Physiological rationale and historical background
The kidneys are the body's primary excretory organ. They continuously remove nitrogenous compounds, salts, and protein breakdown products from the body. In addition, the kidneys strictly regulate homeostasis: water balance, ionic composition, osmotic pressure, and acid-base balance (ABB). When they fail, severe, life-threatening disorders develop. As Academician B. V. Petrovsky noted, kidney transplantation has moved from the experimental stage into routine clinical practice, significantly prolonging the lives of such patients.
Historically, the path to success was challenging. The world's first human kidney allotransplantation (from a cadaver) was performed in the USSR by Yu. Yu. Voronoy in 1934. Technically, the operation was successful, but due to the lack of immunosuppressants and preservation methods, the organ did not function, and the patient died. Similar early attempts by R. Lawler in Chicago (1950) and M. Servelle in Strasbourg also ended in rejection and graft shrinkage. The breakthrough came in 1954, when D. Murray in the USA successfully transplanted a kidney between identical twins (isotransplantation). This proved that a genetically identical organ would engraft and that a completely denervated kidney could function normally.
Surgical technique (from a living donor)
Organizing a transplant requires the simultaneous participation of two surgical teams and strict adherence to asepsis. The graft is traditionally placed in the lower abdomen, near the urinary bladder.
The surgical intervention is divided into two key stages:
- Vascular stage: the renal artery and vein of the donor organ are carefully sutured to the recipient's iliac artery and vein, restoring blood flow.
- Urological stage: to ensure urine outflow, the ureter of the transplanted kidney is either implanted directly into the patient's urinary bladder or anastomosed to the stump of their own ureter.
As for the recipient's own diseased kidney, it may be removed either at the time of the transplant or some time afterward.
Overcoming the tissue barrier and donor matching
To prevent immunological conflict, histocompatibility is essential. Matching of ABO blood groups and leukocyte antigens (French scientist J. Dausset identified 14 types) is taken into account.
Several methods are used to determine the degree of compatibility:
- Skin test (P. Medawar and L. Brent): the patient's lymphocytes are injected intradermally into the prospective donor. The stronger the redness and edema, the higher the incompatibility.
- Test skin graft transplantation: the graft from the most compatible donor is rejected the slowest.
- In vitro lymphocyte culture in vitro: donor and recipient cells are co-cultured with the addition of a stimulant — phytohemagglutinin. In case of incompatibility, lymphocytes transform into large immunoactive cells.
Immunosuppression and ischemic protection
Initially, X-ray irradiation was used to suppress immunity. Later, R. Schwartz (1959) discovered the immunosuppressive effect of 6-mercaptopurine in experiments on rabbits, and chemotherapy displaced irradiation. Today, combination therapy is effective: antilymphocyte serum (ALS) coats and destroys lymphocytes in the blood, while reduced doses of azathioprine and prednisolone suppress their proliferation in lymph nodes. In experiments on dogs, this approach maintained kidney function for up to 1.5 years.
A critical task is organ preservation. The kidney is extremely sensitive to oxygen deprivation (ischemia), which drastically increases lipid peroxidation of cell membranes. For pharmacological protection, antioxidants and membrane stabilizers are administered to the donor prior to harvesting. Without cooling, a kidney survives for 1–1.5 hours. With hypothermia (2–4 °C), this period is extended to 3–12 hours. With prolonged preservation (18–24 hours), function recovers only after several weeks.
To remember the essence of combination immunosuppression, imagine a "double hit": serum (ALS) targets lymphocytes in the blood, while medications (azathioprine and prednisolone) suppress their reserve in the lymph nodes.
Class and exam questions
Who performed the first successful kidney transplant and when?
The world's first transplantation was performed by Soviet surgeon Yu. Yu. Voronoy in 1934, although the organ failed to function. The first fully successful experience was an isotransplantation between identical twins performed by J. Murray in the USA in 1954.
Where exactly are the vessels of the donor kidney sutured?
The transplant's renal artery and vein are anastomosed to the recipient's iliac vessels (artery and vein). The organ is placed in the lower abdomen.
How long can a kidney remain outside the body?
Without cooling, the organ dies within 1–1.5 hours. Using hypothermia (2–4 °C) increases preservation time to 3–12 hours, while with prolonged preservation up to a day, function recovers with a delay.
When was the first successful living-donor transplant performed in the USSR?
In 1965, Academician B. V. Petrovsky performed the USSR's first successful living-donor kidney transplantation at the Institute of Experimental and Clinical Surgery.
What else to study on this topic
- Mechanisms of lipid peroxidation during graft ischemia
- Features of anastomosis formation during the urological stage
- History of the development of hypothermic organ preservation methods
- Ethical aspects of isotransplantation and related living donation
- Dynamics of deceased organ utilization in domestic transplantology
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