transplantation: living kidney donation - polycystic … living kidney donation seth goldberg, md...
TRANSCRIPT
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Transplantation:
Living Kidney Donation
Seth Goldberg, MDSeth Goldberg, MD
May 9, 2016
PKD Foundation
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Abbott
Conflicts of Interest
Abbott
Kadmon – PKD
Otsuka – PKD
Pfizer – PKD
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“Renal Replacement Therapies”
• When kidneys fail, we now have
the ability to support patients via
artificial means indefinitely
• Hemodialysis
• Peritoneal Dialysis
• Transplantation (since 1954)
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Dialysis vs Transplant
Source: Based on UNOS data
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Waiting List
Source: Based on UNOS data
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Source of Kidneys
Source: Based on OPTN data
Washington University: approximately 230 kidney transplants per year
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Living vs Deceased
Modelli de Andrade LG, et al. J Bras Nefrol, 2014
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The Transplant Team• Transplant Surgeons
• Transplant Nephrologists
• Living Donor Nephrologist
• Nurse Coordinators• Nurse Coordinators
• Social Workers
• Pharmacists
• Dieticians
• . . . And Many More
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The Transplant Team• Transplant Surgeons
• Transplant Nephrologists
• Living Donor Nephrologist
• Nurse Coordinators• Nurse Coordinators
• Social Workers
• Pharmacists
• Dieticians
• . . . And Many More
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How To Be a Donor
• Early in the transplant work-up,
potential living donors can be
identified by the recipient
• Usually begins with blood-
relatives, but extends to spouse, in-
laws, friends, etc.
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How To Be a Donor• The potential donor must be in
relatively good health and, as with
the recipient, there is no age cutoff
• The potential donor should not have:
– Kidney Disease
– Diabetes
– Hypertension
– Cancer
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How To Be a Donor• Closeness of match is still relevant
• Blood type
– A, O, B, AB
• Human Leukocyte Antigen matching• Human Leukocyte Antigen matching
– Six HLA positions evaluated
– 2 copies of each, on chromosome 6
– Parent/Child will match at least 3 of 6
– Siblings
• 25% will match 6 out of 6
• 50% will match 3 out of 6
• 25% will match 0 out of 6
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How To Be a Donor
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How NOT To Be a Donor
• Paid donation is NOT permitted
• The insurance of the recipient
generally covers the costs of generally covers the costs of
donation
• However, should abnormalities be
found during the workup, the
potential donor may be referred
back to primary physician and the
costs of additional tests may not be
covered
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The Work-Up• 1) Kidney Function
• 2) Blood Pressure Screening
• 3) Diabetes Screening
• 4) Infection Screening• 4) Infection Screening
• 5) Cancer Screening
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The Work-Up• 1) Kidney Function
• 2) Blood Pressure Screening
• 3) Diabetes Screening
• 4) Infection Screening• 4) Infection Screening
• 5) Cancer Screening
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Kidney Function• The first screening test is the test
we should all already be familiar
with: CREATININE
• From this number, we can
CALCULATE an estimated GFR
from two equations
– MDRD
– CKD-EPI
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Kidney Function• But these equations are still only
estimates. . . we need to be more
certain
• We can MEASURE kidney • We can MEASURE kidney
function by one of two methods
– 24-hour urine for creatinine clearance
– Iothalamate (nuclear med) for GFR
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The Work-Up• 1) Kidney Function
• 2) Blood Pressure Screening
• 3) Diabetes Screening
• 4) Infection Screening• 4) Infection Screening
• 5) Cancer Screening
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Blood Pressure Screening
• Hypertension is common and can
lead to kidney injury over years to
decades
• The donor needs to have a BP • The donor needs to have a BP
<140/90. . . however, for a donor
in their 50s or older, WELL-
CONTROLLED blood pressure on
a single agent may not disqualify
from donation
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Blood Pressure Screening
• We request three
outside readings, and
measure once at the
office visit
• If there is a concern,
we would
recommend a 24-
hour blood pressure
monitor
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The Work-Up• 1) Kidney Function
• 2) Blood Pressure Screening
• 3) Diabetes Screening
• 4) Infection Screening• 4) Infection Screening
• 5) Cancer Screening
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Diabetes Screening• Diabetes mellitus is the most
common reason for patients to
progress to dialysis or transplant
• Screening is with:
– Fasting blood glucose (<100)
– Hemoglobin A1c (<6.0%)
– Urinalysis for microscopic protein
– If still a concern: 2-hour glucose
tolerance test
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The Work-Up• 1) Kidney Function
• 2) Blood Pressure Screening
• 3) Diabetes Screening
• 4) Infection Screening• 4) Infection Screening
• 5) Cancer Screening
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Infection Screening• HIV
• Hepatitis B (sAg, sAb, cAb)
• Hepatitis C
• Syphilis (RPR)• Syphilis (RPR)
• Cytomegalovirus (CMV)
• Epstein-Barr virus (EBV)
• If travel history, may require more testing
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The Work-Up• 1) Kidney Function
• 2) Blood Pressure Screening
• 3) Diabetes Screening
• 4) Infection Screening• 4) Infection Screening
• 5) Cancer Screening
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Cancer Screening• “Age-appropriate” cancer screening
– Chest X-ray
– CT scan of abdomen and pelvis
– Colonoscopy (50+)– Colonoscopy (50+)
• For women:
– Pap smear
– Mammogram (40+)
• For men:
– PSA (50+)
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CT Scan• The CT scan is more than just for
cancer screening
– Presence of TWO kidneys
– Kidney size discrepancy– Kidney size discrepancy
• May require split function study
– Evaluate for kidney stones
• May require urine stone battery
– Road map for surgeons
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Surgical Approach
Mini-Nephrectomy Laparoscopic Nephrectomy
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Surgical Recovery
DONOR: ~3 days
RECIPIENT: ~4 days
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Surgical Recovery
• Recovery time at home: 4-6 weeks
• The creatinine typically rises after donation
(generally to ~1.5), the plateuas after six month
• The creatinine then typically DECREASES over the
next 1-2 years, towards the pre-donation level
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Surgical Recovery• Complications rates are low given the
overall health of the donor
• However, serious complications have
been reported to occurbeen reported to occur
– Donor death: 3 per 10,000
– Donor requiring transplant: 4-10 per 10,000
• We encourage early ambulation after
donation to minimize risk of clots
• Cessation of hormonal therapies 6 weeks
prior to procedure
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Long-Term Outcomes• On average, kidney donors have a life-
expectancy that is INCREASED!
– A series of 400 former donors found no
accelerated loss of kidney functionaccelerated loss of kidney function
– There was no increased prevalence of
hypertension (same as general population)
– No increase in obstetrical risk from general
population, although recommended to delay
pregnancy for at least two months