Clinical Management of Renal Transplantation

DEVELOPMENTS IN NEPHROLOGY

Volume 32

The titles published in this series are listed at the end of this volume.

Clinical Management

of

Renal Transplantation Editor

Mary G. McGeown

CBE, DSc (Hon), DMSc (Hon), MD, PhD, FRCP (Lon., Edin. and Dublin)

Professorial Fellow of Medicine Queen's University of Belfast United Kingdom

Springer-Science+Business Media, B.V.

Library of Congress Cataloging-in-Publication Data

Clinicai management of renal transplantation / editor, Mary G. McGeown p. cm. -- (Developments in nephrology: v. 32)

Inc I udes index.

1. Kidneys--Transplantation. 2. Kidneys--Diseases--Patients--Hospital care. I. McGeown, Mary G. II. Series: Developments in nephrology; 32.

[DNLM: i. Kidney Transpiantation. WJ 368 C6411 RD575.C558 1992 617.4·610592--dc20 DNLMIDLC for Library of Congress

ISBN 978-90-481-4122-7 ISBN 978-94-015-7961-2 (eBook) DOl 10.1007/978-94-015-7961-2

Printed on acid-free paper

All Rights Reserved © 1992 Springer Science+Business Media Dordrecht

Originally published by Kluwer Academic Publishers in 1992. Softcover reprint of the hardcover 1 st edition 1992

91-46770

No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owners.

Dedicated to the staff of the Renal Unit who worked so loyally as a team with me over the years from 1968 to 1988, and to the patients for whom we were privileged to care.

"For mercy has a human heart; Pity, a human face; And Love, the human form divine; and Peace, the human dress. Then every man, of every clime, That prays in his distress, Prays to the human form divine: Love, Mercy, Pity, Peace."

- William Blake.

Table of contents

About the editor xv

List of contributors xvii

Preface xix

Acknowledgements xxi

Chapter 1. History of renal transplantation Mary G. McGeown

1

1. History of renal transplantation 1 2. Development of renal transplantation in Northern

Ireland 3 3. Expansion of renal replacement therapy 5 4. Renal transplantation in Belfast after 1968 6

Chapter 2. Ethical considerations Mary G. McGeown

9

1. Dialysis 9 2. Transplantation 14 3. Human Organ Transplant Act 1989 18 4. The Islamic view 20 5. Appendix: Recommendations on the use of living

kidney donors in the United Kingdom, by the British Transplantation Society; Human Organ Transplant Act 1989 (text) 22

vii

Vlll

Chapter 3. Legal. aspects of renal transplantation 27 J. F. Douglas

l. General principles 27 2. Statutory control of cadaver organ retrieval 27 3. The legal concept of death 29 4. The Human Organ Transplant Act 1989 31 5. The future: international agreement on organ

donation? 33

Chapter 4. Assessment of the patient before renal transplantation 35 J. F. Douglas

l. Selection of patients 35 2. Assessment for transplantation 37 3. Personal 38 4. Primary renal disease 40 5. Urinary tract 46 6. Cardiovascular system 47 7. Other pre-existing diseases 52 8. Infections 55 9. Immunological status 58

10. Information and consent 59 11. Cost effectiveness 59

Chapter 5. Preparation for renal transplantation 1 61 J. F. Douglas

l. Dialysis 61 2. Choice of dialysis 69 3. Starting dialysis 71 4. Regular dialysis 72 5. Drugs and dialysis 73 6. Treatment of anaemia 74

Chapter 6. Preparation for renal transplantation 2 77 J. F. Douglas

l. Hypertension in end-stage renal failure 77 2. Therapeutic approach to hypertension 79 3. Bilateral nephrectomy 81 4. Lower urinary tract preparation 88 5. Other surgical procedures 89

IX

Chapter 7. Preparation for renal transplantation 3 91 J. F. Douglas

1. Immunological preparation 91 2. Renal osteodystrophy 95

Chapter 8. Renal osteodystrophy 107 A. P. Maxwell

1. Pathophysiology 107 2. Hyperparathyroid bone disease 108 3. Low turnover uraemic osteodystrophy 109 4. Mixed uraemic osteodystrophy 110 5. Aluminium deposition in bone 110 6. Clinical and biochemical features 110 7. Treatment 111

Chapter 9. Tissue typing 115 D. Middleton

1. HLA typing 115 2. Screening of recipients' sera for antibodies 122 3. Cross matching of recipients and donors 125 4. Appendix: techniques used in tissue typing 127

Chapter 10. The cadaveric donor 135 G. Lavery

1. Identification of the potential donor 135 2. Brain stem death 136 3. The medical management of the potential donor 141 4. Consent - approaching the family 146 5. The process of retrieval 147 6. Future developments 148

Chapter 11. Retrieval and preservation of the kidney 153 J. A. Kennedy

1. Surgical technique 153 2. Exposure and perfusion technique 154 3. Vascular connections 154 4. The ureter 155 5. The living donor 155 6. Preservation of the donor kidney 157

x

Chapter 12. The living donor 161 B. G. Wilson, W. G. G. Loughridge and S. R. Johnston

