principles of organ transplant
TRANSCRIPT
![Page 1: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/1.jpg)
PRINCIPLES INVOLVED IN ORGAN
TRANSPLANTDR BASHIR YUNUS
SURGERY DEPT.
AKTH
19/1/15
1/19/[email protected] 1
![Page 2: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/2.jpg)
OUTLINE
O INTRODUCTIONO Definition of terms
O Transplant immunology
O Graft rejection
O PRINCIPLESO Pre-operatives
O Intra-operatives
O Post-operative
O COMPLICATIONS
O RENAL TRANSPLATATION
O ETHICAL CONSIDERATIONS
O CONCLUSION
O REFERENCES
1/19/[email protected] 2
![Page 3: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/3.jpg)
INTRODUCTION
DEFINITION OF TERMS
• An organ transplant is a surgical procedure in which a failing organ is replaced by a functioning one from a donor with a compatible tissue type.
• Autograft
• Allograft
• Isograft
• Xenograft
• Orthotopic graft
• Heterotopic graft
1/1
9/2
01
5b
bin
yun
us2
00
2@
gmai
l.co
m
3
![Page 4: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/4.jpg)
INTRODUCTION
• TRANSPLANT IMMUNOLOGY
The immune system recognizes graft from someone else as foreign and triggers response via immune cells or substances they produce -cytokines and antibodies
• Responses are via; recognition, amplification and memory
• CELL; • Lymphocytes; T-lymphocyte, B-lymphocyte, N-killer cells
• Antigen presenting cells(APC); macrophages, dendritic cells
• The Effector Cells; Neutrophils , macrophages and T-lymphocytes
• T-LYMPHOCYTES
• Mediator of cell mediated immunity
• They recognizes MHC antigen on transplant tissues
• Cytotoxic T-cells produces cytotoxic factors (perforins, granzymes) implicated in transplant rejection
1/1
9/2
01
5b
bin
yun
us2
00
2@
gmai
l.co
m
4
![Page 5: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/5.jpg)
Cell-mediated immune response
Defend against intracellular pathogens/rejection
ActiveCytotoxic T cells
MemoryCytotoxic T cells
MemoryHelper T cells
Antigen-presenting cell
Antigen (2nd exposure)
Helper T cell
Engulfed by
Antigen (1st exposure)
Cytotoxic T cell
Key
Stimulates
Gives rise to
+
+
+
+
+ +
+
1/1
9/2
01
5b
bin
yun
us2
00
2@
gmai
l.co
m
5
![Page 6: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/6.jpg)
Cytotoxic T cell
Perforin
Granzymes
TCRCD8
Class I MHCmolecule
Targetcell
Peptideantigen
Pore
Released cytotoxic T cell
Dying target cell
1/1
9/2
01
5b
bin
yun
us2
00
2@
gmai
l.co
m
6
![Page 7: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/7.jpg)
B-LYMPHOCYTES
• Mediators of humeral immunity by antibody production.
• There activation is aided by cytokine and the T-helper cells
• Clonal selection generates plasma secreting antibodies.
• There are 5 major classes of antibodies or immunoglobulin; IgG, IgM, IgA, IgE and IgD the 1st 3 are involve in graft rejection
N-KILLER CELLS
• Cells of innate immunity, capable of killing foreign targets without prior sensitisation
1/1
9/2
01
5b
bin
yun
us2
00
2@
gmai
l.co
m
7
![Page 8: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/8.jpg)
Key
Stimulates
Gives rise to
+
MemoryHelper T cells
Antigen-presenting cell
Helper T cell
Engulfed by
Antigen (1st exposure)
+
+
+
+ +
+
Defend against extracellular pathogens/Transplant rejection
MemoryB cells
Antigen (2nd exposure)
Plasma cells
B cell
Secretedantibodies
Humoral (antibody-mediated) immune response
1/1
9/2
01
5b
bin
yun
us2
00
2@
gmai
l.co
m
8
![Page 9: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/9.jpg)
• ANTIGEN PRESENTING CELLS(APC)
• They capture antigens and display to lymphocytes e.g. Macrophages, dendritic cells and follicular dendritic cells.
