Download - Renal Transplant
RENAL TRANSPLANTATION
PROF DR MOHAMMED YOUSSIFPROF DR MOSTAFA SAEID
NAIM HAZIMI BIN YAHYA 10-5-240
Introduction & Indication
Introduction
• Kidney / renal transplantation is the organ transplant of a kidney into a patient with end-stage renal disease
• End-stage renal disease is the name for kidney failure so advanced it cannot be reversed
• Dialysis and kidney transplantation are the only treatments for this condition
Dialysis vs TransplantCriteria Dialysis Transplant
Life expectency 5+/- years Up to 20 years
Cost Cheap, but require lifelong Expensive, one time
QOL Not good Better than dialysis (diet, energy)
Etc. Restrictive life Long waiting list
Indication
• DM• Malignant HTN• Glomerulonephritis• Hereditary (polycystic kidney) -AD-• Lupus• Tumour(??)
75%
NAWAR NADHRAH BINTI ABDUL WAHID
10-5-241Contraindications for Kidney
Transplantation
Absolute Contraindication
Life threatening condition:-untreated cancer
-infection that cannot be treated
-uncorrectable heart disease
History of chronic non-compliance to treatment:
-affect ability to fully care for themselves
History of chronic and ongoing drug/ alcohol abuse
that cannot be treated :Risk to continue abusing
after transplantation
History of serious psychiatric disease that cannot
successfully treated :Risk for ongoing increased
severity
Relative Contraindication Treated malignancy.
-The cancer-free interval required will vary depending on the stage and type of cancer.
-Consultation with a board-certified oncologist is required in most cases.
-Most centers need 2-5 years of cancer free diagnosis before he could be enlisted in the
candidate to receive living donor organ.
Substance abuse history.
-Patients must present evidence of involvement in at least 12 months of drug-free
rehabilitation.
-This includes written documentation of participation in rehabilitation including negative random
toxicologic screens.
Chronic liver disease.
-Candidates with chronic hepatitis B or C or persistently abnormal liver function testing must have
hepatology consultation prior to transplantation.
Cardiac disease. -All patients over the age of 55 or those with a history of diabetes, hypertension, or tobacco abuse must have dobutamine stress echocardiography, or exercise or pharmacologic stress cardiac scintigraphy. -Any patient with a history of a positive stress test or history of congestive heart failure must have cardiology evaluation prior to transplantation.Structural genitourinary abnormality or recurrent
urinary tract infection.-Urologic consultation is required prior to transplantation.
Past psychosocial abnormality. -Master of Social Work (MSW) or psychiatry evaluation, as appropriate.Aortoiliac disease.-Patients with abnormal femoral pulses or disabling claudication, rest pain or gangrene will require evaluation by a board certified vascular surgeon prior to consideration.-Patients with significant aortoiliac occlusive disease may require angioplasty or aortoiliac grafting prior to transplantation.
NUR AFIQAH AUNI ZAWAWI 10-5-242
Prognosis and Outcomes of Renal Transplantation
Overall, average kidney survival times are:• 1 year – 85-95%• 5 years – 70-80%
• 15 years – 50-60%
• Kidney transplantation is a life-extending procedure. • People generally have better quality of life, and fewer
complications with a kidney transplant than if they stay on conventional dialysis.
• The typical patient will live 10 to 15 years longer with a kidney transplant than if kept on dialysis.
Factors that may affect prognosis
1. Deceased and living donors2. Age of donor and recipient3. HLA-matching4. Cold ischaemia time5. Time on dialysis6. Overall health of the person
receiving the donation
NUR AFIQA BINTI ROSLAN 10-5-243
Preprocedural Care
Basic Pretransplant Studies
Pysical examination
Chest x-rayElectrocardiogram
EchocardiogramUltrasound with doppler
examinationPulmonary function
Upper GI seriesLower GI series
Viral testingMammogram
Pap smearDental evaluations
Blood testsBlood typingTissue typing
Panel reactive antibody (PRA)
Renal function studies
Donor GFR at least 80 ml/minCT – Renal
vasculature and parenchymal abnormalities
Steps will precede the transplant
Explain the procedure
Receive dialysis (on
routine)
Living transplant ( fast 8 hours)
Cadaver organ transplant (fast when
notified kidney available)
Receive sedative
sign a consent
Other specific preparation
(based on medical condition)
NUR AKMA ZAINAL SHAHROM10-5-244
Matching of Donors and Recipients
Histocompatibility (HLA) matching
• transplant outcome correlates with number of HLA mismatches.
