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Renal transplantation

is the preferred
treatment for patients
with end-stage renal
disease. It offers
better quality of life
and confers greater
longevity than long-
term dialysis.
Common Causes of End-Stage Renal Disease

• Diabetes mellitus
• High blood pressure
• Glomerulonephritis
• Polycystic Kidney Disease
• Severe anatomical problems of the
urinary tract
Contraindications

 Cardiac and pulmonary insufficiency


 Hepatic disease
 some cancers.
Sources of kidneys
Living donors
The donor must be in excellent health, well informed
about transplantation, and able to give informed
consent. Any healthy person can donate a kidney
safely.
Deceased donors
A deceased donor kidney comes from a person who
has suffered brain death.
Deceased donors can be divided in two groups:
• Brain-dead (BD) donors
• Donation after Cardiac Death (DCD) donors
Paired Exchange Kidney Transplant
(or "Family Swap")
• A "paired exchange" allows patients who have willing but
incompatible donors to "exchange" kidneys with one another-the
kidneys just go to different recipients than usually expected.
• That means that two kidney transplants and two donor surgeries
will take place on the same day at the same time.
Living Donor Kidney Transplantation
• Better long-term results
• No need to wait on the transplant waiting list for a kidney from a
deceased donor
• Surgery can be planned at a time convenient for both the donor
and recipient
• Lower risks of complications or rejection, and better early
function of the transplanted kidney
Potential Barriers to Living Donation
• Age < 18 years unless an emancipated minor
• Uncontrollable hypertension
• History of pulmonary embolism or recurrent thrombosis
• Bleeding disorders
• Uncontrollable psychiatric illness
• Morbid obesity
• Uncontrollable cardiovascular disease
• Conronic lung disease with impairment of oxygenation or ventilation
• 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
Transplant Evaluation Process
Blood Type Testing
The recipient and donor should have either the same blood type or
compatible ones, unless they are participating in a special
program that allow donation across blood types.
• If the recipient blood type is A Donor blood type must be A or O
• If the recipient blood type is B Donor blood type must be B or O
• If the recipient blood type is O Donor blood type must be O
• If the recipient blood type is AB Donor blood type can be A, B,
AB, or O
The AB blood type is the easiest to match because that
individual accepts all other blood types.
Blood type O is the hardest to match
Tissue Typing
The second test, which is a blood test for human leukocyte
antigens (HLA), is called tissue typing
• To receive a kidney where recipient's markers and the donor's
markers all are the same is a "perfect match" kidney. Perfect
match transplants have the best chance of working for many
years. Most perfect match kidney transplants come from
siblings.
• Although tissue typing is done despite partial or absent HLA
match with some degree of "mismatch" between the recipient
and donor.
Crossmatch

• If there are antibodies to the donor kidney, the body may destroy
the kidney. For this reason, when a donor kidney is available, a
test called a crossmatch is done to ensure the recipient does not
have pre-formed antibodies to the donor .
• The crossmatch is done by mixing the recipient's blood with
cells from the donor. If the crossmatch is positive, it means that
there are antibodies against the donor.
• Crossmatches are performed several times during preparation for
a living donor transplant, and a final crossmatch is performed
within 48 hours before this type of transplant.
Serology
Testing is also done for viruses, such as HIV (human
immunodeficiency virus), hepatitis, and CMV (cytomegalovirus)
EBV, Hep.B,C to select the proper preventive medications after
transplant. These viruses are checked in any potential donor to
help prevent spreading disease to the recipient.
Pre-transplant Period
This period refers to the time that a patient is on the deceased
donor waiting list or prior to the completion of the evaluation of
a potential living donor.
The recipient undergoes testing to ensure the safety of the
operation and the ability to tolerate the anti-rejection medication
necessary after transplantation.
The type of tests varies by age, gender, cause of renal disease,
and other concomitant medical conditions. These may include,
but are not limited to:
• General Health Maintenance: general metabolic laboratory
tests, coagulation studies, complete blood count, colonoscopy,
pap smear and mammogram (women) and prostate (men)
• Cardiovascular Evaluation: electrocardiogram, stress test,
echocardiogram, cardiac catheterization
• Pulmonary Evaluation: chest x-ray, spirometry
Potential Reasons of Excluding Transplant
Recipient
• Uncorrectable cardiovascular disease
• History of metastatic cancer or ongoing chemotherapy
• Active systemic infections
• Uncontrollable psychiatric illness
• Current substance abuse
• Current neurological impairment with significant
cognitive impairment and no surrogate decision maker
Transplant Surgery
• The transplant surgery is performed under general anesthesia.
• The operation usually takes 2-4 hours.
• This type of operation is a heterotopic transplant meaning the
kidney is placed in a different location than the existing kidneys.
• The original kidneys are not usually removed unless they are
causing severe problems such as uncontrollable high blood
pressure, frequent kidney infections, or are greatly enlarged.
• The renal artery of the new kidney, previously branching from
the abdominal aorta in the donor, is often connected to
the external iliac artery in the recipient.
• The renal vein of the new kidney, previously draining to
the inferior vena cava in the donor, is often connected to
the external iliac vein in the recipient.
• The donor ureter is anastomosed with the recipient bladder.
• Recovery in the hospital is usually 3-7 days.
• Complications can occur with any surgery.
Post operative period

