preparation for transplantation (mih)
TRANSCRIPT
How to prepare a couple for renal transplantation?
Ayman Refaie, MDChief Transplantation & dialysis Unit
Urology & Nephrology CenterMansoura University
Successful Transplantation
GOAL
Good Preparation=
A- Recipient Evaluation: Guidelines
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)
Recipient Evaluation: Original kidney disease
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 disease
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
UTP
MCUG
• 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
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
Standard donor criteria (SDC): Guidelines
Standard donor criteria (SDC): Guidelines
Standard donor criteria (SDC): Guidelines
Standard donor criteria (SDC): Guidelines
Standard donor criteria (SDC): Guidelines
Standard donor criteria (SDC): Guidelines
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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
Potential kidney donor
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
Potential kidney donor
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
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• 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.
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• 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, 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)
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
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, 8 biopsied
ALL: GFR , measured, isotopic scintigraphy and estimation of renal reserve.
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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
MRU
CTU
Donor : Angiography
MRA
CTA
Donor Evaluation: RadiologyMansoura Experience
Donor Evaluation: RadiologyMansoura Experience
Donor Evaluation: RadiologyMansoura Experience
.
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
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.
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Dilemma in selection of living donors
Donor EvaluationMansoura Experience
Donor EvaluationMansoura Experience
Donor EvaluationMansoura Experience
Donor EvaluationMansoura Experience
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:
Number: Blood group : Social status: Offsprings:
I- EVALUATION : Nephrology Urology Special ECG
II- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.
RFT LFT Bl. Sugar Hematology
Viral profile: HBV HCV CMV HIV
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
DONOR
جامعة المنصورة مركز أمراض الكلى والمسالك البولية
MANSOURA UNIVERSITY UROLOGY & NEPHROLOGY CENTER
MANSOURA EGYPT
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:
Number: Blood group : Social status: Offsprings:
I- EVALUATION : Nephrology Urology Special ECG
II- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.
RFT LFT Bl. Sugar Hematology
Viral profile: HBV HCV CMV HIV
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
DONOR
جامعة المنصورة مركز أمراض الكلى والمسالك البولية
MANSOURA UNIVERSITY UROLOGY & NEPHROLOGY CENTER
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 ============================================================
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:
Number: Blood group : Social status: Offsprings:
I- EVALUATION : Nephrology Urology Special ECG
II- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.
RFT LFT Bl. Sugar Hematology
Viral profile: HBV HCV CMV HIV
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
DONOR
جامعة المنصورة مركز أمراض الكلى والمسالك البولية
MANSOURA UNIVERSITY UROLOGY & NEPHROLOGY CENTER
MANSOURA EGYPT
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:
Number: Blood group : Social status: Offsprings:
I- EVALUATION : Nephrology Urology Special ECG
II- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.
RFT LFT Bl. Sugar Hematology
Viral profile: HBV HCV CMV HIV
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
DONOR
جامعة المنصورة مركز أمراض الكلى والمسالك البولية
MANSOURA UNIVERSITY UROLOGY & NEPHROLOGY CENTER
MANSOURA EGYPT
Rt / LT
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.
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Successful Transplantation
GOAL
Good Preparation
=
Thank You