Ayman Refaie MD Chief Transplantation amp dialysis Unit Urology amp Nephrology Center Mansoura University Successful Transplantation GOAL Good Preparation ID: 1045201
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1. How to prepare a couple for renal transplantation?Ayman Refaie, MDChief Transplantation & dialysis UnitUrology & Nephrology CenterMansoura University
2. Successful Transplantation GOALGood Preparation=
3. A- Recipient Evaluation: Guidelines
4. A- Recipient Evaluation: Guidelines
5. 1- History2- Clinical3- Laboratory4- Radiology5- Endoscopy6- Histopathology A- Recipient Evaluation
6. Active infection (TB, acute hepatitis, HIV ,) Malignancy Severe psychiatric & mental disorders Non complianceContraindications of kidney transplantation
7. Recipient Evaluation: Malignancy
8. Original kidney disease Medical illness Family history (renal failure) Dialysis (Type, duration, adequacy…..) DrugsRecipient Evaluation: History
9. General examination Chest & heart Liver ECGRecipient Evaluation: Clinical
10. History: Nephrotic syndrome, stones, hypertension, DM, family history Clinical InvestigationsRecipient Evaluation: Original kidney disease
11. Impact of recurrent glomerular diseases on death-censored graft survival(Ziad El-Zoghby, Cosio AJT 9:527-535, 2009)
12. Recipient Evaluation: Original kidney disease
13. Recurrent Renal Disease Primary FSGSIgA Nephropathy Mesangiocapillary Glomerulonephritis Membranous Nephropathy Diabetic NephropathyPrimary Hyperoxaluria Amyloidosis SLEANCA Associated Systemic Vasculitis Goodpasture’s Disease Alport Syndrome HUSCystinosis Recipient Evaluation: Original kidney disease
14. Recipient Evaluation: Original kidney diseaseMansoura Experience
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17. Urine analysis, culture, ZN&PCR (TB) Full chemistry: Liver function Complete blood count (CBC) Viral profile: HCV, HBV, CMV, HIV, EBVRecipient Evaluation: Laboratory
18. UTP Abdominal US Micturating cysto-urethrogram (MCUG) Chest x-ray / EchocardiographyRecipient Evaluation: Radiology
19. Recipient Evaluation: Abd U/S
20. Recipient Evaluation: Plain x-rayChest x-rayUTPMCUG
21. Gastroduodenoscopy CystoscopyRecipient Evaluation: Endoscopy
22. Renal Liver RectalRecipient Evaluation: Histopathology
23. InfectionStones / ObstructionV-U reflux ( nephrouretrectomy )Polycystic kidneysUncontrolled hypertensionIndications of native nephrectomy
24. V-U reflux (Treatment options)Mansoura Experience
25. V-U reflux (Treatment options)Mansoura ExperienceConclusion: Injection with PDS for reflux accompanying CRF is an appealing treatment and results in an acceptable success rate and very low morbidity.
26. B- Donor Evaluation
27. Standard donor criteria (SDC): Guidelines
28. Standard donor criteria (SDC): Guidelines
29. Standard donor criteria (SDC): Guidelines
30. Standard donor criteria (SDC): Guidelines
31. Standard donor criteria (SDC): Guidelines
32. Standard donor criteria (SDC): Guidelines
33. Standard donor criteria (SDC): Guidelines
34. 34Kidney 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.
35. Should be free from any disease Potential kidney donor
36. 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, HBVPotential kidney donor
37. 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
38. 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
39. 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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41. General examination: BMI, BPChest & heartLiverECGEchocardiogram and/or exercise stress test:(>50 years old)Pulmonary function tests for smokersDonor Evaluation: Clinical
42. Obese donorsPatients 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. 42
43. 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
44. Ambulatory blood pressure monitoring has been proposed as a more sensitive method than office blood pressure measurements in identifying hypertension in living donorsBlood pressure assessment in potential kidney donorsClinic BP hypertension defined as 140/90Ambulatory BP hypertension defined as mean 24-h 130/80.
45. 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.
46. 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.
47. Diabetes MellitusPotential 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.
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49. 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.
