To analyze the clinical management ofthe renal transplant recipient from a kidney living donor.The renal transplantation (RT) from a living donor withoutsurgical complications has a very low frequency ofacute tubular necrosis (ATN) that facilitates enormouslythe clinical control. The scheme of follow-up after-RTmust include: (1) Hemodynamic monitoring; (2) Clinicalmanagement; (3) Renal allograft monitoring: renalfunction, diuresis, radionuclide imaging and ultrasound-Doppler; (4) Pharmacological treatment: analgesia,gastric protection, antibiotic prevention; (5) Monitoringof the immunosuppressive therapy; (6) Digestive monitoring;(7) Control of the cardiovascular risk; (8) Preventionsinfectious; (9) Osteodistrophia control. In living donor RTa rapid normalization of the renal function and a timeof hospitalization reduced are observed. The presenceof a long ATN or a renal dysfunction of the graft mustforce to realize an early renal allograft biopsy.

Despite representing a small percentageof the transplant activity in our country, living donorkidney transplantation is a good alternative for the futurebecause the needs exceed the offer of cadaver donororgans. We present the evolution of living donor kidneytransplantation in Spain from the beginning in accordanceto the ONT (Organización Nacional de trasplantes),and our current situation in comparison with othercountries, as well as data obtained from the experiencein our hospital which began in 1965.

Living donation for kidney transplantationis being promoted due to the shortage of organs, theimproved outcomes of living donor transplants and theevolution of immunosuppression regimens. The processof organ donation from a living donor affects not onlymedical-surgical features but also emotional, social andeconomic. Using kidneys from living donors involves agreat responsibility in evaluation and selection.Candidates for donation undergo an extensive set ofexaminations in order to optimize selection and to plansurgery. Radiological evaluation is one of the mostimportant features of the evaluation process and selectionof the kidney; it shows precisely the renal vascular anatomy, which is decisive in the choice of the kidneyand helps to optimize the process and diminish risks andcomplications during extraction and/or transplantation.The advantages on imaging tests allow to evaluatepotential donors in a safely, fast and almost noninvasive matter. The aim of the process is to select the kidneywith less likelihood of failure due to technical reasons,and always leave the best kidney for the donor.

We briefly describe the current twosurgical techniques for living donor nephrectomy. Theshortage of cadaver donor organs and progressiveacceptation of laparoscopic procedures have significantly increased the number of living donor transplants in ourenvironment.Laparoscopic nephrectomy is being rapidly andprogressively incorporated to the therapeutic armamentariumin most hospitals. It is a new ally in eliminatingreluctante and increasing the number of renal grafts fortransplantation.We can say that nowadays most transplant centresperform exclusively laparoscopic donor nephrectomy.

Glomerular diseases are an importantand frequent cause of renal transplant graft loss in themid-long term, mainly due to primary renal diseaserecurrence. Glomerular diseases have particularconnotations in living donor kidney transplantation, dueto the risk of primary disease recurrence and subsequentgraft loss, and also the risk of development of glomerulardisease related donors have for their genetic similitude.The incidence of glomerular disease recurrence aftertransplantation varies with type, being especiallyfrequent in IgA nephropathy and type II membranousproliferative glomerulopathy. The difference betweenhistological and clinical recurrence should always beestablished, being much more frequent the first. Renalbiopsy is the essential diagnostic test to detect and confirmthe existence of glomerular disease after transplant, withimmunofluorescence study being necessary to determinethe type of glomerular disease.

OBJECTIVES: The objective of this paper is to review the various surgical techniques for living donor kidney transplantation. METHODS: We perform a bibliographic review adding our experience in living.kidney transplantation. RESULTS: We present various techniques indicating which one is the most appropriate for each case. CONCLUSIONS: We should promote living door kidney transplantation if we want to increase the number of transplants performed. It is a complex transplant because the graft lacks of vascular patches; there are various surgical techniques that we can choose depending on the case.

Living donor kidney transplantation hasbecome the option of preference for the treatment ofendstage renal disease, whenever its performance ispossible.The advantages of patient and graft survival should bebalanced with risks associated with donation.Therefore, the evaluation of candidates for living donorkidney transplantation is mainly the comprehensiveevaluation of these risks: medical, psychological, socialand economic. Evaluating risks implies we are treatinga controversial process, the medical progress, which ismodifiable with time, even in the family and/or socialenvironment of the donor-receptor couple. Short andlong-term safety of living donor nephrectomy is directlyengaged to the existence of a healthy donor. This he isthe main objective of standard evaluation of candidates.Currently, with a growing demand of this option, minor abnormalities or risk factors detected during evaluationdo not always become a formal contraindication, butwe should try to establish a most objective threshold forthe acceptance of donors in all evaluated spheres, for surgical risks and others directly related or not with renalmass reduction, and even for those engaged to the existenceof a genetic link between donor and receptor, whichmight determine the presence of any future primaryrenal disease. As for other donation types, the process of evaluationshould also ensure minimal risks for the receptor, withthe same safety criteria applied to cadaver donors.We can conclude that careful evaluation of candidatesfor living kidney donation is the best guarantee for theirsafety and transplant success, and, in our opinion, it isthe best instrument to offer an adequate informed consent.

