6/11/2018 Objectives TRANSPLANTATION Understand Identify Review “THE ART OF THE Understand the Identify donor and Review standard DO- OVER” kidney transplant recipient factors transplant recipient selection that lead to immunosuppression process. successful regimens. transplant outcomes. 1
6/11/2018 Quantity or Quality Benefits of Kidney Transplantation Risks of Transplantation Surgery Immunosuppression Bleeding Opportunistic infections Longer Life Urinary leak Malignancy Death Diabetes Debility Gout Improved Quality of Life Anesthesia Diarrhea Urine retention Insomnia Lymphocele Tremor DVT Hypertension No Dialysis Pneumonia Alopecia Acute myocardial infarction Hypomagnesemia or hyperkalemia T cells This Photo by Unknown Author is licensed under CC BY This Photo by Unknown Author is licensed under CC BY-SA 2
6/11/2018 HLA PROTEINS This Photo by Unknown Author is licensed under CC BY-SA LYMPHOID ORGANS This Photo by Unknown Author is licensed under CC BY-SA Maintenance Immunosuppression • Tacrolimus (Prograf) – diabetes, hypertension, insomnia, tremor, diarrhea • Mycophenolate (Myfortic or Cellcept) – diarrhea, fatigue, bloating • Prednisone – fluid retention, weight gain, acne, fat redistribution, bruising 3
6/11/2018 Drugs that raise CNI levels Drugs that lower CNI levels Calcineurin Inhibitor This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY-NC-SA This Photo by Unknown Author is licensed under CC BY-SA Living Donor Types • Neurologic death criteria • Cardiac death criteria Deceased 4
6/11/2018 Donor Factors POSITIVE OUTCOMES NEGATIVE OUTCOMES Younger age Older age Greater HLA match with recipient HLA mismatched with recipient Higher GFR Lower GFR Absence of diabetes or hypertension Presence of diabetes or hypertension Neurologic death Cardiac death Less ischemic More ischemia Transplant Candidate Evaluation Pre-Transplant • Multidisciplinary Team evaluation (Surgeon, Physican, Phase Coordinator, Social Worker, Pharmacist, Dietitian, Independent Donor Advocate for donors) Transplant • Presented and approved at SELECTION COMMITTEE Phase • Three outcomes – (a) UNOS listed, (b) sent back for further evaluation, (c) denied and given alternate referral options Post-Transplant Phase • Waitlist management – education and maintenance of health • Additional consents – (a) PHS elevated risk; (b) high KDPI donor 5
6/11/2018 1. Advanced kidney disease : Regulations for 9. Obesity : Candidates must have a body mass index listing for transplantation state that candidates must (BMI, weight/body surface area) of <38. Recipient Factors either be on dialysis or have near loss of kidney 10. Functional status : Candidates must be able to function with a creatinine clearance < 20cc/min walk short distances and perform activities of daily living (normal is >80). without assistance. 2. Adequate urinary tract : POSITIVE OUTCOMES NEGATIVE OUTCOMES 11. Psychosocial status : Candidates must be 3. Acceptable cardiovascular function : motivated, have demonstrated compliance with medical Contraindications to transplantation include and dialysis regimens, not suffer from psychosis, live in Older age Younger age significant un-correctible coronary artery disease a stable environment, capable of supporting compliance and/or poor cardiac pump function. with the transplant regimen including transportation, Greater HLA match with recipient HLA mismatched with recipient and not be an active substance abuser, (+/- cannabis) 4. Acceptable vascular system : 12. Financial considerations : 5. Acceptable lung function : Smokers may be Ideal BMI or non-diabetic Under or 0verweight or diabetes declined until they are able to quit (based on age and medical history). Good fitness Poor fitness 6. Acceptable liver function : 7. Active significant fungal or bacterial infection is Less sensitized Highly sensitized a contraindication to transplantation. 8. Cancer screening : Appropriate for age tests will Disease with lower risk of recurrence Disease with higher risk of recurrence be necessary including colonoscopy (age>50yo), prostatic specific antigen, etc. Transplant Phase • Starts with donor offer – local donor vs import • Transplant center reviews the HLA match run and calls their potential recipients – each kidney has a primary candidate and backup candidate • Either admit potential recipient or have them provide blood for a final crossmatch • Medical suitability and final clearance • Dialysis coordination if necessary • Schedule surgery – time of day, cold ischemic time, surgeon “freshness” 6
6/11/2018 Post-Transplant Phase • Conduct frequent lab tests and office visits • Review side effects of medication • Evaluate surgical healing and remove staples, tubes, and stent • Balance immune suppression medication • Screen for infection • Address psychological concerns This Photo by Unknown Author is licensed under CC BY-NC QUESTIONS? 7
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