preparation for transplantation (mih)

How to prepare a couple for renal transplantation?

Ayman Refaie, MDChief Transplantation & dialysis Unit

Urology & Nephrology CenterMansoura University

Successful Transplantation

Good Preparation=

A- Recipient Evaluation: Guidelines

1- History2- Clinical3- Laboratory4- Radiology5- Endoscopy6- Histopathology

A- Recipient Evaluation

• Active infection (TB, acute hepatitis, HIV ,)• Malignancy• Severe psychiatric & mental disorders • Non compliance

Contraindications of kidney transplantation

Recipient Evaluation: Malignancy

• Original kidney disease• Medical illness• Family history (renal failure)• Dialysis (Type, duration, adequacy…..)• Drugs

Recipient Evaluation: History

• General examination• Chest & heart• Liver• ECG

Recipient Evaluation: Clinical

• History: Nephrotic syndrome, stones, hypertension, DM, family history

• Clinical

• Investigations

Recipient Evaluation: Original kidney disease

Impact of recurrent glomerular diseases on death-censored graft survival

Unknown, 5%

Fibrosis/atrophy30%

Recurrent GN16%

Medical16%

Acute Rejection11%

Tx Glomerulopathy16%

De Novo GN7%

(Ziad El-Zoghby, Cosio AJT 9:527-535, 2009)

Recurrent Renal Disease • Primary FSGS• IgA Nephropathy • Mesangiocapillary Glomerulonephritis • Membranous Nephropathy • Diabetic Nephropathy• Primary Hyperoxaluria • Amyloidosis • SLE• ANCA Associated Systemic Vasculitis • Goodpasture’s Disease • Alport Syndrome • HUS• Cystinosis

Recipient Evaluation: Original kidney diseaseMansoura Experience

• Urine analysis, culture, ZN&PCR (TB)

• Full chemistry: Liver function

• Complete blood count (CBC)

• Viral profile: HCV, HBV, CMV, HIV, EBV

Recipient Evaluation: Laboratory

• UTP

• Abdominal US

• Micturating cysto-urethrogram (MCUG)

• Chest x-ray / Echocardiography

Recipient Evaluation: Radiology

Recipient Evaluation: Abd U/S

Recipient Evaluation: Plain x-ray

Chest x-ray

• Gastroduodenoscopy• Cystoscopy

Recipient Evaluation: Endoscopy

• Renal

• Liver

• Rectal

Recipient Evaluation: Histopathology

• Infection

• Stones / Obstruction

• V-U reflux ( nephrouretrectomy )

• Polycystic kidneys

• Uncontrolled hypertension

Indications of native nephrectomy

V-U reflux (Treatment options)Mansoura Experience

Conclusion:

Injection with PDS for reflux accompanying CRF is an appealing treatment and

results in an acceptable success rate and very low morbidity.

B- Donor Evaluation

Standard donor criteria (SDC): Guidelines

Kidney transplant physicians and surgeons met in Amsterdam, The

Netherlands, from April 1–4, 2004 for the International Forum on the Care of

the Live Kidney Donor.

Forum participants included over 100 experts and leaders in transplantation

representing more than 40 countries from around the world.

• Should be free from any disease

Potential kidney donor

Exclusion Criteria Age younger than 21 (18 years, abroad)

Hypertension

Diabetes

History of thrombosis or embolism

Psychiatric contraindications

Obesity: body mass index > 35

Coronary artery disease, reduced cardiac function, symptomatic valvular, peripheral

vascular disease

Chronic lung disease

Recent malignancy

Infections: HIV, HCV, HBV

Informed Consent for Living Kidney Donation

Should be explained to the potential donor (both verbal and written)

Information about living kidney donation should be provided.

The risks of short and long-term complications must be fully explained

According to the report of the Amsterdam Forum on the care of live kidney donors:

*A prior history of the following malignancies excludes living related kidney donation:Melanoma, testicular cancer, renal cell carcinoma, choriocarcinoma, hematologic malignancy, bronchial cancer, breast cancer, and monoclonal gammopathy. *A prior history of malignancy may only be acceptable for donation if:

Prior treatment of the malignancy does not decrease renal reserve or place the donor at increased risk for end-stage renal disease.

The specific cancer is curable and the potential transmission of the cancer can reasonably be excluded, for example: - colon cancer (Dukes A, more than 5 years ago), - nonmelanoma skin cancer. - carcinoma in situ of the cervix.

Donors with history of malignancy

Elderly donors

• Most of the studies confirmed the safety and applicability of using

older donors provided that they are cautiously selected and

extensively examined.

• Using specific immunosuppressive protocols for this special donor

subgroup to decrease the incidence of interstitial fibrosis and tubular

atrophy, especially with CNI-based protocols

• General examination: BMI, BP

• Chest & heart

• Liver

• ECG

• Echocardiogram and/or exercise stress test:(>50

years old)

• Pulmonary function tests for smokers

Donor Evaluation: Clinical

Obese donors

• Patients with a BMI > 40 should be discouraged from donating, especially when other comorbid conditions are present.