• Dendritic cells; initiate T-cells response
• Macrophages; Initiate effector phase of cell mediated immunity
• Follicular dendritic cells; display antigens to B-lymphocytes in humeral response.
• EFFECTOR CELLS
• They eliminate antigens by phagocytosis
• E.g neutrophils, macrophage and T-lymphocytes
1/1
9/2
01
5b
bin
yun
us2
00
2@
gmai
l.co
m
9
![Page 10: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/10.jpg)
APC
1/1
9/2
01
5b
bin
yun
us2
00
2@
gmai
l.co
m
10
![Page 11: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/11.jpg)
TRANSPLANT ANTIGENS
Human leucocytes antigen(HLA);
O a group of highly polymorphic cell surface molecules
O They act as antigen recognition unit on T-lymphocytes and are the major trigger for graft rejection
O Types; class1 –A,B,C present in all nucleated cells, class2 – HLA-DR,DP,DQ present only on APC
O Class 2- HLA-DR are most important in rejection
O CD8+ and CD4+ recognize class 1 and 2 receptors respectively
1/19/[email protected] 11
![Page 12: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/12.jpg)
MHC;
O Major histocompatibility complex. They are clusters of genes on the short arm of chromosome 6 expressed on the cell surface as HLA i.e. genes that encode HLA.
ABO
O These blood group antigen are expressed not only on red blood cells but by most cell types as well.
O Incompatibility leads to hyperacute rejection
1/19/[email protected] 12
![Page 13: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/13.jpg)
GRAFT REJECTION;
Rejection of transplanted organs is a bigger challenge than the technical expertise required to perform the surgery. It results mainly from HLA and ABO incompatibility.
O Hyperacute
O Acute
O Chronic
1/19/[email protected] 13
![Page 14: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/14.jpg)
Hyperacute rejection
O Immediate graft destruction due to ABO
or preformed anti- HLA antibodies.
O Characterized by intravenous
thrombosis and interstitial hemorrhage.
O Risk factors are previous failed transplant
and blood transfusions
O Kidney transplant is vulnerable to
hyperacute rejection
1/19/[email protected] 14
![Page 15: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/15.jpg)
Acute rejection
O Usually occurs during the first 6month
O May be cell mediated (T-cell), antibody
mediated or both
O Characterized by cellular infiltration of
the graft(cytotoxic, B- cells, NK cells and
macrophages )
1/19/[email protected] 15
![Page 16: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/16.jpg)
CHRONIC REJECTION
O it occurs after 6month
O Most common cause of graft failure
O Antibodies play important role
O Non- immunological factors contribute to
the pathogenesis
O Characterized by myointimal
proliferation in graft arteries leading to
ischemia and fibrosis
1/19/[email protected] 16
![Page 17: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/17.jpg)
PRINCIPLES
1. PRE-OPERATIVE
O Patient selection and Evaluation
O Counseling
O Informed consent
O optimization
1/19/[email protected] 17
![Page 18: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/18.jpg)
PATIENT SELECTION AND EVALUATION
RECIPIENT
O Patient who met the indication for transplant –ORGAN FAILURE
O Clinical evaluation; history and physical examination to rule out other diseases and co-morbidities
O Immunological evaluationO Serology; HIV, Hepatitis, CMV, VDRL
O Tissue typing & cross matching
O Blood group
O Infection screening – septic work-up, mantoux
O Others ; FBC, clotting profile, FBS, ECG, U/Ecr, tumour markers, stool microscopy
1/19/[email protected] 18
![Page 19: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/19.jpg)
Patient selection
O DONOR
a) Cadaveric
O Individuals with severe brain injury
resulting in brain death-Brain death is
defined as “complete irreversible
cessation of all brain functions”.
