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RENAL TRANSPLANTATION

PROF DR MOHAMMED
YOUSSIF
PROF 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 Transplant
Criteria

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
75%
Malignant HTN
Glomerulonephritis
Hereditary (polycystic kidney) -ADLupus
Tumour(??)

NAWAR NADHRAH BINTI


ABDUL WAHID
10-5-241
Contraindications for Kidney
Transplantation

Absolute Contraindication
Life threatening
condition:
-untreated cancer
-infection that cannot
be treated
-uncorrectable heart
disease

History of chronic noncompliance 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 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.

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

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
Overall, average kidney survival
on dialysis.
times are:
1 year 85-95%
5 years 70-80%
15 years 50-60%

Factors that may affect


prognosis
1.
2.
3.
4.
5.
6.

Deceased and living donors


Age of donor and recipient
HLA-matching
Cold ischaemia time
Time on dialysis
Overall health of the
person receiving the
donation

NUR AFIQA BINTI


ROSLAN
10-5-243
Preprocedural Care

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

Steps will precede the


transplant
Explain the
procedure
Receive
sedative
Other specific
preparation
(based on
medical
condition)

sign a
consent

Receive
dialysis (on
routine)

Living transplant
( fast 8 hours)
Cadaver organ
transplant (fast
when notified
kidney available)

NUR AKMA ZAINAL


SHAHROM
10-5-244
Matching of Donors and
Recipients

Histocompatibility (HLA) matching


transplant outcome correlates with number of HLA
mismatches.
HLA incompatibility

proliferation & activation of

recipients CD4+ & CD8+ T-cells


cell allo-antibody production

activation of Bcellular 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
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.

Panel Reactive Antibodies (PRA)

results of HLA-antibody testing in a recipients


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 (hyperacute rejection).
introduction of antibody elimination methods and
anti-B cell agents

increased numbers

successful ABO-incompatible transplantations


(even without splenectomy).

NURUL IMAN BINTI


ZULKEFLI
10-5-245
Postoperative Care

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

Mycophenola Inhibits de novo


te
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
immunosuppre
ssion and in
treatment of
rejection

NURUL AQMAR MOHD


SUHAIMI
10-5-246
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

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

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

NURULZIANI IZZATI BINTI


MOKHTAR
10 5 248
Renal Transplantation
from
Deceased Donor

Deceased donor can be divided into two


groups:

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

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
CONTRAINDICATIONS:
(to increase their probability of
transplantation)
active infections
HIV infection
extracranial malignancy
poor renal function in the donor
advanced donor age

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, 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

NURUL ATIQAH BINTI ABU


SAHMAH
10-5-250
Ureteroneocystostomy &
Ureteroureterostomy in Renal
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

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 lowflow state from hypotension or vascular kinking due to
surgical error.
Renal artery stenosisis 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 revealshydronephrosis.

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 rejection


Hyperacute
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

Infections

Infection due to
theimmunosuppressantdrugs 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,.

THANK YOU

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