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Chapter 11
Conclusion
Transplantation has been one of the great success stories of the 20th century, and in our lifetimes has moved from an experimental technique—in the early years, often fraught with catastrophic complications—to a widely performed, often routine, procedure with excellent results. As we progress into the 21st century, the potential for further developments remains undiminished.
Currently, living donation is considered the best option for renal transplantation, with 1-year graft survival rates of about 98%. Paired-exchange schemes, nondirected (altruistic) donations, and extended chains are all ensuring that living-donation rates are increasing. Criteria for donor acceptance are widening—for example, with the use of obese or well-controlled hypertensive donors, or those with urolithiasis—but long-term data on such donors are needed to ensure safety. Antibody-incompatible programs are now increasingly common, and results from blood-group-incompatible renal transplants appear to be comparable with those from compatible living donors. Transplants are being offered to those who would previously have been denied an organ due to human leukocyte antigen (HLA) incompatibility. The newfound focus on antibody-mediated rejection in the last few years will likely improve short- and long-term outcomes; results from trials of new agents such as eculizumab and bortezomib, which may improve outcomes in this group, are eagerly awaited.
Surgical techniques in living donation have undergone a revolution in recent years, with minimally invasive procurement (laparoscopic approach) becoming the standard. Single-port laparoscopy and E-NOTES include some of the recent advances in this area. Robotic assistance has been used and may become more common as the next generation of robots appears, with haptic feedback and cost-efficient and less-cumbersome equipment.
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