1/19/[email protected] 19
![Page 20: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/20.jpg)
Other criteria;
O Normothermic patient.
O No respiratory effort by the patient.
O The heart is still beating.
O No depressant drugs intake should be there while evaluating the patient.
O Individual should not have any sepsis, cancer (except brain tumour).
O Not a HIV or hepatitis individual.
1/19/[email protected] 20
![Page 21: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/21.jpg)
b. Living donor;
a living donor should be healthy
Living unrelated donor or
Living related donor.
O Improved graft survival
O Less recipient morbidity
O Early function and easier to manage
O Avoidance long waiting time for transplant
O Less aggressive immunosuppressive regimen
1/19/[email protected] 21
![Page 22: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/22.jpg)
O Contra-indications for living donor ;
O Mental disease
O Disease organ
O Morbidity and mortality risk
O ABO incompatibility
O Crossmatching incompatibility
O Transmissible disease
1/19/[email protected] 22
![Page 23: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/23.jpg)
Evaluation; to assess for suitability
O CLINCAL; history of risk factors for infection, malignancy in the past 5 years. Presence of co-morbidities
O ABO typing.
O Serology tests.
O Infection and malignant screening
O CT-Angiogram;
O Intravenous urography.
O HLA typing.
1/19/[email protected] 23
![Page 24: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/24.jpg)
FACTORS DETERMING ORGAN FUNCTION AFTER TRANSPLANT
DONOR CHARACTERISTICS
O ■ Extremes of age
O ■ Presence of pre-existing disease in the transplanted organ
O ■ Haemodynamic and metabolic instability
PROCUREMENT-RELATED FACTORS
O ■ Warm ischaemic time
O ■ Type of preservation solution
O ■ Cold ischaemic time
RECIPIENT-RELATED FACTORS
O ■ Technical factors relating to implantation
O ■ Haemodynamic and metabolic stability
O ■ Immunological factors
O ■ Presence of drugs that impair transplant function
1/19/[email protected] 24
![Page 25: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/25.jpg)
Tissue typing
O The tissue typing laboratory carries out 3 tasks
O To determine the HLA type of blood for both donor and recipient by PCR.
O Lymphocyte crosshatching to exclude circulating antibodies in recipient against HLA expressed by donor.
O HLA antibody screening and specificityin recipient before and after transplant to guide immunosuppressive therapy
1/19/[email protected] 25
![Page 26: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/26.jpg)
O Positive cross matching;
O Recipient antibodies attacks donor’s.
O Not suitable for transplant
O Negative cross matching;
O Recipient antibodies donot attack donor
O Suitable for transplant
O Methods;
O Microcytotoxic assay, mixed lymphocytes, flow cytometory, DNA analysis.
1/19/[email protected] 26
![Page 27: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/27.jpg)
PRE-OPERATIVE
O Patient selection and Evaluation
O Counseling
O Informed consent
O optimization
1/19/[email protected] 27
![Page 28: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/28.jpg)
COUNSELING
O May involve professional counselors/ psychotherapist
O Aimed at preventing / minimizing possible complication
O Need for adherance to post-op maintenance medications
O Regular follow-up thorough evaluation
O life style modification; smoking, alcohol, sedentary life style, junks, excessive salt ingestion.
1/19/[email protected] 28
![Page 29: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/29.jpg)
INFORMED CONSENT
O Living Donor ;
O Education
O Willingly not for any financial reason or
under duress
O Most undergo extensive screening –
medical phycological
O Involve family
O Surgery and anaesthetic complications
complications outline to patients
1/19/[email protected] 29
![Page 30: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/30.jpg)
O DECEASE DONOR
O Some Factors influencing refusal to consent by relatives;
O non-acceptance of brain death.
