deceased donor kidney transplantation-recipient care

DECEASED DONOR KIDNEY TRANSPLANTATION-

POST TRANSPLANT RECIPIENT CARE

Dr. Vishal GolayIPGME&R, Kolkata

Topic overview Outcomes of deceased donor kidney

transplantation (DDKT).

Surgical issues.

General post-transplant care.

Outcomes

2008 OPTN/SRTR Annual Report

Am J of Transplant 2007; 7: 1797–1807

Recipient issues in Surgery DDKT are generally conducted at a short

notice.

Immediate pretransplant dialysis should be avoided to minimize DGF.

If HD is necessary, UF should be minimal.

Some differences in surgical techniques (Carrel aortic patch, IVC extensions, dual kidney transplantation).

Induction Immunosuppression.

Options for induction immunosuppression are: Antithymocyte globulin.

IL2R Antibodies (Basiliximab/Daclizumab)

CD-52 Antibody (Alemtuzumab).

Induction Immunosuppression.

ATG is traditionally used in patients at high risk for acute rejection.

ATG also theoretically benefits recovery from DGF due to delayed start of CNIs.

Induction Immunosuppression.

Anti CD52 antibody (Alemtuzumab): Off label use.

“prope” (almost) tolerance enabling lowering the CNI dose or early steroid withdrawal.

The INTAC study showed lesser AR compared to IL2Ra in low risk(n=335) and similar results to ATG in high-risk (n=139) patients at the end of 3 yrs in an early steroid withdrawal protocol (but ECD, DCD, prolonged CIT and cross match positive were excluded).

Hanaway et al. N Engl J Med 2011;364:1909-19.

High Risk factors for acute rejection (KDIGO): Number of HLA mismatches. Younger recipient age. Older donor age. Blacks. PRA>0% Presence of DSA. ABO incompatibility. Cold ischemia time >24 hours

In these settings the KDIGO guidelines favor the use of lymphocyte depleting agents rather than an IL2Ra

Other immunosuppresive protocols in DDKT Steroid withdrawal protocols has been found

to be successful in DDKT even in those with ECD.

Data from Cornell Medical center, NYTransplantation 2012;94

Data from Cornell Medical center, NYTransplantation 2012;94

Data from the OPTN/UNOS showed that rATG based induction perform better than IL2Ra and Alemtuzumab induction in a Tac/MMF/Early CSWD regimen.

This could be due to the favorable effects of rATG induction in high-immune risk patients.

Sureshkumar et al. Transplantation2012;93: 799–805

Immunosuppressive protocold in DDKT

Nephrol Dial Transplant (2011) 26: 317–324

Delayed Graft Function

Defined as: “failure of the kidney allograft to function immediately post transplant with the need of more than dialysis session within one week.”

Incidence of DGF is variable: Living Donors Tx--------------3% Standard Criteria DDKT-----21% Expanded criteria DDKT----29%

USRDS Data

It can be compounded by acute rejection and CAN. DGF translates to a 40% reduction in long term graft survival.

Patients with both DGF and acute rejection had a 5-year survival rate of 34%.

Transplantation 1997; 63: 968–974.

Patients with DGF had a 49% pooled incidence of acute rejection compared to 35% incidence in non-DGF patients.Nephrol Dial Transplant 2009; 24: 1039–1047.

Causes of ischemia in the deceased donor kidneys.

1. Preharvest donor state

2. Organ procurement surgery

3. Organ transport and storage

4. Transplantation of recipient

Prolonged second warm ischemia time

Trauma to renal vesselsHypovolemia/hypotension

5. Postoperative periodCyclosporine/tacrolimusAcute heart failure (MI)Hemodialysis

Strategies to prevent DGF Ischemic preconditioning. Vasodilatory agents (endothelin receptor

antagonists, CCB and adenosine A1 receptor antagonists.

Anti-inflammatory agents. Induction immunosuppression (suppression of

leucocyte-rich vascular congestion & endothelial injury).

Post-transplant dialytic therapy

Best is to avoid dialysis. Minimal anticoagulation. Avoidance of hemodynamic instability. Peritoneal dialysis is best avoided in the 1st

week due to risks of peritonitis and spillage over the wound site.

PD can be safely started in extraperitoneal transplants with small volumes and gradually increased.

Approach to a DGF

Brenner, The Kidney

Quality of Life

Nephrol Dial Transplant (2002) 17: 2204–2211

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