Residente Urologia CES Trasplante Renal Pablo Sierra S. Residente Urologia CES

Historia Emerich Ullman 1902 Primer reporte de trasplante renal exitoso Autotrasplante vasos del cuello perro 5 dias

Historia Alexis Carrell 1905 Metodo moderno de sutura vascular Nobel 1912

Historia R. Stitch 1907 Autotrasplante Ureteroneocistostomia

Historia M. Jabulay 1906 Marrano - Humano Cabra - Humano Horas duracion

Historia Ernst Unger 1909 Foxterrier - Boxer 14 dias orina Mortinato - Simio No funciono, pero anastomosis intacta Simio - Humano Barrera bioquimica Fallo el trasplante pero la anastomosis quedo intacta, planteo similitud entre simios y humanos y la posibilidad de que existiera un barrera bioquimica

Historia Carrell - Murphy - Landsteiner 1914 NY Todos los esfuerzos comienzan a centrarse hacia la respuesta inmunologica pues la tecnica qx ya estaba depurada Carrell - Murphy - Landsteiner 1914 NY Benzol o Radiacion aumenta la aceptacion de organos Esfuerzos hacia respuesta inmunologica

Historia Hamburguer- Kuss-Dubost- Servelle 1950 Paris Tx Madre - Hijo 22 dias Tecnica actual Hubo una brecha en que se dejo de investigar pues era muy dificil saber si el tx estaba funcionando o no pues no se contaba con cr ni bun Paris hamburguer nefrologo con la ayuda de kuss dubost y servelle. kuss describe la tecnica actul y ubicacion en fosa iliaca uno de los primeros casos que duro algo. no se uso inmunosupresion

1948 Cortisona estos personajes describen el funcionamiento de las hormonas suprarrenales por lo que les dan el nobel el descubrimiento de la cortisona tuvo un efecto inicialmente alentador, pero posteriormente con el descubren que tiene mejor efecto induciendo tolerancia... con radiacion

Irradiación corporal total Posteriormente se utilizo radiacion subtotal

Historia Hemodialisis 1953 Uso de hemodialisis para preparar los pacientes y llevarlos en mejores condiciones al trasplante

Historia David M Hume 1953 10 trasplantes Pierna 6 meses función Boston Murio en un accidente aereo

J. Murray Trasplante entre gemelos monocigotos funciono 8 años, el paciente murio de IAM

1962 Azatioprina solo 1 de 12 de gemelos no identicos no tuvo rechazo

Optimismo Tx no relacionado 1960 Inmunosupresion 6 mercaptopurina + Metotrexate Azatioprina + prednisona + irradiacion subtotal Mejor dialisis, retorno 1968 2do Tx posible 1969 Preservacion Collins 1970 HLA 1970 Ciclosporina 1990 Tacrolimus - Micofenolato - MTOR con la mejoria en la dialisis ya era posible que si el tx fallaba, quedaba el retorno a dialisis

Extracción

44–4, cont’d. D, The aorta and IVC are controlled below the renal vessels, heparin is administered to the donor, and the great vessels are cannulated. The proximal aorta is occluded, the IVC is vented into the chest or through the distal IVC cannula, and in situ flushing with an ice cold preservation solution is performed through the aortic cannula. E, The gastrocolic ligament is divided, the small bowel mesentery is divided along with the superior mesenteric artery and vein, and the small bowel is divided at the ligament of Treitz. F, The esophagus is divided, and, with further dissection, the en bloc specimen consisting of the liver, stomach, spleen, pancreas, both kidneys, aorta, and IVC is removed. G, The specimen is placed “face down” in a pan of slush and is separated, first, by splitting the aorta posteriorly between lumbar arteries to identify all renal arteries; second, by transecting the aorta between the superior mesenteric artery and the renal arteries; third, by splitting the anterior aortic wall between the renal arteries; fourth, by transecting the IVC just above the entrance of the renal veins; and fifth, by dividing the left renal vein where it enters the IVC. (A and B, From Barry JM. Cadaver donor nephrectomy. In: Novick AC, Streem SB, Pontes JL, editors. Stewart’s operative urology. Baltimore: Williams & Wilkins; 1989. p. 294– 300; C-G, from Barry JM. Donor nephrectomy. In: Marshall FF, editor. Textbook of operative urology. Philadelphia: WB Saunders; 1996. p. 235–47.)

