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  • 1. Pediatric Transplantation Pediatric GU Review UCSD Pediatric Urology George Chiang MD Sara Marietti MD Outlined from The Kelalis-King-Belman Textbook of Clinical Pediatric Urology 2007 (not for reproduction, distribution, or sale without consent)
  • 2. Advantages Over Dialysis
    • Better growth after transplant
    • More cost-effective
    • Improved quality of life
  • 3. Pediatric Transplantation
    • Steady improvement in adult/pediatric pt survival and graft survival over last decade
    • Acute rejection rates (1 st 12 mo) at all time low
    • Because grafts/patients survive longer, increase in long-term complications
  • 4. GU Involvement in Ped Transplant
    • GU causes are responsible for 25% of childhood ESRD
    • MC Causes:
    • - obstructive uropathy
    • - aplastic/hypoplastic/dysplastic kidney
    • - focal segmental glomerulosclerosis
    • - reflux nephropathy
    • - polycystic disease
  • 5. GU Involvement
    • High number of pediatric transplant patients require adjunctive surgical procedures prior to transplant (ex. Augment, catheterizable channel)
    • More pt performing CIC than the adult population
  • 6. Preparing For Transplantation
    • Multidisciplinary approach – GU, neph, tx surgery, social worker, RN, dietician
    • Medical Evaluation
    • - as optimal as possible
    • - good physical fitness and weight control
    • - aggressive nutritional support
    • - possibly growth hormone therapy
    • - immunization status
  • 7. Medical Eval (Cont.)
    • - warts
    • - psychosocial stability
    • - frequent/comprehensive follow up
    • - access/compliance with immunosuppression
  • 8. Goals of Urologic Evaluation
    • Confirm adequate storage
    • Confirm adequate emptying
    • In pt with known GU problem (PUV, spina bifida) may need special void regimen, CIC or Ach prior to trasplant
    • If pt is fully diverted, must un-divert and cycle reservoir prior to transplant
  • 9. Evaluation of Lower Urinary Tract
    • Etiology of renal failure (ex valves)
    • History of lower urinary tract dysfunction
    • Voiding diary
    • Uroflow and PVR
    • VCUG
    • Urodynamics
    • Individualized approach
  • 10. Indications for Pretransplant Nx
    • Stones not cleared by minimally invasive techniques
    • Solid renal tumors
    • Polycystic kidneys, symptomatic, extend below iliacs, infections
    • Significant proteinuria
    • Recurrent pyelonephritis
    • High grade hydronephrosis
    • Infected stones
    • Severe hypertension
    • Infected reflux
    • Malignancy risk (Denys-Drash)
  • 11. VUR Managment
    • Controversial
    • Some studies have shown increased number of post-tx uti’s if not addressed prior to transplant
    • If recurrent infections with VUR (pretransplant) should do reimplant or bilateral N-U
  • 12. Timing of Transplant
    • Living donors allow for transplant prior to initiation of dialysis
    • However, deceased donors have now reached equivalent graft survival in the first few years of transplant
  • 13. The Live Donor
    • Many pediatric transplants are live donor – the parent
    • Need extensive information and medical work up
    • Newer – live donor exchange program (first done in 2001)
  • 14. Living Donor Medical Evaluation
    • Primary
    • - H&P
    • - blood type
    • - tissue type
    • - psych eval
    • - pregnancy test
  • 15. Living Donor Medical Evaluation
    • Secondary
    • - CBC, Coag, AMA-renal, Chol, LFT, UA, US, Renal Arteriography, CXR
    • - Infection screen: Epstein Bar, HIV, Hep B/C, PPD, ucx
    • - Pelvic exam, pap, if >40 then mammogram
    • - Rectal in male, if >40 then PSA
  • 16. Living Donor Medical Evaluation
    • Tertiary
    • - FMHx DM: 2 hr post-prandial glucose
    • - If cardiac risk factors: stress test, echo
    • - If pulm symptoms: PFT’s
  • 17. Transplantation - Recipient
    • Pt supine
    • Foley placed, antibacterial solution instilled
    • Central venous access
    • Second-generation cephalosporin
  • 18. Transplantation
    • >20kg retroperitoneal
    • 10-20kg retroperitoneal if small kidney
    • <10kg intraperitoneal
