Dual kidney transplantation: An Emerging Strategy to Expand the Donor Pool

Deepa. S¹, Subathra Devi M², Maha Lakshmi³

¹Nursing Supervisor, Kauvery Hospital, Cantonment, Tamil Nadu

²Nurse Educator Kauvery Hospital.Cantonment, Tamil Nadu

³Nursing Superintendent, Kauvery hospital, Cantonment, Tamil Nadu

Abstract

Dual kidney transplantation is an evolving surgical approach in which both kidneys from a single deceased donor are transplanted in to one recipient. This strategy is primarily used to expand the donor pool by utilizing marginal or extended criteria donor kidneys that may not provide adequate function if transplanted singly. Nurses play a pivotal role in the perioperative and long -term management of patients undergoing DKT. This article provides a comprehensive overview of dual kidney transplantation with special emphasis on nursing responsibilities, pre-operative assessment, post-operative care, complications patient education and long-term outcomes.

Background

End stage renal disease continues to increase worldwide, while the availability of donor kidneys remains limited. To overcome this shortage transplant centers have begun using kidneys from elderly donors and donors with controlled diabetic mellitus. Dual kidney transplantation is one such approach where both kidneys from an elderly diabetic donor are transplanted into single recipient to improve renal function and graft survival. Although this strategy expands the donor pool, it presents additional nursing challenges related to infection risk.

Introduction

Chronic kidney disease and end –stage renal disease remain major global health challenges. Renal transplantation is the treatment of chronic of ESRD, offering improved quality of life and survival compared to dialysis. However, the persistent shortage of donor organs has led to innovative transplant strategies including dual kidney transplantation.

Dual kidney transplantation involves transplanting both kidneys from a single donor into one recipient to achieve sufficient nephron mass. Nurses are central to ensuring patient safety, early graft function and long- term transplant success.

Case presentation

Hope this case presentation will help to understand the stressful transplant process and development of an early post renal transplant complication can be the whole transplant team. A 59 years old male, known case of chronic kidney disease with end stage renal disease on maintenance hemodialysis and systemic hypertension, was admitted for cadaveric dual kidney transplantation.

Social history: He does not have any social history of cigarette smoking, alcohol addiction.

Allergies: No known medicine or environmental allergies.

Past medical history: Hypertension and End stage renal disease on maintenance hemodialysis.

Past Surgical history: No past surgical history.

Physical Examinations

Vital signs,

Temp	98.6degree farenhit.
HR	94/min,
RR	24/min
BP	160/90mmHg
Spo2	97% in RA
CVS	S1S2 (+)
RS	B/L AE (+)
P/A	Soft

Initial Evaluation

POCUS

Mild LVD
IVC collapsing on breathing.
Lung-No B lines
Abdomen -Free fluid present.

Markable investigations

Haemoglobulin	11.7to 8.1g/dl
WBC	5430 to 8130cells/cmm
Urea	66mg/dl
Creatinine	7.72mg/dl to 2.75mg/dl
ABG	7.32
Na	136mg/dl to 137mg/dl
Pottassium	7.19mg/dl to 3.14mg/dl
Blood group	O positive

Imaging examination (USG Abdomen on 21.12.25)

Tx Kidney in RIF and LIF Region with DJ stent in situ
Thickened and edematous GB wall
Mild to Moderate right pleural effusion.

Initial Evaluation

Pre Transplant Evaluation

Comprehensive multidisciplinary fitness assessment was completed through Pulmonology, Cardiology, Urology and Anaesthesia.
CDC crossmatch: Negative
Donor specific antibodies: Not detected on single antigen bead testing.
Donor Details / Rationale for Dual Kidney Transplant
Donor: 67-year-old female, brain-dead donor from Government Rajaji Hospital, Madurai.
Donor kidneys were small and from an older donor, with normal biopsy and serum creatinine.
In view of donor age and limited renal mass (nephron endowment), both kidneys were allocated and implanted into a single recipient as a Dual Kidney Transplant (DKT) to ensure adequate nephron mass and avoid a marginal single-kidney outcome.

Perioperative Management

Induction immunosuppression: IV methylprednisolone (Solumedrol) and anti-thymocyte globulin (ATLG).

Immediate postoperative period: Moderate urine output, less than typically expected in live donor transplants. Developed delayed graft function (DGF) requiring one session of hemodialysis.

Surgery notes

Dual kidney cadaveric renal transplantation was performed on 16 December 2025. Both grafts were implanted in a single sitting. The intraoperative course was uneventful.

On 16.12.2025: Cadaver renal transplantation done under General anaesthesia

Under SAP, under epidural, under spinal patient in supine position parts painted and draped
Using right modified Gibson’s incision
Layers opened, retroperitoneum entered
Peritoneum retracted upward
Right external iliac artery & vein skeletonised
Bed prepared in RIF
Graft kidney (cadaver left kidney) received after adequate perfusion & bench dissection (single renal artery, single renal vein and single ureter)
Renal artery was anastomosed to right external iliac artery in end to side fashion using 7-0 prolene
Ureter was anastomosed to urinary bladder, after keepin 5Fr DJ stent using 5-0 PDS
20 Fr DT kept in RIF
Using left modified Gibson’s incision layers opened, retroperitoneum entered
Right external iliac artery and vein skeletonised
Bed prepared in RIF
Graft kidney (cadaver left kidney) received after adequate perfusion & bench dissection (single renal artery, single renal vein and single ureter)
Renal vein was anastomosed to left external iliac artery in end to side fashion using 6-0 prolus
Renal artery was anastomosed to left external iliac artery in end to side fashion using 7-0 prolene
Ureter was anastomosed to urinary bladder and after keeping 5 Fr DJ stent using 5-0 PDS
20 Fr DT kept in RIF
Wound closed in layers
Sterile dressing done

