuries.

Renal mobilization

The kidneys are mobilized while preserving the integrity of their capsule, pedicles, and periureteral structures.

Excessive traction on the renal arteries and veins must be avoided.

Arterial preservation

Procurement should aim to preserve adequate arterial length and to recognize possible accessory branches.

When appropriate, an aortic patch can be preserved to facilitate later reconstruction or implantation.

Venous preservation

The right renal vein requires special attention because of its usually shorter anatomical length.

In certain cases, venous reconstruction or extension may be needed during bench surgery.

Ureteral preservation

Sufficient ureteral length is preserved, together with periureteral tissue.

Dissection too close to the ureter can compromise its blood supply and increase the risk of later urological complications.

Final check

Before sending the graft to the bench, the following are verified:

• Integrity of the parenchyma.
• Presence and number of arteries.
• Integrity of the renal vein.
• Length and apparent blood supply of the ureter.
• Absence of unnoticed injuries.
• Identification and traceability of the organ.

8. Renal bench surgery

Bench surgery allows the graft to be prepared for implantation.

The presentation describes removal of excess lymphofatty tissue, review of the vessels, and repair of injuries or anatomical variants.

Arterial evaluation

All renal arteries are identified, including polar and accessory branches.

The reconstruction strategy depends on their caliber, distribution, and anatomical arrangement.

Venous evaluation

The renal vein is inspected, identifying injuries, tributary branches, and the need for reconstruction.

Ureteral evaluation

The integrity of the ureter is verified, and the tissue that accompanies its blood supply is not removed unnecessarily.

9. Renal preservation and ischemia-reperfusion

Preservation is a fundamental stage of transplantation.

Its goal is to reduce the metabolism of the organ and limit cellular damage while it is separated from the recipient's circulation.

Stages of damage

The presentation distinguishes four components:

1. Injury before procurement.
2. Injury during preservation.
3. Warm ischemic injury.
4. Reperfusion injury.

Ischemia and cellular metabolism

During ischemia, oxygen availability decreases and ATP production is altered.

Degradation of nucleotides and accumulation of metabolites favor injurious processes that can intensify during reperfusion.

Reperfusion

When blood flow is restored, the supply of oxygen can trigger oxidative stress, inflammatory activation, and endothelial damage.

Reperfusion is necessary to recover graft function, but it can also reveal the damage accumulated during ischemia.

Physiological basis of preservation

The goals described in the presentation include:

• Minimizing cell swelling.
• Preventing acidosis.
• Limiting expansion of the interstitial space.
• Reducing oxidative damage.
• Promoting recovery of energy metabolism.

10. Errors and complications of renal procurement

Arterial injury

It can involve a main renal artery or an accessory branch. Early recognition makes it possible to assess the options for repair during bench surgery.

Venous injury

Injury to or excessive shortening of the renal vein can make implantation difficult and require reconstruction.

Ureteral devascularization

Excessive dissection of the periureteral tissue can promote later complications of the urinary tract.

Inadequate perfusion

Incorrect cannulation, obstruction of the circuit, or insufficient distribution of the preservation solution can compromise the quality of the graft.

Damage during handling

Traction, compression, or capsular injury can affect the integrity of the organ.

Coordination problems

Lack of communication between teams can cause errors in the surgical sequence or compromise structures needed for other grafts.

11. Conclusions

Renal procurement is a complex surgical procedure that requires anatomical knowledge, technical precision, and coordination between teams.

The fundamental principles are:

1. Plan the procurement according to the organs that will be procured.
2. Recognize and preserve vascular variants.
3. Obtain adequate cold perfusion.
4. Avoid injury to the pedicles and to the ureteral blood supply.
5. Minimize ischemia times.
6. Perform careful bench surgery.
7. Ensure correct identification, preservation, and transport of the graft.