1. Advantages of live donation 161 2. Disadvantages of live donation 161 3. Suitability of an individual to become a live donor 162 4. Pre-operative assessment of a potential living

donor 162 5. The donor nephrectomy 163 6. Transplantation of a kidney from a live donor 164 7. Post-operative care of the donor 164

Chapter 13. Insertion of the kidney P. F. Keane and R. Kemohan

1. General principles 2. The standard kidney transplant operation 3. Variations in technique 4. Post-operative care 5. Transplantation in children

Chapter 14. Management of the recipient during operation J. P. Alexander

167

167 167 171 175 176

181

1. Historical 181 2. Pharmacokinetics in renal failure 181 3. Drugs used in anaesthesia in the renal failure

patient 183 4. Anaesthetic management of the living donor 190 5. Anaesthetic management of the cadaveric donor 191 6. Anaesthetic management of the recipient 192 7. Renal transplantation in children 198

Chapter 15. Immunosuppression Mary G. McGeown

201

Xl

I. Total body irradiation 202 2. Azathioprine 202 3. Corticosteroid 205 4. Antilymphocyte serum 211 5. Cyclophosphamide 212 6. Splenectomy 212 7. Thymectomy 213 8. Thoracic duct drainage 213 9. Bilateral nephrectomy 213

10. Blood transfusion 214 II. Local irradiation of the graft 215 12. Subtotal irradiation 216 13. Cyclosporin A 216 14. Monoclonal antibodies 222 15. Plasma exchange 223 16. FK 506; rapamycin 223 17. Immunosuppression in Belfast 223 18. Immunosuppressive therapy for children as used

in Belfast 226 19. Appendix: immunosuppressive therapy for

children as used in Belfast 227

Chapter 16. Nursing care of the patient with a renal transplant 231 Mary G. McGeown

I. Nursing care in the immediate post-operative period 231

2. Fluid and electrolyte balance 235 3. Care of the wound 236 4. Control of post-operative pain 236 5. General management 237 6. Drugs 238 7. Early symptoms and signs of rejection 239 8. Advice before discharge 240

Chapter 17. Graft dysfunction and its differential diagnosis 243 C. C. Doherty

I. Early post-transplant graft dysfunction 243 2. Late post-transplant graft dysfunction 251 3. Renal transplantation in older patients 255 4. Post -transplant proteinuria 255 5. Graft biopsy 257

xii

Chapter 18. The pathology of renal transplantation 263 Claire M. Hill

1. Historical background 263 2. Technical aspects 264 3. Rejection 265 4. Differential diagnosis 269 5. Recurrent disease 270 6. Donor disease 273 7.· De novo glomerulonephritis 274 8. Pathology of the transplanted ureter 274

Chapter 19. Surgical complications of renal transplantation 277 R. A. Donaldson

1. Excretory tract complications 278 2. Vascular complications 283 3. Fluid collections associated with renal allografts 286 4. Miscellaneous surgical complications 287

Chapter 20. Early medical complications after renal transplantation 291 P. McNamee

1. Fluid balance 291 2. Electrolyte disturbances 292 3. The diabetic transplant patient 294 4. Graft non-function 295 5. Graft rejection 296 6. Infection after transplantation 298

Chapter 21. Diagnostic imaging of the post-transplant kidney 305 A. Larkin

1. Ultrasound 306 2. Doppler ultrasound 313 3. Radionuclide studies 315 4. Angiography 319 5. Antegrade pyelography 322 6. Intravenous urography 322 7. Computerized axial tomography 324 8. Magnetic resonance imaging 325

xiii

Chapter 22. Management after discharge from hospital 329 w. Nelson

1. Review visits 329 2. Investigations 337 3. Drug treatment 341

Chapter 23. Rehabilitation after renal transplantation 349 J. H. Brown

1. Psychological and psychiatric problems 349 2. Employment 351 3. Exercise/recreation 352 4. Renal transplantation in children 352 5. Comparison of dialysis and transplantation 354 6. Quality of life studies 355

Chapter 24. Reproduction after renal transplantation 357 J. H. Brown

1. The kidney in pregnancy 357 2. Maternal complications 358 3. Foetal complications 360 4. Obstetrical aspects 362 5. Pre-pregnancy counselling 364 6. Antenatal care 364 7. Contraception 365 8. Breast feeding 366 9. Reproduction and the male recipient 366

Chapter 25. Results of renal transplantation 369 Mary G. McGeown

1. Belfast results 375

Index 379

About the editor

After graduating in medicine, the editor worked for three years in the Queen's University Department of Biochemistry obtaining the degree of PhD. Returning to medicine, she spent some five years on research on calcium metabolism and the causes of renal calculi. In 1959 she set up a service for the treatment of acute renal failure. During the next decade this service was expanded to include the management of nephrological problems in general, and the treatment of advanced chronic renal failure by haemodi-alysis. A renal transplant unit was established in 1968. The results of renal transplantation achieved in the Belfast Unit have been acknowledged as being amongst the best in the world. In 1983 she was made an honorary Doctor of Science by the New University of Ulster, and in 1991 an honorary Doctor of M~dical Science by the Queen's University of Belfast. In 1985 she was appointed Commander of the British Empire by Her Majesty the Queen.

xv

List of Contributors

John P. Alexander, MB, Bch, BAO, FRCPI, FFARCSI, DA, Consultant anaesthetist, Intensive Care Unit, Belfast City Hospital, Belfast.