• HLA incompatibility proliferation & activation of recipient’s
CD4+ & CD8+ T-cells activation of B-cell allo-antibody
production cellular and humoral graft rejection
• HLA-A, HLA-B, and HLA-DR phenotypes should be determined in all
potential recipients and donors.
Cross-matching• detects preformed allo-antibodies in recipient’s serum
directed against lymphocytes of the potential donor.
• carried out using unseparated lymphocytes or T-
enriched lymphocytes of the potential donor
• complement-dependent lymphocytotoxicity (CDC)
assay.
• positive T-cell cross-match is a contraindication to
transplantation.
Panel Reactive Antibodies (PRA)• results of HLA-antibody testing in a recipient’s serum expressed
as the percentage of panel reactive antibodies (%PRA) and as
the HLA specificity against which these antibodies react
• Sera from potential organ recipients screened for HLA-specific
antibodies every 3 months or 2 and 4 weeks after every
immunising event.
• flow cytometry & ELISA (use solubilised/recombinant HLA
molecules instead of lymphocytes more specific &
sensitive
ABO compatibility
• blood group antigens can behave as
strong transplant antigens.
• incompatibility in the ABO antigen system between donor and
recipient can cause early HAR (hyper-acute rejection).
• introduction of antibody elimination methods and anti-B cell
agents increased numbers successful ABO-incompatible
transplantations (even without splenectomy).
NURUL IMAN BINTI ZULKEFLI10-5-245
Postoperative Care
POSTOPERATIVE MANAGEMENTPostoperative management involves 2 key tasks :
1) Maintain the normal fluid balance.With improving renal function:
• fluid balance must be maintained• hypertension management may need modification, and• electrolyte abnormalities may require correction.
2) Administration of immunosuppression.Current immunosuppressive therapy can be divided into 2 phases : induction and maintenance
IMMUNOSUPPRESSIVE DRUGSCalcineurin inhibitors
•Cyclosporin•Tacrolimus•Sirolimus
Antiproliferative agent
•Mycophenolate
Steroid
•Prednisone
IMMUNO SUPPRESSIVE
DRUGS
EXAMPLE OF DRUGS NAME
MECHANISM OF ACTION SIDE EFFECTS ADVANTAGES
Calcineurin inhibitors
CyclosporineTacrolimus
Target proliferating T cells by blocking the elaboration of cytokines
•Dose-related nephrotoxicity•Hypertension
Antiproliferative agent
Mycophenolate Inhibits de novo synthesis of purines during the S phase
•Nausea•Diarrhea
reduces interstitial fibrosis associated with chronic rejection in animal models
Steroid Prednisone •bone disease•hypertension•peptic ulcer disease•glucose intolerance•growth retardation•infection•obesity•lipid abnormalities
A key role in induction and maintenance of immunosuppression and in treatment of rejection
NURUL AQMAR MOHD SUHAIMI10-5-246
Technique Of Living Donor Renal Transplantation
LAPAROSCOPIC DONOR NEPHRECTOMY
• Tiny incisions and a scope or camera• Shorter recovery period • Complication rate : very low• Quality and function of the transplanted kidneys are excellent.• significantly better long-term survival than kidneys from a
deceased donor• New technique - Embryonic natural orifice transumbilical surgery (e-NOTES) - Laparoendoscopic single site (LESS) surgery
• Blood Type Incompatible• Paired Exchange• Plamapheresis• Positive Crossmatch• Waiting List Exchange• Blood Type Incompatible
Kidney Transplant
Potential Barriers to Living Donation• Age < 18 years• Uncontrollable hypertension• History of pulmonary embolism or
recurrent thrombosis• Bleeding disorders• Uncontrollable psychiatric illness• Morbid obesity• Uncontrollable cardiovascular disease• Conronic lung disease• History of melanoma• History of metastatic cancer• Bilateral or recurrent nephrolithiasis
(kidney stones)• Chronic Kidney Disease (CKD) stage 3 or
less• Proteinuria > 300 mg/d excluding
postural proteinuria• HIV infection
Special programs for living donor transplants
NURULZIANI IZZATI BINTI MOKHTAR10 – 5 – 248
Renal Transplantation from
Deceased Donor
• Deceased donor can be divided into two groups:
Brain-dead (BD) donors
Cardiac Death (DCD) donors
• their heart and body is maintained alive but their brain has died.