The first successful kidney transplant inSpain was performed in 1965. It`s been forty yearsalready and currently Spain is the country with thehighest cadaver donation rates worldwide. The so-calledSpanish model of transplantation is well known for itsorganization and excellent results. These results arethe consequence of a perfect network organization.Furthermore, the organ procurement organization -Organización Nacional de Trasplantes-, regionalcoordinators, national health system hospital network,hospital transplant coordinators, and all professionalsinvolved in the process of donation and transplantationhave perfectly well defined functions and work with thecommon objective of optimizing resources and makingthe most of the opportunities.Provided that one of the main characteristics of theSpanish model is the possibility of adaptation to themoment’s necessities, we proceed to review and evaluateit from its beginning to current days.

Living donor kidney transplantation is thebest therapeutic option for endstage renal failure. Inspite of being an underused option in our country, itacquires an important role reducing the waiting lists fortransplantation because cadaver donation is notenough. Living donor kidney transplantation offers multipleadvantages when compared with cadaver donortransplantation: longer graft and patient survival on theshort, mid and long-term; the fact that a scheduledprocedure allows us to optimize donor and receptor´sconditions; and ischemia time between nephrectomyand transplantation can be shortened to a minimum. Agood initial function without need of dialysis (up to 90%)and lower incidence of rejection, which diminishes theneed of antirejection drugs, should also be emphasized.

Donor kidney transplantation’s graft andpatient survivals are better than cadaver donor’s. InSpain, living donor kidney transplantation hardlyaccounts for 1% of transplant activity in comparison to60% in United States. Accordingly to bibliography, theexperience of the Renal Transplant Unit of the HospitalClinic de Barcelona has demonstrated better graft andreceptor survival for living donor recipients. The analysisof 184 living donor kidney transplants and 1678 cadaverdonor transplants performed between 1978 and 2002showed that graft survival was higher in the group ofliving donors (p < 0.01). At the same time, graft survivalwas clearly better in receptors of HLA haploidenticalgrafts (n =142) (p < 0.05). The introduction of newand better immunosuppressive drugs, as well as betterdiagnostic and therapeutic management of acute rejection,prophylaxis for infections, and control of complicationshave contributed to better results. The absence of acuterejection between 1978 and 1983 was 45.1%,between 1984 and 1998 was 57.3% and 84.7%between 1999 and 2003.In conclusion, these results demonstrate better graft andpatient survival for living donor kidney transplants incomparison with cadaver donor receptors. Altogetherwith the low risk involved for donors should incentivateauthorities, professionals, and patients to promote thesetherapeutic option by means of adequate informationand wider diffusion. Living donor kidney transplantationshould contribute together with cadaver kidneytransplantation to lessen our long waiting lists, becausethey are not excluding options.

OBJECTIVES: Living donors for kidney transplantation have attracted interest from different points of view because medical issues are accompanied by other features involving ethical, legal and socialissues. We analyze all aspects involved in living donation for kidney transplantation.METHODS: we analyze: 1. Ethical issues: requirements to become living donor, donor-receptor relationship, informed consent, donor’s motivations, risk/benefit. 2. Legal issues: We review Spanish laws and Council of Europe’s recommendations. 3. We also analyze how to coordinate the process in order to guarantee protection to donors.RESULTS/CONCLUSIONS: Living donor kidney trans-plantation is a growing therapeutic option. The process of living donation should comply with several legal and ethical requirements, and cooperation between different professionals to guarantee protection todonors.

The increase of living donor kidneytransplants has prompted new interest for better knowledgeof the risks of mobidity and mortality and long-termconsequences of nephrectomy. Peroperative morbidityvaries in revised series, partially in relation to surgicaltechnique: laparoscopic or open nephrectomy. Wereview the most frequent complications by surgicaltechnique. In the long term, the causes of mortalityamong donors are similar to general population withaging

Currently, kidney transplantation is the treatment of choice in children with end stage renal disease, showing higher survivals than dialysis and proper weight-height, social and psychological -intellectual development. The indications for transplantation have been extended with time, so that today the indication for kidney transplantation is set for end stage renal disease with symptoms that cannot be eliminated by conservative treatment. In the pediatric age, mainly in children under two years, living donor kidney transplantation is specially indicated because it has longer survival than cadaver donor kidneys. Complications may appear: rejection, high blood pressure, infections, neoplasias, adverse events related to immunosuppressive drugs, and primary renal disease recurrences, besides surgical complications. Five-year results have improved over the last 5 decades, being mortality lower than 5%. Graft survival may reach 90% for living donor kidneys and 17% for cadaver donor. Factors related to graft survival include age (worse in receptors under 2 yr.), pretransplant dialysis, acute rejection, and race (better in caucasians).