cadaveric transplant renal transplant, cold preservation

1. Dr. Joel Arudchelvam
Consultant Vascular and Transplant Surgeon
Teaching Hospital Anuradhapura

2.  Renal Replacement Therapy
 Dialysis
 Renal transplantation
 Live Donor
 Deceased Donor

3. SURVIVAL AND MODES OF RRT
Charlotte Medin et al. Nephrol. Dial. Transplant.
2000;15:701-704

4.  Renal Replacement Therapy
 Dialysis
 Renal transplantation
 Live Donor - 94% 5Yrs
 Deceased Donor - 76% 5yrs

5.  Why
 Number of patients awaiting transplants
 Number with potential live donors
 Complications for live donors

6.  Types
 Donation after brain death - DBD
 Donation after cardiac death - DCD

7.  Identification of potential donors
 Early confirmation of the brain death
 consent
 Prompt notification of the retrieval team
 Careful and intensive management of the donor
 Rapid retrieval of the organs

8. Who is a deceased donor:
An individual is considered dead if:
1.irreversible cessation of circulatory and respiratory function
or
2.irreversible cessation of all functions of the entire brain,
including the brain stem.
JAMA Nov 13, 1981 – Vol 246, No. 19

9. Who is a deceased donor:
An individual is considered dead if:
1.irreversible cessation of circulatory and respiratory function
or
2.irreversible cessation of all functions of the entire brain,
including the brain stem.
JAMA Nov 13, 1981 – Vol 246, No. 19

10.  Severe head trauma
 Cerebrovascular injury
 Prolonged cardiac resuscitation or asphyxia
 Tumors brain surgery

13.  Coma
 No evidence of responsiveness.
 No motor response to noxious stimuli

14.  Absence of Brainstem Reflexes
 No pupillary reflex
 Absent corneal reflex.
 Absent - gag
 oculocephalic testing (doll’s eyes test)
 Oculovestibular testing – ice water
irrigation of each ear canal

16. ****Detailed
documentation

17.  Age less than 65 years
 S Creatinine normal
 No chronic kidney disease
 Serological test
 Hep B,C, HIV
 No sepsis
 malignancy

18.  Identification of potential donors
 Early confirmation of the brain death
 consent
 Prompt notification of the retrieval team
 Careful and intensive management of the donor
 Rapid retrieval of the organs

19.  Members
 Anaesthetist
 Coordinators
 Tissue cross match facilities
 Retrieval team
 Transplant team
 Theatre/ ward/dialysis unit/ ICU staff
 Etc.

20.  Identification of potential donors
 Early confirmation of the brain death
 consent
 Prompt notification of the retrieval team
 Careful and intensive management of the donor
 Rapid retrieval of the organs

22.  Stabilize the donor
 Manage the donor – To optimize the function and
viability of all transplantable organs.
 Preserve organ
“

23.  Cardiac
 Respiratory
 Renal
 Endocrine
 General care

25. (A) Sternotomy and midline laparotomy with or without bilateral extension.
(B) Exposure of the thoracoabdominal organs

28.  Hypothermia
 Prevention of oedema
 Prevention of acidosis
 Neutralise the formation of reactive O2 species

29.  Hypothermia
 Metablism at 4 C – 10%
 Ideal temperature - 4 C
 Prevention of oedema
 Prevention of acidosis
 Neutralise the formation of reactive O2 species

30.  Prevention of oedema
 Impermeants – saccharides e.g – Mannitol
 Anions – citrate, gluconate, lactobionate
 Colloids – dextran,polyethylene glycol
 Prevention of acidosis
 Buffers – phosphate and histidine
 Neutralise the formation of reactive O2 species
 Antioxidants – glutathione, tryptophan, allopurinol

31.  Euro-Collins - EC
 University of Wisconsin - UW
 Histidine-tryptophan-ketoglutarate - HTK
 Celsior

32.  Euro-Collins - EC
 University of Wisconsin - UW
 Histidine-tryptophan-ketoglutarate - HTK
 Celsior

33. Euro-Collins
University of
Wisconsin
Histidine-
tryptophan-
ketoglutarate
Celsior
Impermeant
Glucose Lactobionate
Mannitol
Lactobionate
Mannitol Raffinose Mannitol
Hydroxyethyl
starch
Buffer
Phosphate
Phosphate Histidine Histidine
Bicarbonate
Antioxidant Mannitol
Allopurinol Tryptophan Glutathione
glutathione Mannitol Mannitol
Histidine Histidine
All units expressed in mmol/L.

34. Euro-Collins
University of
Wisconsin
Histidine-
tryptophan-
ketoglutarate
Celsior
Impermeant
Glucose Lactobionate
Mannitol
Lactobionate
Mannitol Raffinose Mannitol
Hydroxyethyl
starch
Buffer
Phosphate
Phosphate Histidine Histidine
Bicarbonate
Antioxidant Mannitol
Allopurinol Tryptophan Glutathione
glutathione Mannitol Mannitol
Histidine Histidine
All units expressed in mmol/L.

35. • Lower aorta mobilised
• Heparin 300 IU/Kg
• Aorta cannulated
• Suprarenal aorta clamped
• Perfused with Cold preservation
solution

38.  Make sure all
areas are
perfused well

41.  National protocol development
 Maintenance of common list for recepient
 Establishment of donor coordination programme –
countrywide
 Education on recognition of potential donor, donor
management, consent
 Education of public
 Establish clear legal pathways
 Train more personnel - ? Surgeons (8 vs 4)
 Transplantation and post op facilities
 Operating theatres and ICU facilities
 Follow up plans

42. Thank You