    • Retroperitoneal is ideal to preserve peritoneal cavity for PD if necessary
  • 19. Transplantation
    • Infant/toddler – aorta or aorto-iliac junction
    • Young child – common iliac
    • Adolescent/adult – external iliac
    • Aggressively avoid hypotension
    • Expand blood volume to CVP of 12-16
    • Adult allograft can sequester 200-300 ml of blood from the circulation
  • 20. Transplantation
    • Reimplant can be either intra/extravesical
    • Extravesical advantages – shorter OR time, less obstruction, less hematuria, less urinary extravasation
  • 21. Post-Op Care
    • Fluid and electrolyte management
    • Fresh transplant has decreased concentrating ability so may have excessive uop first few days
    • 1:1 replacement
  • 22. Early Graft Dysfunction
    • Mostly preventable
    • Signs – oliguria, Cr does not fall
    • No uop – concern for arterial thrombosis, most centers do immediate doppler US after closure
    • Most have native kidneys so uop as measure can be challenging
  • 23. Initial Good UOP, then Drop
    • Low intravascular volume – bolus
    • CI toxicity - >20 ng/ml
    • Rejection – dx by biopsy
    • Venous thrombosis
    • Urine leak
  • 24. Post-Op Fluid Collection
    • Lymphocele – intervene if symptomatic, expanding or obstructive
    • Urine leak
    • Hematoma
  • 25. Immunosuppression
    • Very individualized but usually triple therapy with CI, antimetabolite, steroids
    • Target ranges based on estimated rejection risk balanced against side effects of the medications
  • 26. Immunosuppressive Therapy
    • LESS
    • First-time caucasian recipient
    • Live donor kidney
    • No evidence of pre-sensitization
    • MORE
    • Repeat transplant
    • Deceased donor
    • Evidence of pre-sensitization
    • Recipients who are african-american
  • 27. Prophylaxis
    • Bacterial: peri-op for wound infection, then targeted toward uti and pneumocystis carinii (Bactrim)
    • CMV – determined by risk (recipient and donor history of CMV exposure and strength of immunosupp)
    • Epstein Barr virus – no effective prophylaxis, many peds recipients are neg, adult donors are positive
    • Antifungals – first few months while immunosupp is highest
  • 28. Prophylaxis
    • If pt has acute rejection and need to increase immunosuppressive therapy, recycle the full spectrum of prophylactic meds as well
    • GI – H2 blocker for steroid-induced gastritis and ulcers
  • 29. Urologic Complications
    • 5.6% of all cases
    • - urinary extravasation
    • - ureteral anastomotic obstruction
    • - ureteral necrosis
    • - symptomatic VUR
    • Urologic problems result in allograft loss 31% of the time
  • 30. Renovascular Complications
    • 5.5% of all cases
    • - technical (3.2%):anastomotic defect, vascular angulation, vascular compresseion
    • 86% of all vascular complications result in allograft loss
  • 31. Urolithiasis
    • 6% of adults, 5% of pediatric tx kidneys
    • Etiology
    • - low uop
    • - elevated calcium excretion
    • - disturbance in uric acid metabolism secondary to CI therapy
    • - increased frequency of uti
    • - hypocitraturia, hypomagnesuria, hypophosphaturia
    • - suture material present
  • 32. Post-transplant VUR
    • Post-tranplant VUR without pyelonephritis has not been linked to allograft loss in either adult/kids
    • Post-transplant VUR with pyelonephritis has been linked to allograft loss, these should be corrected
    • Attempts at deflux have failed to correct it
    • In kids, VUR can be from incompletely managed bladder…may need Ach or CIC
  • 33. Long-term
    • Transition to adult can be hard
    • Decreased compliance in teenage years is an issue
    • Need long term follow up of donors who may develop htn/proteinuria
    • Attempting to create Donor Database to better follow these pt
    • If donor loses solitary kidney, placed at top of transplant list
  • 34. Summary
    • 33% of pediatric tx pt require urologic surgery prior to transplant
    • No pt is transplanted while diverted
    • Living donors have better graft survival long term
    • Improvements in immunosuppression have significantly improved graft survival, specifically in the first few years