J. Henry Brown, MD, MRCP, Senior registrar, The Mary G. McGeown Regional Department of Nephrology, Belfast City Hospital, Belfast.

Ciaran C. Doherty, MD, FRCP, Consultant nephrologist, The Mary G. McGeown Regional Department of Nephrology, Belfast City Hospital, Belfast.

Richard A. Donaldson, BSc, MB, BCh, BAO, FRCS, Consultant urologist and consultant transplant surgeon, Department of Urology, Belfast City Irospital, Belfast.

James F. Douglas, MB, BCh, BAO, FRCP, BCL, Consultant nephrologist and head of The Mary G. McGeown Regional Department of Nephrology, Belfast City Hospital, Belfast.

Claire M. Hill, MD, FRCPath, FRCPI, Senior lecturer and consultant pathologist, the Queen's University of Belfast, Institute of Pathology, Royal Victoria Hospital, Belfast.

S. Robin Johnston, FRCS, Consultant urologist, Department of Urology, Belfast City Hospital, Belfast.

xvii

Patrick F. Keane, MD, FRCS, Senior registrar, Department of Urology, Belfast City Hospital, Belfast

Joseph A. Kennedy, MCh, FRCS, Consultant urologist and head of the Department of Urology, Belfast City Hospital, Belfast.

Robert M. Kernohan, FRCS Ed, Consultant transplant surgeon and consultant urologist, Departments of Urology and Nephrology, Belfast City Hospital, Belfast.

Alan Larkin, MB, BCh, BAO, MRCP, Consultant radiologist, Department of Radiology, Belfast City Hospital, Belfast.

Gavin G. Lavery, MD, FFARCS, Consultant anaesthetist, Robert Gray Regional Intensive Care Unit, Royal Victoria Hospital, Belfast.

W. Gordon G. Loughridge, MA, MB, BCh Camb, MD, FRCS Ed, Consultant urologist, Department of Urology, Belfast City Hospital, Belfast.

A. Peter Maxwell, MD, MRCP, Senior registrar, The Mary G. McGeown Regional Department of Nephrology, Belfast City Hospital, Belfast.

xviii

Derek Middleton, BSc, MD, MRCPath, Top scientific officer and head of Department of Tissue Typing, Central Laboratories, Belfast City Hospital, Belfast.

Mary G. McGeown, CBE, DSc (Hon), DMSc (Hon), MD, PhD, FRCP, FRCPE, FRCPI, Professorial fellow, the Queen's University of Belfast, Department of Medicine, Belfast City Hospital, Belfast.

Peter T. McNamee, MD, MRCP, Consultant nephrologist, The Mary G. McGeown Regional Department of Nephrology, Belfast City Hospital, Belfast.

William Nelson, MD, MRCP, Consultant nephrologist, The Mary G. McGeown Regional Department of Nephrology, Belfast City Hospital, Belfast.

Brian G. Wilson, MCH, FRCP, Senior registrar, Department of Urology, Belfast City Hospital, Belfast.

Preface

Young doctors often come to work in a kidney transplant centre, as part of their training rotation, without previous knowledge of transplantation and indeed without the intention of staying there for any lengthy period. They may well be bewildered about where to begin reading on the subject, which takes in a number of specialties, including nephrology, transplant surgery, immunology, tissue typing, urology, general medicine and general surgery, not to mention laboratory sciences such as bacteriology, haematology and biochemistry, and presupposes some knowledge of them all. Publications at all levels abound on these subjects, but the doctor new to the field cannot read and digest them immediately on arrival. We have tried to provide a clear and concise picture of the care needed by patients who are being prepared for renal transplantation or who have recently received a kidney transplant. This account has been written in a form which we hope can be easily understood by senior medical students and nurses, as well as the medically qualified.

Renal transplantation commenced in the Renal Unit of the Belfast City Hospital in 1968, and over the 22 year period over 600 transplants have been carried out, using mainly cadaveric donors. During this period the team working in the Belfast Renal Transplant Unit has acquired considerable experience of all aspects of renal transplantation. We have together written this book in the hope that it will prove to be of use as an introduction to the subject.

xix

Acknowledgements

All departments of the Belfast City Hospital have contributed in one way or another to our work of renal transplantation and without them it would not have been possible. We are very grateful for their help.

We wish to acknowledge the invaluable support of the Northern Ireland Kidney Research Fund and its devoted fund-raisers, and their Research Secretary, Mrs Pat Watters.

We wish to thank Mrs Pauline Patterson and Mrs Ruby Watson for typing the final text.

Emeritus Professor Gordon Dunstan, MA, FSA, DD (Hon), kindly read chapter 2 and gave much helpful advice.

xxi