• BMI of 35 – 40 should be approved by donor surgeon. • Obese patients should be encouraged to lose weight prior to kidney

donation. • Obese patients should be informed of both acute and long term

risks, especially when other co-morbid conditions exist.

• Obese donors, the risk of greater intra operative complications,

more hypertension, diabetes and proteinuria is anticipated.

• Obesity has been found to be a common and strong risk factor for

CKD, focal glomerulosclerosis , and end stage renal disease.

• Biopsies of obese patients commonly show glomerular changes

such as glomerulomegaly and increased mesangial matrix.

Obese donors

• Ambulatory blood pressure monitoring has been

proposed as a more sensitive method than office

blood pressure measurements in identifying

hypertension in living donors

Blood pressure assessment in potential kidney donors

Clinic BP hypertension defined as 140/90

Ambulatory BP hypertension defined as mean 24-h

130/80.

Out of 63 individuals with hypertension by clinic BP, 62% had white-coat

hypertension by ambulatory BP and were therefore eligible to donate.

Out of 115 individuals who were normotensive by clinic BP, 17% had masked

hypertension by ambulatory BP and were excluded from donation.

Hypertensive donors

Short-term results of donation from well controlled, mild hypertensive

donors with a reasonable graft outcome, but more detailed studies are

needed for more reassurance on the long-term outcome.

Some with easily controlled hypertension who meet other defined

criteria (age >50 years, GFR >80 ml/min, and urinary albumin

excretion <30 mg/day) may represent a low-risk group for

development of kidney disease after donation and may be acceptable

as kidney donors.

Diabetes Mellitus

• Potential donors with several risk factors for diabetes,

such as parental history, impaired fasting glucose, and

elevated BMI, most likely should not donate.

• A history of gestational diabetes is a contraindication.

Microscopic haematuria

Persistent microscopic haematuria mostly indicates underlying occult

renal disease, and a renal biopsy is indicated in that situation for clear

decision making regarding acceptance, as recommended by the

Amsterdam Forum group.

• Donors with dysmorphic persistent haematuria should be excluded.

Recipient Evaluation: Laboratory Mansoura Experience

Thirty potential living related kidney donors with asymptomatic microscopic

hematuria of nonsurgical causes were included in this study

They were subjected to kidney biopsies which were examined by light

microscopy, direct and indirect immunofluorescent microscopy, and electron

microscopy

Hereditary nephritis (with or without sensorineural deafness) was found to be the

most common cause of asymptomatic microscopic hematuria (25/30)

Isolated C3 deposits disease (3/30)

IgA nephropathy (1/30)

IgM nephropathy (1/30)

Conclusion: The relatives of uremic patients with asymptomatic microscopic hematuria

should not be considered for kidney donation even if they are strongly motivated.

• Urine analysis X3, ± phase contrast (RBCs)

• Urine culture and ZN & PCR (TB)

• Creatinine clearance

• Full chemical & hematological profile

• Viral profile: HBV, HCV, HIV, CMV, EBV

Donor Evaluation: Laboratory

• ABO group

• Tissue typing

Matching

• Cross match

• PRA: Class I, II

• HLA:

– Class IA B

– Class II DR

Tissue Typing(Histocompatability testing)

1, 8, 103,14, 17

2, 7, 1110, 16, 8

2, 7, 113, 14, 17

3, 14, 17

10, 16, 8

1, 8, 102, 7, 11

1, 8, 1010, 16, 8

SISTERBROTHERSISTERSISTERBROTHER

FATHER MOTHER

HLA is inherited as a “set” of the three HLA groups, A, B, DR. This set is known as a “haplotye”

Tissue Typing(Histocompatability testing)

• UTP, Non contrast spiral CT

• Abdominal US

• Chest X-ray

• Urinary system (IVP MRU CTU)

• Vascular system ( Angiography, MRA, CTA)

• Renogram

Donor Evaluation: Radiology

Donor Evaluation: Plain x-ray

Chest x-ray UTP

Donors with stones

As stated by the Amsterdam forum, asymptomatic

small stones (<1.5 cm) can be accepted after careful

selection and exclusion of any metabolic abnormalities.

The stone can be treated conservatively, during surgery

or with lithotripsy.

Donor Evaluation: Abd U/S

Donors with grade I echogenicity: 34 (32.7 + 8.45) years

Donors normal echogenicity: 10 matched controls

ALL: GFR , measured, isotopic scintigraphy and estimation of renal reserve.