O Superstitions relating to being reborn with a missing organ
O A delay in funeral
O Lack of consensus within family members
O Fear of social criticism
O Dissatisfaction with the hospital staff
O Religious believes
1/19/[email protected] 30
![Page 31: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/31.jpg)
INFORMED CONSENT
O RECIPIENT
O Nature of disease and the need for
transplant
O Outcome and complications
O Need for compliance to
immunosuppressive therapy
O Other available options
1/19/[email protected] 31
![Page 32: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/32.jpg)
OPTIMIZATION OF RECIPIENT
Correction of derangements, getting patient ready for surgery
O Correction of anaemia
O Uremia
O Dehydration
O Treatment of infection
O Treatment of malaria
O Deworming of patient
O Central line
O Urethral catheter
O Loading dose immunosuppression 12hr pre-op
O Prophylactic antibiotics
1/19/[email protected] 32
![Page 33: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/33.jpg)
PRINCIPLES
INTRA-OPERATIVE
Organ procurement and preservation
Living donors
a. Strict asepsis and hemostasis
b. Adequate exposure
c. Control of the vessels above and below
the organs to be removed is done- cross
clamping
d. Removal of the organ
1/19/[email protected] 33
![Page 34: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/34.jpg)
1/1
9/2
01
5b
bin
yun
us2
00
2@
gmai
l.co
m
34
![Page 37: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/37.jpg)
NONHEART-BEATING KIDNEY DONATION
Initiation of preservation in situ- for
DCD donors- donation after circulatory
death donors
1/19/[email protected] 37
![Page 38: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/38.jpg)
h. Transplantation/vascular reconstruction
Warm ischemic time ; time an organ remains at body temperature between which the blood supply is cut off before cold perfusion. (within 30min)
Cold ischemic time ; the time between the chilling of the organ, after blood supply has been cut off and the time it is warmed by reconnection
1/19/[email protected] 38
![Page 39: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/39.jpg)
Maximum and optimal cold storage times (approximate)a
O Organ Optimal (hours ) Safe maximum(hours)
O Kidney < 24 48
O Liver < 12 24
O Pancreas < 10 24
O Small intestine < 4 8
O Heart < 3 6
O Lung < 3 8
Assuming zero warm ischaemic time and organs obtained from a non-marginal
1/19/[email protected] 39
![Page 40: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/40.jpg)
PRINCIPLES
O Post-operativeO Post-operative assessment
O Clinical –vital signs; fever, tarchychadia, hypertension, pain at site of transplant, pedal oedema (compession of external iliac vein), decrease urine volume- features of hyperacute rejection
O Investigations ; U/Ecr
USS- increase in size, pelvicalyceal dilation
Biopsy; mononuclear infiltrates, fibrinoid necrosis, interstitial haemorrhage.
Others
O Maintenance immunosuppression
O DVT prophylaxis
O Treatment of infection
O Regular follow up
1/19/[email protected] 40
![Page 41: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/41.jpg)
IMMUNOSUPPRESSION
O The principles are the same for type of organ transplant; maximize graft protection and minimize side effect.
O The agents used to prevent rejection act predominantly on T cells.
O The need for immunosuppression is highest in the first 3 month but indefinite treatment is needed
O It increase the risk of infection and malignancy.
