transplant 101 transplant 101: overview

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  • 1. Transplant 101

2. Transplant 101: Overview

  • Transplant as treatment for ESRD
  • The pretransplant evaluation
    • Contraindications to transplantation
  • Deciding on a donor
    • Deceased
      • United Network for Organ Sharing (UNOS) and organ allocation
    • Living
      • Determining a suitable candidate
      • Donor evaluation
      • Matching donor and recipient

3. History of Kidney Transplantation

  • Initial experiments date back to World War II
  • AZA debuted in 1960s
    • Transplant outcomes improved
  • CsA introduced in the early 1980s
    • 1-year graft survival rate exceeds 80%
  • Now, transplant patients have survival advantages over those remaining on dialysis

4. Treatment Modalities forESRD Patients (2002) N = 431,284 USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States.2004. 5. Transplant-Related Quality-of-Life Benefits

  • Relatively unrestricted diet
  • Freedom to travel
  • Ability to become pregnant and bear children
  • Can engage in training for athletic competition
  • Lifestyle free of dialysis constraints

6. ESRD Survival by Treatment Modality National Kidney Foundation. Available at: http://www.kidney.org. 7. Treatment Modality in ESRD Patients Alive Beyond 10 Years USRDS 2000 Annual Data Report: Atlas of End-Stage Renal Disease in the United States.2000. 8. Graft Survival in 2405 Paired-Kidney Transplants: Short vs Long ESRD Time Adapted with permission from Meier-Kriesche HU, et al.Transplantation . 2002;74:1377-1381. 9. Survival Benefit of Transplant vs Remaining on Waiting List Adapted with permission from Ojo AO, et al.J Am Soc Nephrol . 2001;12:589-597. 10. Contraindications to Transplantation

  • Active malignancy or metastatic cancer
    • Immunosuppression can enable tumor growth
  • Cirrhosis
    • Unless simultaneous liver transplant is planned
  • Severe myocardial dysfunction or peripheral vascular disease
    • Unless due to potentially reversible ischemia, which should be corrected prior to transplant
  • Other severe, irreversible extrarenal disease
  • Active mental illness
    • If patient cannot give informed consent or comply with drug regimens

Kasiske BL, et al.Am J Transplant.2001;1 (suppl 2):1-15. 11. Contraindications to Transplantation (contd)

  • Chronic infection or untreated current infection
  • Irreversible limited rehabilitative potential
  • Persistent nonadherence to treatment
  • Active substance abuse
    • Must be treated prior to transplant; drug screening may be required as proof of drug-free status
  • Primary oxalosis
    • Unless combined liver/kidney transplant is an option

Kasiske BL, et al.Am J Transplant.2001;1 (suppl 2):1-15. 12. Referring Patients to the Transplant Center

  • The referring nephrologist is responsible for coordinating all pretransplant care
    • Point person in coordinating care with transplant center, specialists (eg, cardiology)
  • Encouraging patients to learn about transplantation helps improve outcomes
  • Transplantation can be preemptive
    • Identify potential donors
  • Patient can be listed when GFR 140/90 mm Hg or need for medication
  • Diabetes
  • Proteinuria
    • >250 mg/24 hours
  • GFR