N16 - Renal transplantation Flashcards
(31 cards)
What is the prevalence of CKD in Hungary?
- 1 in 14 have >50% decreased kidney function
- 1 in 140 have >75% decreased kidney funtion
- 1 in 1000 is on dialysis or is a renal transplant recipient
What is the treatment for CKD5?
CKD5 is stage 5 of chronic kidney disease, eGFR<15mL/min
75% are not eligible for transplantation
- conservative therapy
- dialysis (peritoneal and hemo-)
25% are eligible for transplatation
- kidney transplant
- dialysis (peritoneal and hemo-)
What are the steps in case of renal transplantation?
- waiting list
- donation - allocation
- transplantation
- early postoperative period
- patient care
What are the indication for kidney transplantation?
- CKD, eGFR<20mL/min/1.73m2 to get on the waitlist
- best results with preemptive transplantation but most patients receive a transplant after starting dialysis
How does the transplatation waiting list work?
in a new patient that transplantation is indicated, check their eligibility and the a decision is made by the Regional Waiting List Committee
What are absolute contraindications of kidney transplantation?
- active malignant disease (sustained disease-free state cannot be attained)
- irreversible cardiovascular diseases
- peripheral atherosclerosis (cerebral, peripheral)
- coronary vascular disease
- progressing vitium
- cardiac failure, high pulmonary artery BP - decompensated hepatic cirrhosis (simultaneous liver-kidney transplant should be considered)
- irreversible respiratory failure
- psychosocial instability
- if a temporary contraindication becomes sustained
(if life expectancy is < 2 years)
What are relative contraindications of kidney transplantation?
- ABO incompatibility
- severe obesity (BMI>40)
- advanced age is not contraindicated but optimally <75 years
- HIV seropositivity is not contraindicated if there is successful and sustained (HA)ART treatment
What are temporary contraindications of kidney transplantation?
- surgical/technical cause: arterial occlusion, stenosis, urological malformation/disorder
- increased peri-/early postoperative risk: myocardial infarction, stroke
- increased immunosuppression: infections, malignancies
- if an active disease is directly harmful for kidney graft (ie. active recurrent glomerulonephritis)
What are the types of deceased donors?
heart beating donor: donation after brain death
non-heart beating donor: donation after circulatory death
What are the types of living donors?
living, unrelated donor
- paid, unrelated is prohibited!!
- emotional relative is allowed: spouse, friend, colleague etc.
living, related donor
Who can be a donor in Hungary?
when alive: informed consent is necessary
when deceased: presumed consent (they did not refuse organ donation while alive)
What are the conditions for donor organ allocation?
- negative crossmatch (XM): there is no antibody in the recipient’s serum against donor’s HLA antigens (donor-specific antibody - DSA)
- blood group compatibility
- HLA match
- urgency, level of immunisation, waiting time
- clinical criteria: age, gender, body dimensions
How does blood group compatibility work between donor and recipient?
- in case of deceased donor, pick same blood group recipient
- O donor blood group is only for O recipient
- living donation: can be possible even in case of blood group differences
What is the process of donation?
- development of brain death
- perception of signs of brain death
- donor report
- donor evaluation
- donor treatment
- statement of brain death
- report of Eurotransplant
- Eurotransplant organ allocation
- organ procurement
- transplantation
- follow up
Who can become a kidney donor in Hungary?
- only someone who is able to give consent (no children)
- genetical relatives
- emotional relatives (should be approved by ethical committee)
- Ethical committee must approve that donation is happening w/o threat, restitution, compulsion, pressure or deception
- donors can revoke consent anytime until procurement of organ
What are the advantages of living kidney donation for the recipient?
- better graft survival after 1 year (95% instead of 90%)
- half life of kidney is higher: 20 years instead of 13 years
- immediate kidney function so no dialysis is necessary postoperatively
- shorter waiting time, preemptive transplantation
What are the advantages of living kidney donation for the donor?
- surgically safer, quick healing
- donor is discharged after 4 days
- after 4 wks they are pretty much back to their normal life
What is the location of a transplanted kidney?
- heterotopic
- iliac fossa
- extraperitoneal
What are the anastomoses of renal graft?
arteries and veins
- donor renal v. and a. with recipient common/external/internal iliac v. and a.
ureter
- neoimplantation (directly to bladder)
- uretero-ureteral anastomosis (end-to-end or end-to-side)
What are the complications in early postoperative period?
early postoperative period = first 2 wks
- delayed graft function
-
surgical complications
- arterial/venal: 1.2% (rare technical failure)
- ureter: leakage (reanastomosis is necessary)
- wound healing: remove suture after 21 days
- peri-graft fluidum, lymphocele - immunological: acute rejection, T-cell or/and antibody mediated
- infections: respiratory, urinary tract
perioperative mortality is rare
What is the frequency of follow ups for postoperative patient care in transplantation?
- 0-3 months: weekly
- 3-6 months: every 2 weeks
- 6-12 months: every 3 weeks
- 1-2 years: monthly
- 2-3 years: every 2 months
- 3+ years: every 3 months or more if necessary
What is the alloreactive immune response?
innate immunity
- ischemic reperfusion injury (IRI) at the time of resuming circulation
adaptive immunity
- cell mediated: T cell mediated rejection (TCMR)
- antibody mediated rejection (ABMR) by the formation of donor-specific HLA antibodies
Immunosuppression is necessary lifelong, while having a functioning graft!!
What is the pathomechanism of immunosuppression in case of allograft?
- basiliximab (Simulect): monoclonal IL-2R antibody (anti-CD25α)
- alemtuzumab (MabCampath): monoclonal anti-CD52 antibody
- thymoglobulin/ATG-Fresenius (Grafalon): anti-thymocyte polyclonal antibody
What are the maintenance immunosuppression drugs for renal transplantation?
1. steroids:
- prednisone/methylprednisolone
2. calcineurin-inhibitors (CNI):
- cyclosporin (Sandimmun-Neoral)
- tacrolimus (Prograf, Advagraf, Envarsus)
3. proliferation inhibitors (mTOR)
- sirolimus (Rapamune)
- everolimus (Certican)
4. lymphocyte proliferation inhibitors
- selective: mycophenolate-mofetil (cellcept); mycophenolate-Na (myfortic)
- non-selective: azathioprine (Imuran)