1/19/[email protected] 41
![Page 42: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/42.jpg)
AGENT MODE OF ACTION SIDE FFECT
CALCINEURINE
INHIBITORS
Cyclosporine
tacrolimus
Block IL-2 gene
transcription
Nephrotoxicity,
hypertension,
dyslipidaemia, hirsutism,
gingival hyperplasia,
neurotoxicity and diabetes
AZATHIOPRINE Prevents lymphocyte
proliferation
Leucopenia,
thrombocytopenia,
hepatotoxicity,
gastrointestinal
symptoms
MYCOPHENOLIC ACID
DERIVATIVES eg MMF –
mycofenolate mofetil
Prevents lymphocyte
proliferation
Leucopenia,
thrombocytopenia,
gastrointestinal symptoms
CORTICOSTEROIDS Widespread anti-
inflammatory
effects
Hypertension,
dyslipidaemia, diabetes,
osteoporosis, avascular
necrosis,
cushingoid appearance
mTOR-inhibitors
Sirolimus, everolimus
Blocks IL-2 receptor signal
transduction
Thrombocytopenia,
dyslipidaemia,
pneumonitis, impaired
1/19/[email protected] 42
![Page 43: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/43.jpg)
AGENT MODE OF ACTION SIDE EFFECT
ANTIBODY THERAPIES
a. OKT3 monoclonal
antibody
b. Anti-CD25 monoclonal
antibody
c. Polyclonal antibody
[antilymphocyte
globulin (ALG) or anti-
lymphocyte serum (ALS)]
Depletion and blockade of
T
Cells
Targets activated T cells
Depletion and blockade of
lymphocytes
a. Cytokine release
syndrome, pulmonary
oedema, leucopenia
b. None described
c. Leucopenia,
thrombocytopenia
1/19/[email protected] 43
![Page 44: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/44.jpg)
REGIMENS
O Immunosuppressive agents are given as O Induction; early post-op period
O Maintanance ; given for life
O Rescue agents ; to reverse acute rejection
O Induction regimen (most currently used ) CNI + anti CD 25 monoclonal antibody
Triple therapy ; CNI, antiproliferative agent (MMF) and steroids
Dual therapy ; CNI + MMF or steroids
Polyclonal antibody (ALG/ALS)
1/19/[email protected] 44
![Page 45: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/45.jpg)
O Maintenance ;
O mTOR- inhibitors (esp in kidney transplant
because they provide a noo-nephrotoxic
alternative to CNI)
O Multidrug therapy ; steroids, antiproliferatives,
CNIs, lymphocytes sequestration –FTY720
O Acute rejection;
O Polyclonal antibody combine with induction
regimen- quadruple therapy.
1/19/[email protected] 45
![Page 46: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/46.jpg)
COMPLICATIONS OF IMMUNOSUPPRESSION
O INFECTIONS; high risk of opportunistic infections
O Bacterial; common during first month after transplantation / before recovery from surgery
Community acquired infections
Wound infection
UTI (catheter related)
Tuberculosis
1/19/[email protected] 46
![Page 47: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/47.jpg)
O Viral ; highest in the first six month
CMV infection; may presents as pnuemonia, gastrointestinal disease, hepatitis, retinitis, encephalitis
Herpes simplex virus (HSV) ; mucocuteneous lesions sometimes around the genitalia
BK-virus; graft dysfunction
Herpes zoster infection; chicken pox
O Fungal ; pneumocystic jiroveci(carinii), candidiasis, aspergillosis
O Parasitic; strongiloides, leimaniasis, toxoplasmosis
1/19/[email protected] 47
![Page 48: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/48.jpg)
O MALIGNANCY
Post transplant lymphoprolipherative
disease (PTLPD); seen 1-3% of kidney
transplant with 50% mortality
Squamous cell ca of the skin
Basal cell ca and malignant melanoma are
higher in transplant patient than the genral
population
50% of transplant patient would develop skin
malignancy in 20years
Kaposi sarcoma; 300 fold increased risk1/19/[email protected] 48
![Page 49: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/49.jpg)
KIDNEY TRANSPLANTO Indications
O End-stage renal disease
Causes
O glomerulonephritis;
O diabetic nephropathy;
O hypertensive nephrosclerosis;
O renal vascular disease;
O polycystic disease;
O pyelonephritis;
O obstructive uropathy;
O systemic lupus erythematosus;
O analgesic nephropathy;
O metabolic disease (oxalosis, amyloid).