Donors with grade I echogenicity: 34 (32.7 + 8.45, 23–48) years, 17 biopsied

Donors normal echogenicity: 10 matched controls

Donors with grade I echogenicity: 34 (32.7 + 8.45, 23–48) years, 17 biopsied

Donors normal echogenicity: 10 matched controls, 8 biopsied

Segmental patch of sclerosis, periodic acid-Schiff X200 Mild segmental mesangial thickening, PASX400

Mild focal tubular atrophy, PASX200 Mild focal interstitial fibrosis, Masson trichrome X200

Conclusion:

Grade 1 echogenicity might be a sign of unrecognized kidney disease.

Renal biopsy is mandatory when such related donors are the only available ones.

Abnormal histopathology contraindicates donation.

Donor: urography

Donor : Angiography

Donor Evaluation: RadiologyMansoura Experience

• Multiple arteries did not affect clinical outcomes of open donor nephrectomy.

• For laparoscopic donor nephrectomy , multiple arteries were associated

with longer operative times and increased blood loss. Neither multiple

arteries nor vascular reconstructions influenced recipient creatinine

clearance or ureteral complication rate.

However, accessory arteries to the lower pole were associated with an

increased rate of ureteral complications.

Kok et al Transplantation. 2008 Jun 27;85(12):1760-5

Multiple renal arteries

Tuesday, May 2, 2023 GCP Aurangabad. 78

Donor Evaluation: Renogram

• Is it an easy task?

• Potential living donors should undergo a rigorous screening• Procedure to ensure the best functional outcome for recipients• No or minimal morbidity for donors.

Dilemma in selection of living donors

Donor EvaluationMansoura Experience

Conclusions:

Although kidneys from living donors provide the best functional outcome, 50% of potential candidates must be excluded.

Donor EvaluationMansoura Experience

TRANSPLANT PREPARATION SHEET

Name : Sex: Age: Y Wt: Kg

Number: Blood group : Social status: Offsprings:

1- EVALUATION : Nephrology Urology Special ECG

II- IMMUNOLOGY : *CXM:-ve *HLA: % *DR: % *MLC: : 1

III- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.

RFT LFT Bl. Sugar Hematology Sputum (Z.N.PCR)

Viral profile: HBV HCV CMV HIV

IV- RADIOLOGY : U.S. UTP C.X.R. MCUG Others

V- ENDOSCOPY : FOGD Bladder Rectum

VI- BIOPSY : Renal Liver Rectum Others

VII- DIALYSIS DURATION :

VIII- ORIGINAL KIDNEY DISEASE :

IX: UOP : c.c /day

NAME : Sex: Age: Y Wt: Kg Consanguinity:

I- EVALUATION : Nephrology Urology Special ECG

II- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.

RFT LFT Bl. Sugar Hematology

III- RADIOLOGY : C.X.R. U.S. UTP M.R.U

LT: LT: LT: ml/min

RT RT : RT: ml/min

* Patient : Renal allotransplantation.

* Donor : Nephrectomy

M.R.A. Renogram Flush

RECIPIENT

جامعة المنصورة مركز أمراض الكلى والمسالك البولية

MANSOURA UNIVERSITY UROLOGY & NEPHROLOGY CENTER

MANSOURA EGYPT

IX: UOP : c.c /day

LT: LT: LT: ml/min

RT RT : RT: ml/min

RECIPIENT

MANSOURA EGYPT

Transplantation Preparation Sheet RecipientName Sex: Age: y Wt: kg Ht cm TX NO Blood group: social state: offspring:I-Evaluation: Nephrology Urology special ECG------------------------------------------------------------------------------------------------------VII-Dialysis duration------------------------------------------------------------------------------------------------------VIII-Original kidney disease:-------------------------------------------------------------------------------------------------------IX-UOP: ML/dayII-Immunology: CXM HLA % DR % PRA : I

II------------------------------------------------------------------------------------------------------ III-Laboratory: Urine analysis culture ZN&PCR for TB RFT LFT BL.sugar Hematology sputum(zn>PCR) Viral profile HBV HCV CMV HIV --------------------------------------------------------------------------------------------------------- IV-Radiology: US UTP CXR MCUG others-------------------------------------------------------------------------------------------------------V-Endoscopies: FOGD Bladder RectumVI-Biopsy: Renal Liver Rectum Others ============================================================

IX: UOP : c.c /day

LT: LT: LT: ml/min

RT RT : RT: ml/min

RECIPIENT

MANSOURA EGYPT

IX: UOP : c.c /day

LT: LT: LT: ml/min

RT RT : RT: ml/min

RECIPIENT

MANSOURA EGYPT

Rt / LT

The living kidney donor: giving life, avoiding harm

Mansoura Post Donation Clinic

• Over the last decade.

• Mansoura Post donation Clinic.

• Recipient (hand in hand) with his/her related donor

• Evaluation: Clinical: BP, BMI Lab: urinalysis, S. Cr, Cr Clearance, etc….. U/s for the remaining kidney

• Medications: provided when needed.

Successful Transplantation

Good Preparation

Thank You

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