Kidney Transplant
5036050365wRVU: 44.98 — Renal transplant with concurrent recipient nephrectomy50380wRVU: 29.36 — Renal autotransplantation50200wRVU: 2.32 — Renal biopsy, percutaneous (if intraoperative biopsy performed)
End-stage renal disease: [diabetic nephropathy / FSGS / IgA nephropathy / hypertensive nephrosclerosis / polycystic kidney disease]
Same
Deceased donor [/ living donor] renal transplant, right [/ left] iliac fossa
[Attending name], MD
[Fellow/Resident name]
General endotracheal
Patient presents with end-stage renal disease secondary to [etiology] on [hemodialysis / peritoneal dialysis] since [date]. [Preemptive transplant / living donor / deceased donor, PRA [X]%.] Cross-match [negative / virtual negative]. HLA mismatch [X]/6. CMV: donor [+/-], recipient [+/-]. Cold ischemia time [X] hours. Induction immunosuppression: [basiliximab / thymoglobulin]. Risks including delayed graft function, primary non-function, rejection, vascular thrombosis, ureteral leak, lymphocele, and death discussed. Consent obtained.
Kidney [appeared viable / showed [some mottling / excellent perfusion] on back table]. Bench preparation included [ligation of accessory vessels / double renal arteries anastomosed to Carrel patch / ureteral stent placed]. On reperfusion, kidney [pinked immediately / had delayed reperfusion]. Excellent urine output noted intraoperatively.
The patient was positioned supine. A [right / left] curvilinear iliac fossa (Gibson) incision was made. The external oblique, internal oblique, and transversalis fascia were divided. The retroperitoneal space was developed. The external iliac artery and vein were dissected free and controlled with vessel loops.
The kidney was brought to the field. The renal vein was anastomosed end-to-side to the external iliac vein using running [5-0 / 6-0 Prolene]. The renal artery was anastomosed end-to-side to the external iliac artery using running [5-0 / 6-0 Prolene]. Clamps released; [excellent perfusion, immediate turgidity and color change]. Urine noted in ureter within minutes of reperfusion.
Ureteroneocystostomy was performed using the [Lich-Gregoir extravesical technique]. A [4-0 Vicryl / 3-0 Vicryl] running anastomosis was performed. A [double-J ureteral stent / no stent] was placed.
Hemostasis confirmed. [A closed-suction drain was placed near the hilum.] Fascia closed with running PDS. Skin closed with staples. Patient tolerated the procedure well.
None
[Back-table tissue biopsy sent / None]
[X] mL
[Closed-suction Jackson-Pratt drain / None]
Patient taken to transplant ICU / floor in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: End-stage renal disease: [diabetic nephropathy / FSGS / IgA nephropathy / hypertensive nephrosclerosis / PKD]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Deceased donor [/ living donor] renal transplant, [right / left] iliac fossa
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with ESRD secondary to *** on [hemodialysis / peritoneal dialysis]. [Deceased donor / Living donor.] Cross-match negative. HLA mismatch ***. CMV D/R: ***. Cold ischemia time: *** hours. Induction immunosuppression: [basiliximab / thymoglobulin]. Risks including DGF, primary non-function, rejection, vascular thrombosis, ureteral leak, and lymphocele discussed. Informed consent obtained.
FINDINGS: Kidney appeared viable with [excellent / adequate] bench anatomy. [Double renal arteries / Carrel patch / Single artery.] On reperfusion: [immediate turgidity and color change / delayed reperfusion]. Urine output noted intraoperatively.
DESCRIPTION OF PROCEDURE:
Patient supine. [Right / left] Gibson incision; retroperitoneal space developed; external iliac artery and vein dissected and controlled with vessel loops. Renal vein anastomosed end-to-side to external iliac vein with running 5-0 Prolene. Renal artery anastomosed end-to-side to external iliac artery with running 5-0 Prolene. Clamps released; excellent perfusion confirmed. Ureteroneocystostomy via Lich-Gregoir extravesical technique; [double-J ureteral stent placed]. Hemostasis confirmed. [JP drain placed at hilum.] Fascia closed with PDS; skin with staples. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Back-table biopsy to pathology / None]
COMPLICATIONS: None
DRAINS: [JP drain / None]
DISPOSITION: Patient to transplant [ICU / floor] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Living donor kidney transplant
Same implantation technique. Note shorter cold ischemia time and typically better graft quality. Document donor relationship. Back-table preparation may be simpler (single artery, shorter ureter).
Dual kidney transplant (marginal donors)
Both kidneys placed in same recipient, typically from older or marginal donors. Document dual implantation, individual anastomoses, and rationale for dual placement.
Transplant with recipient nephrectomy
CPT 50365. Document indication for concurrent nephrectomy (infection, hypertension, massive polycystic kidneys). Performed through same Gibson incision or separate midline incision.
Charting Tips
- Document cold ischemia time and warm ischemia time
- State number of renal arteries and veins and anastomotic technique for each
- {'Note reperfusion quality': 'immediate vs. delayed, color, turgidity, urine output'}
- Document ureteral stent use and planned removal date (typically 4-6 weeks)
- Record drain placement location and output at end of case
- Induction immunosuppression agent should be in the operative note
Billing Tips
- Bill 50360 for renal transplant, including care of the donor organ (implantation only, 30.17 wRVU, 90-day global). Bill 50365 when transplant includes a concurrent nephrectomy of the recipient's native kidney (33.24 wRVU). Use 50360 for the straightforward implantation.
- Deceased donor kidney procurement (back-table preparation and retrieval) is not separately billable by the transplanting surgeon. It is covered by the transplant center's organ acquisition cost. The implanting surgeon bills 50360 regardless of whether the organ came from a deceased or living donor.
- Vascular anastomosis revisions or ureteral revisions performed at the same session are included in 50360. Do not separately bill anastomosis codes. Document all anastomoses performed.
- 90-day global period: biopsy of the transplanted kidney (use 50200 for percutaneous renal biopsy), rejection workup visits, and Doppler surveillance are not separately billable surgical fees within 90 days but generate radiology/pathology fees independently.
- Immunosuppression management, biopsy interpretation, and nephrology co-management are physician E/M services billed independently by the respective providers and are not included in the surgical global.