1/19/[email protected] 49
![Page 52: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/52.jpg)
1/19/[email protected] 52
![Page 53: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/53.jpg)
O Donor Nephrectomy
O Open or laparoscopic
O Open donor nephrectomy is the gold standard
O Open donor nephrectomy is via the 12th rib
incision, and in fat patient 10th rib or
hypogastrium
O Extraperitoneal : avoid devascularizing ureter,
sharp dissection, avoid diathermy near vessels
O Renal vasculature dissect flush to IVC/Aorta
O Ligate lumbar veins posteriorly ± gonadal vein
1/19/[email protected] 53
![Page 54: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/54.jpg)
Donor Kidney Bench Surgery
O The kidney is perfused with ice-cold
preservative
O Iced saline is mashed into a slush and
kidney immersed
O Extra veins ligated, accessory artery(ies)
anastamosed together
O Kidney now ready for transplanting
1/19/[email protected] 54
![Page 55: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/55.jpg)
THE TRANSPLANT
O Right donor kidney to left recipient site and vice versa
O Gibson’s incision; Curvilinear incision 2 cm above the inguinal ligament, from midline to just above the anterior Sup. Iliac Spine
O End to side venous anastamosis 5/0 prolene
O End to end arterial anastamosis 5/0 prolene
O Implant ureter to bladder 1/19/[email protected] 55
![Page 56: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/56.jpg)
1/19/[email protected] 56
![Page 57: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/57.jpg)
COMPLICATIONS
O TECHNICAL O Vascular hemorrhage; Vascular thrombosis 10-
20%, within 2-3 days→ technical, 2/12→rejection, most are lost: ↓urine output, ↑creat
O Urological ; infection, fistula, obstruction
O Wound infection
O RENAL O Acute tubula necrosis
O Cortical necrosis
O Lymphocele
O Graft rupture
O Recurrent glomerulo-nephritis
1/19/[email protected] 57
![Page 58: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/58.jpg)
Outcome
O Patient survival after deceased donor renal transplantation is >90% at 1 year and > 80% at 5 years.
O Graft survival is around90% at 1 year and 75% at 5 years. Graft survival after a second transplant is only marginally worse than after a first graft.
O After living-related kidney transplantation, overall graft survival is around 95% at 1 year and 85% at 5 years.
1/19/[email protected] 58
![Page 59: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/59.jpg)
ETHICAL CONSIDERATION
INTERNATIONAL PERSPECTIVES ON THE ETHICS AND REGULATION OF HUMAN CELL AND TISSUE TRANSPLANTATION O Consent for removal of human cells and
tissues O Confidentiality of donor data O Unpaid donationO Fair procurement of cells and tissues O Stewardship for donated cells and tissuesO Quality and safety of HC/HT procurement and
processingO Fair distribution of processed cells and tissuesO Consent for HC/HT transplantation 1/19/[email protected] 59
![Page 60: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/60.jpg)
Future trend
O Genetic engineering –cloning
O Newer specific immuno-suppresive
therapy
1/19/[email protected] 60
![Page 61: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/61.jpg)
CONCLUSION
O Organ transplant is a successive
therapeutic option for treatment of end-
stage organ disease. Success depends
on improved surgical technique,
immunosuppression, organ
preservation and follow-up .
1/19/[email protected] 61
![Page 62: Principles of organ transplant](https://reader034.vdocuments.us/reader034/viewer/2022052301/55a702b81a28abc01f8b45f6/html5/thumbnails/62.jpg)
REFERENCES
O Bailey and Love’s “Short Practice of Surgery” 26th edition CRC press Taylor and Francis group. 2013
O E.A Badoe et al, “Principles and Practice of surgery including pathology in the tropics” 4th
edition, Assembly of God Literature Center ltd, 2009
O M.A.R Al-Fallouji; “Postgraduate Surgery the candidate guide”. 2nd Edition. Rced Educational and Professional Pub. Ltd 1998
O Sabiston texbook of surgery. 18th edition.2007
O Andrew C et al “Operative urology at the clevelandclinic” 2nd edition. 2006.
1/19/[email protected] 62