 Depending on its quality, the new kidney usually begins


functioning immediately.
 Living donor kidneys normally require 3–5 days to reach
normal functioning levels, while cadaveric donations stretch that
interval to 7–15 days.
 Hospital stay is typically for 4–10 days.
 If complications arise, additional medications (diuretics) may be
administered to help the kidney produce urine.
• Immunosuppressant drugs are used to suppress the immune
system from rejecting the donor kidney. These medicines must
be taken for the rest of the recipient's life.
• The most common medication regimen today is a mixture
of tacrolimus, mycophenolate, and prednisolone.
• Some recipients may instead take cyclosporin, sirolimus,
or azathioprine.
• The risk of early rejection of the transplanted kidney is increased
if corticosteroids are avoided or withdrawn after the
transplantation.
The post transplant period requires close monitoring of
• kidney function
• Early signs of rejection
• Adjustments of the various medications
• Vigilance for the increased incidence of immunosuppression-
related effects such as infections and cancer.
• Rejection is an expected side effect of transplantation and up to
30% of people who receive a kidney transplant will experience
some degree of rejection.
• Most rejections occur within six months after transplantation,
but can occur at any time, even years later. Prompt treatment can
reverse the rejection in most cases.
• Anti-Rejection Medications
• Anti-inflammatory Medication
Prednisone is taken orally or intravenously
 Anti-proliferative Medications
Azathioprine (Imuran®) is taken orally or intravenously
 Cytokine Inhibitors
Cyclosporine is taken orally.
• Antilymphocyte Medications
Antithymocyte globulin (Thymoglobulin®) is given
intravenously.
Complications
• Transplant rejection (hyperacute, acute or chronic)
• Infections and sepsis due to the immunosuppressant drugs that
are required to decrease risk of rejection
• Post-transplant lymphoproliferative disorder (a form
of lymphoma due to the immune suppressants)
• Imbalances in electrolytes including calcium and phosphate
which can lead to bone problems
• Proteinuria
• Hypertension
• Other side effects of medications including gastrointestinal
inflammation and ulceration of the stomach and
esophagus, hirsutism(excessive hair growth in a male-pattern
distribution) with ciclosporin, hair loss with
tacrolimus, obesity, acne, diabetes mellitus type
2, hypercholesterolemia, and osteoporosis.
Early complications of kidney transplant
• Risk of abscesses within the abdominal walls
• Bleeding
• Incisional hernia
• Urinary fistulae
• A risk of post-operative formation of blood clots or arterial
thrombosis. These may get dislodged from the operative site and
travel up to the lungs or brain leading to life threatening
complications.
Late complications of kidney transplant
• Narrowing of the ureters and obstruction to flow of urine from
kidney into the bladder - ureteric stenosis.
• Pyelonephrritis or infection of the kidneys after surgery
• Opportunistic infections include herpes simplex infection in the
first four weeks and then cytomegalovirus infection. Fungal and
bacterial infections are also seen.
• Kidney stones may be transplanted with the donor kidney or
may form later in the new kidney. There may be manifestations
of blood in urine (hematuria), infections and obstruction.
• Renal artery stenosis or narrowing of the renal arteries is a late
complication.
• Risk of cancers of skin or lymphomas
• Recurrence of the original kidney dysfunction that damages the
new kidney
Care of Donor

• The operation takes 2-3 hours.


• Recovery time in the hospital is typically 1-3 days.
• Donors often are able to return to work as soon as 2-3 weeks
after the procedure.
Rejection
• The immune system of the body perceives the kidney as a
foreign object or tissue and mounts a reaction against it. This
may lead to massive damage to the new kidney.
• Early signs of rejection include fever and soreness at the site of
the new kidney and reduction in the amount of urine production.
• To prevent rejection reaction immune suppressing medications
are prescribed right after the operation.
Types of Rejection
• Hyperacute: occurs within minutes of insertion. This means the
donated kindey should be removed immediately.
• Accelerated: This occurs within a few days in patients
previously sensitised. There may be fever, swollen new kidney
and high rise of levels of creatinine in blood. High dose steroids
are given to combat this but may fail and removal may be
needed.
• Acute cellular rejection – This occurs in a quarter of all
patients usually in 1-3 weeks but can occur up to 12 weeks.
There may be fluid retention, rising blood pressure and rapid
increase in blood creatinine.
• Chronic rejection – In this type there is a gradual rise in serum
creatinine and excretion of protein in urine along with high
blood pressure. This type of rejection is not corrected by
increasing immunosuppression therapy