Professional Documents
Culture Documents
PROF DR MOHAMMED
YOUSSIF
PROF DR MOSTAFA SAEID
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 Transplant
Criteria
Dialysis
Transplant
Life
expectency
5+/- years
Up to 20 years
Cost
QOL
Not good
Etc.
Restrictive life
Indication
DM
75%
Malignant HTN
Glomerulonephritis
Hereditary (polycystic kidney) -ADLupus
Tumour(??)
Absolute Contraindication
Life threatening
condition:
-untreated cancer
-infection that cannot
be treated
-uncorrectable heart
disease
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 includeswrittendocumentation 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.
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.
Basic Pretransplant
Studies
Pysical
examination
Viral testing
Mammogram
Pap smear
Dental
evaluations
Upper GI series
Lower GI series
Chest x-ray
Electrocardiogram
Echocardiogram
Ultrasound with
doppler
examination
Pulmonary function
Blood tests
Blood typing
Tissue typing
Panel reactive
antibody (PRA)
Renal
function
studies
Donor GFR
at least 80
ml/min
CT Renal
vasculature
and
parenchymal
abnormalitie
s
sign a
consent
Receive
dialysis (on
routine)
Living transplant
( fast 8 hours)
Cadaver organ
transplant (fast
when notified
kidney available)
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
recipients 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.
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 (hyperacute rejection).
introduction of antibody elimination methods and
anti-B cell agents
increased numbers
POSTOPERATIVE MANAGEMENT
Postoperative 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
DRUGS
IMMUNO
SUPPRESSIVE
DRUGS
EXAMPLE OF
DRUGS NAME
MECHANISM OF
ACTION
SIDE EFFECTS
ADVANTAGES
Calcineuri
n
inhibitors
Cyclosporine
Tacrolimus
Target proliferating
T cells by blocking
the elaboration of
cytokines
Dose-related
nephrotoxicity
Hypertension
Antiprolifer
ative agent
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
immunosuppre
ssion and in
treatment of
rejection
Special programs
for living donor
transplants
Blood Type
Incompatible
Paired Exchange
Plamapheresis
Positive Crossmatch
Waiting List Exchange
Blood Type
Incompatible Kidney
Transplant
Potential Barriers
to Living Donation
Brain-dead
(BD) 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
Cardiac Death
(DCD) donors
patients who do not
meet the braindead criteria
They have unlikely
chance of recovery,
elected via a living
will or through
family to have
support withdrawn
techniques
Intravascular perfusion of
the involved organs with
cold (ie, 4C) 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
URETERONEOCYSTOSTOMY
Uretero-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).
URETEROURETEROSTOMY
Uretero-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-toend) or transuretero-ureterostomy (end-toside)
Only done if anastomosis of the ureter to the
bladder ureteroneocystostomy (UNC) is not
possible.
Defunctionalized natives (recipient) bladder
Devascularized donors ureter
End-to end
End-to-side
Chronic
rejection
Infections
Infection due to
theimmunosuppressantdrugs that are
required to decrease risk of rejection.
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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