50. Recipient Evaluation: Laboratory Mansoura Experience
51. Thirty potential living related kidney donors with asymptomatic microscopic hematuria of nonsurgical causes were included in this studyThey were subjected to kidney biopsies which were examined by light microscopy, direct and indirect immunofluorescent microscopy, and electron microscopy
52. 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)
53. Conclusion: The relatives of uremic patients with asymptomatic microscopic hematuria should not be considered for kidney donation even if they are strongly motivated.
54. Urine analysis X3, ± phase contrast (RBCs) Urine culture and ZN & PCR (TB) Creatinine clearance Full chemical & hematological profile Viral profile: HBV, HCV, HIV, CMV, EBVDonor Evaluation: Laboratory
55. ABO group Tissue typingMatching
56. Cross match PRA: Class I, IIHLA:Class I A BClass II DRTissue Typing(Histocompatability testing)
57. 1, 8, 103,14, 172, 7, 1110, 16, 82, 7, 113, 14, 173, 14, 1710, 16, 81, 8, 102, 7, 111, 8, 102, 7, 111, 8, 1010, 16, 8SISTERBROTHERSISTERSISTERBROTHERFATHERMOTHERHLA is inherited as a “set” of the three HLA groups, A, B, DR. This set is known as a “haplotye”
58. Tissue Typing(Histocompatability testing)
59. Tissue Typing(Histocompatability testing)
60. UTP, Non contrast spiral CTAbdominal USChest X-rayUrinary system (IVP MRU CTU)Vascular system ( Angiography, MRA, CTA)RenogramDonor Evaluation: Radiology
61. Donor Evaluation: Plain x-rayChest x-rayUTP
62. 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.
63. Donor Evaluation: Abd U/S
64. Donors with grade I echogenicity: 34 (32.7 + 8.45) yearsDonors normal echogenicity: 10 matched controlsALL: GFR , measured, isotopic scintigraphy and estimation of renal reserve.
65. Donors with grade I echogenicity: 34 (32.7 + 8.45, 23–48) years, 17 biopsiedDonors normal echogenicity: 10 matched controlsALL: GFR , measured, isotopic scintigraphy and estimation of renal reserve.
66. Donors with grade I echogenicity: 34 (32.7 + 8.45, 23–48) years, 17 biopsiedDonors normal echogenicity: 10 matched controls, 8 biopsiedALL: GFR , measured, isotopic scintigraphy and estimation of renal reserve.
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68. Segmental patch of sclerosis, periodic acid-Schiff X200Mild segmental mesangial thickening, PASX400
69. Mild focal tubular atrophy, PASX200Mild focal interstitial fibrosis, Masson trichrome X200
70. 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.
71. Donor: urographyMRUCTU
72. Donor : AngiographyMRACTA
73. Donor Evaluation: RadiologyMansoura Experience
74. Donor Evaluation: RadiologyMansoura Experience
75. Donor Evaluation: RadiologyMansoura Experience
76. .Donor Evaluation: RadiologyMansoura Experience
77. 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):1760-5Multiple renal arteries
78. Tuesday, February 02, 2016GCP Aurangabad.78
79. Donor Evaluation: Renogram
80. Donor Evaluation: Renogram
81. Is it an easy task?Potential living donors should undergo a rigorous screeningProcedure to ensure the best functional outcome for recipientsNo or minimal morbidity for donors.
82. 82Dilemma in selection of living donors
83. Donor EvaluationMansoura Experience
84. Donor EvaluationMansoura Experience
85. Donor EvaluationMansoura Experience
86. Donor EvaluationMansoura Experience
87. Donor EvaluationMansoura Experience
88. Donor EvaluationMansoura Experience
89. Conclusions: Although kidneys from living donors provide the best functional outcome, 50% of potential candidates must be excluded.Donor EvaluationMansoura Experience
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91. 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 ============================================================
92. Rt / LTRt / LT
93. The living kidney donor: giving life, avoiding harm
94. Mansoura Post Donation ClinicOver the last decade.Mansoura Post donation Clinic.Recipient (hand in hand) with his/her related donorEvaluation: Clinical: BP, BMI Lab: urinalysis, S. Cr, Cr Clearance, etc….. U/s for the remaining kidneyMedications: provided when needed.94
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101. Successful Transplantation GOALGood Preparation=
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104. Thank You