Elongación vena renal Figure 44–5. A-G, Methods of extending the right renal vein include modifications of the IVC and a free graft of donor external iliac vein. The first two methods are valuable when the cephalad portion of the right renal vein has been compromised by the separation of the liver graft from the kidney grafts. (A and B, From Barry JM, Lemmers MJ. Patch and flap techniques to repair right renal vein defects caused by cadaver liver retrieval for transplantation. J Urol 1995;153:1803; C, from Barry JM, Fuchs EF. Right renal vein extension in deceased kidney transplantation. Arch Surg 1978;113:300; D and F, from Barry JM, Hefty TR, Sasaki T. Clam-shell technique for right renal vein extension in cadaver kidney transplantation. J Urol 1988;140:1479; E, from Corry RJ, Kelley SE. Technic for lengthening the right renal vein of cadaver donor kidneys. Am J Surg 1978;135:867; G, from Nghiem DD. Spiral gonadal vein graft extension of right renal vein in living renal transplantation. J Urol 1989;142:1525.)

Doble Arteria renal Preparation of the kidney transplant with multiple renal arteries. A and B, Use of aortic patches when the kidney is from a deceased donor. C and D, Pair of pants or three-legged pair of pants is used when an aortic patch is not available, such as when the kidney is from a living donor. E, Anastomosis of segmental renal artery to main renal artery. The segmental renal artery can also be anastomosed to the inferior epigastric artery using an end-to-end technique.

Trasplante Antibiótico Profiláctico: Cefalosporina Si nefrectomía por enf renal poliqustica: Fluoroquinolona Inmunosupresión previo o durante cirugía fluoroquinolona penetra los quistes

Sonda 3 vias (identificacion y lavado vejiga) Paciente > 20kg extraperitoneal contralateral FID vasos mas superficiales Preservacion del cordon espermatico para llenar y vaciar vejiga de solucion con antibiotico. ligera extension y rotacion lateral izq hacia el cirujano exposicion Gibson o rutherford (kuss) en ptes obesos preferir FID por vasos mas superficiales se liga el ligamento redondo en las mujeres

The renal vein is anastomosed to the external iliac vein, usually medial to the external iliac artery. When the recipient has a tortuous iliac artery, the venous anastomosis is best performed lateral to the bowed external iliac artery. B, In the absence of significant recipient arteriosclerosis, the renal artery is commonly anastomosed to the internal iliac artery with 5-0 or 6-0 monofilament, nonabsorbable sutures. Many prefer to perform the renal artery anastomosis before the venous anastomosis. If significant internal iliac arteriosclerosis is present or the contralateral renal artery has been used in a previous renal transplant in a man, the external or common iliac arteries become the target vessels for renal artery anastomosis. C, The completed venous and arterial anastomoses. Tener la precaucion de que si se usa la vena iliaca interna en un lado y el paciente sera trasplantado dos riñones, en el otro ldo se debe usar la externa: impotencia vascular uso de heparina cuando se hace el clampaje?, manitol? verapamilo (reperfusion injury) furosemida (previo a soltar el clampaje)

Reimplante Ureterovesical Three examples of extravesical ureteroneocystostomy. A, An anterolateral seromuscular incision is made down to the bulging bladder mucosa. The bladder is drained, the mucosa incised, and the ureter anastomosed to the bladder (as shown) with fine absorbable sutures. A distal anchoring stitch to hold the ureter to the bladder is used to prevent proximal migration in the tunnel (not shown). The seromuscular layer is then loosely closed over the ureter. Lych Gregoir

Reimplante Ureterovesical B, Steps a through c are completed with the bladder full of an antibiotic solution. The anesthesiologist unclamps the catheter before mucosal incision, and steps d through g are completed with fine absorbable sutures. Barry

Reimplante Ureterovesical C, Double-needle mattress suture is placed through the spatulated ureter, the ends of the suture and ureter are introduced into the bladder lumen, and the suture is tied outside the bladder wall. If the seromuscular incision is too large, it is closed over the ureter with interrupted fine absorbable sutures.

Reimplante Ureterovesical Transvesical ureteroneocystostomy. A, A No. 8-Fr catheter is passed through the submucosal tunnel and tied to the transplant ureter. B, The ureter is drawn through the tunnel, transected, and anastomosed to the bladder with fine absorbable sutures. The distal suture anchors the ureter to the bladder muscularis. Finally, the cystotomy is closed with one or two layers of absorbable sutures.