Implant details

Implant name	Batch number
Clip Horizon Medium Blue Teleflex	36526082025 / 10026645
Clip Horizon Titanium Small Red Teleflex	48204102025 / 10027190
Clip Horizon Titanium Medium Large Green Weck	54524102025 / 10027452
Stent 5 Fr X 16 Cm Blueneem	65124112025 / 10027903

Post-operative period

The patient remained hemodynamically stable postoperatively.
He had good initial urine output, which subsequently reduced to oliguria, associated with elevated serum potassium levels.
Ultrasound showed good graft perfusion in both transplanted kidneys, with no vascular or urological complication.
In view of oliguria and hyperkalemia, he underwent multiple sessions of hemodialysis for delayed graft function
Following evaluation and optimisation of fluids, blood pressure, immunosuppression and dialysis, urine output improved progressively.
A renal allograft biopsy was performed without complications to evaluate delayed graft function. Histopathology report is awaited.
By postoperative day seven, serum creatinine had improved to 3.1 mg/dL with improving urine output and stable metabolic parameters.
Tacrolimus levels were monitored and remained within the desired range; dosing was adjusted as required.
At discharge, he is stable, ambulant, and clinically improving, with acceptable and improving graft parameters after dual kidney transplantation.

Nursing management

Assess the patient physical psychological and social status
Review medical history comorbid conditions and dialysis history
Monitor baseline vitals body weight and fluid status
Coordinate preoperative dialysis
Obtained informed consent clearly documenting for dual kidney
Collaborate with medical team to plan dual kidney in same sitting
Encourage high protein and iron rich diet
Educate the patient and family about surgical procedure, anesthesia and recovery
Provide emotional and spiritual support
Prepare the OT with adequate equipment and manpower for dual transplantation
Maintain strict aseptic precaution during the procedure
Monitor vital signs, urine output, blood loss continuously
Ensure iv fluid and volume expanders are ready
Monitor haemoglobin/Tacrolimus level and potassium level regularly
Observe the signs of bleeding

Discharge medications

S.No	Drug Name	Strength	Frequency			Route of admin	Relationship with meal	Days
			M	A	N
1	Tab. Vingraf	-	1.5 Mg (7AM)	0	1.75 Mg (7PM)	Oral	Before food	Till review
2	Tab. Mycofit	360 Mg	1	0	1	Oral	After food	Till review
3	Tab. Wysolone	20 Mg	1	0	0	Oral	After food	Till review
4	Tab. Septran ds	1	0	0	1	Oral	After food	Till review
5	Tab. Vagacyte	450 Mg	0	1	0	Oral	After food/ Alternative days	Next dose on 28.12.2025 Till review
6	Tab. Revlamer	400 Mg	1	1	1	Oral	After food	Till review
7	Tab. Ecosprinav	75/20 Mg	0	1	0	Oral	After food	Till review
8	Tab. Nicardia	60 Mg	1	0	1	Oral	After food	Till review
9	Tab. Minipress xl	5 Mg	1	0	1	Oral	After food	Till review
10	Tab .Arkamin	0.3Mg	1	1	1	Oral	After food	Till review
11	Tab. Staha	5Mg	1	0	1	Oral	After food	Till review
12	Tab. Cardivas	6.25 Mg	1	0	1	Oral	After food	Till review
13	Syp. Looz	15 Ml	0	0	1	Oral	After food	Till review
14	Candid mouth paint	-	1 - 1 - 1 - 1			L/A		Till review
15	Chlorhexidine mouth wash	5 Ml	1	1	1	Oral	Before food	Till review
16	Inj. Epo	6000U	1	0	0			3/7 /Last dose on 26.12.2025 next dose on 29.12.2025

Health education

Immunosuppression: Continue tacrolimus, mycophenolate, and steroids as per the advised regimen.

Monitoring: Check urine output daily and report any reduction. Follow up for serum creatinine and tacrolimus levels as scheduled.

Anemia Management: Continue erythropoietin therapy until hemoglobin normalizes.

Weight Management: Adopt dietary modifications and supervised physical activity.

Dietary Advice: Continue renal transplant diet and adhere to prescribed fluid restrictions.

Liver Evaluation: Attend follow-up for planned fibroscan to assess liver status.

Infection Precautions: Maintain strict hand hygiene, avoid crowded areas, and wear a mask in public spaces.

Conclusion

The successful completion of the first dual kidney transplantation in Tamilnadu represents a significant milestone in renal transplantation and offers a promising solution to the persistent shortage of suitable kidney donors. This case demonstrates that kidney obtained from elderly or expanded criteria donors can be effectively utilized when transplanted as a dual graft resulting in satisfactory renal function and improved patient outcomes. Appropriate donor and recipient selection meticulous surgical technique and comprehensive post-transplant nursing care were key factors contributing to the success of this procedure. The experience supports Dual kidney transplantation as a safe and viable strategy to expand the donor pool and may encourage wider adoption of this approach in similar clinical settings.

Dual kidney transplantation is an effective strategy to address organ shortage while maintaining acceptable graft and patient outcomes. Nursing care is integral to the success of DKT encompassing preoperative preparation, postoperative management; patient education and long term follow up. Enhanced nursing knowledge and evidence based practice can significantly improve transplant outcomes and patient quality of life.

Dual kidney transplantation: An Emerging Strategy to Expand the Donor Pool

Dual kidney transplantation: An Emerging Strategy to Expand the Donor Pool

Deepa. S1, Subathra Devi M2, Maha Lakshmi3

Nightingale Journals

Deepa. S¹, Subathra Devi M², Maha Lakshmi³