• Their bodies are maintained on a breathing machine
• their families are asked to give consent for their organs to be used for transplantation
• patients who do not meet the brain-dead criteria
• They have unlikely chance of recovery,
• elected via a living will or through family to have support withdrawn
special priorities for transplantation:
•HLA zero-mismatch pairings (because of their documented improved graft survival rate)•Pediatric recipients (to minimize the impact of chronic renal failure on growth)•Patients with a high panel-reactive antibody titer (to increase their probability of transplantation)
CONTRAINDICATIONS:• active infections• HIV infection• extracranial malignancy• poor renal function in the donor • advanced donor age
ADVANTAGES
50/50 chance of maintaining their function for 10-20 years post-
transplant
50-60% are fully functional immediately upon transplantation
living donor does not need to undergo a kidney donor operation
which has associated discomforts and risks
a kidney can last up to 72 hours before being transplanted due to: advances in preservation techniques
• Intravascular perfusion of the involved organs with cold (ie, 4°C) preservation solution (UW solution) which contain:
high levels of potassium impermeant sugars albumin or dextrans free radical scavengers and other
agents (eg, allopurinol)
kidneys are removed with care
packed sterilely in UW solution and kept at 4° C during transport to the appropriate transplant centers
NURUL ATIQAH BINTI ABU SAHMAH10-5-250
Ureteroneocystostomy & Ureteroureterostomy in Renal
Transplant
URETERONEOCYSTOSTOMYUretero-neo-cysto-stomy (UNC):• Means reimplantation of the ureter into the bladder.• UNC is performed by bringing the ureter through a
tunnel in the bladder submucosa (Leadbetter-Politano approach).
URETEROURETEROSTOMYUretero-uretero-stomy (UU):• Means anastomosis of the segments of ureter, with
excision of the intervening injured or scarred ureter
Maybe a direct uretero-ureterostomy (end-to-end) or transuretero-ureterostomy (end-to-side)
• Only done if anastomosis of the ureter to the bladder ureteroneocystostomy (UNC) is not possible. – Defunctionalized native’s (recipient) bladder– Devascularized donor’s ureter
End-to end End-to-side
NURUL AWATIF BINTI ABD RAHMAN 10-5-251
Complications of Renal Transplantation
Anatomic complications of surgery• Renal artery thrombosis is a complication most commonly seen in the
hospitalization period immediately after transplantation. It is caused by a low-flow state from hypotension or vascular kinking due to surgical error.
• Renal artery stenosis is typically a later complication. It presents as uncontrolled hypertension, allograft dysfunction, and peripheral edema.
• Urine leaks occur at the ureterovesical junction .They result from disruption of the anastomotic connection of the ureter to the graft, generally within the first 2 months after transplantation.
• Ureteral stenosis and obstruction are relatively late complications, occurring months or years after.Ultrasonography reveals hydronephrosis.
• Lymphocele, a circumscribed collection of retroperitoneal lmph as a result of operative trauma to lymphatics. It presents as a mass at the graft site that can impinge on and obstruct the ureter.Occuring 1-2 months after transplantation.
Computed tomographic- angiography demonstrates (arrow) a proximal stenosis of the transplant kidney artery.
Allograft dysfunction and rejectionHyperacute rejection -happens in the operating room within hours of the
transplant.- due to unrecognized compatibility of blood groups A, AB, B, and O (ABO) or to a positive T-cell crossmatch (class I human leukocyte antigen [HLA] incompatibility)
Acute rejection -appears within the first 6 months after transplantation- Rejection is secondary to prior sensitization to donor alloantigens (occult T-cell crossmatch) or a positive B-cell crossmatch.
Chronic rejection -rejection occurs more than 1 year after transplantation and is a major cause of allograft loss.-Requires clear strong evidence for a solely chronic immunological process.- Certain non-specific histological features and/or anti-HLA antibodies.
Infections
• Infection due to the immunosuppressant drugs that are required to decrease risk of rejection.
• Infection most commonly occurs in mucocutaneous areas , the urinary tract , and the respiratory tract .
• Cytomegalovirus , herpes simplex virus , and varicella-zoster virus are the most frequent viral pathogens. Infection is the most common cause of death, such as pneumonia.
Malignancy -Transplant recipients higher risk for many cancers than
members of the general population as a result of the following factors:
• Chronic immunosuppression• Chronic antigenic stimulation• Direct neoplastic action of immunosuppressants
-Transplant recipients are at particularly high risk for infection-related malignancies, such as non-Hodgkin lymphoma, Hodgkin lymphoma, and Kaposi sarcoma,.
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