Evaluation of adult kidney transplant candidates


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Evaluation of adult kidney transplant candidates

  1. 1. Assessment of adult kidney transplant recipient Dr Sunil kumar Prajapati
  2. 2. Purpose of evaluation• Minimize the morbidity and mortality & maximize quality of life• Protect living donors & scarce resource of deceased and living donor kidneys• Survival advantage of transplantation – – any age, gender, ethnicity, with/without diabetic kidney disease
  3. 3. Timing of evaluation• If preemptively transplanted (before dialysis) - best outcomes• GFR ≤20 mL/min• Rate of progression – Patient with diabetes may progress relatively rapidly hence there is no sense in delaying transplantation if a living donor is available – eGFR - 30 mL/min• Clinically uremic
  4. 4. Interested in transplantation Yes Preliminary screening (no comorbidities) No obvious C/I ABO blood group, HLA typing Complete medical evaluation, history, examination & test Relative C/I No C/I Absoluet C/IJudge case by case Optimize medical status No transplant If no living donor place Proceed with living on waiting list donor transplant if available Review every 2 years
  5. 5. Relative/absolute Contraindications• Not irreversible contraindications – life-threatening infections, cancer, unstable CVD, noncompliance, psychatric illness – Not expected to survive >2 years with a kidney transplant – ABO incompatibility, Positive T cell mismatch – Severe obesity BMI >40
  6. 6. Cardiovascular Disease History & examination Low risk Medium risk (Age > 45 High risk (angina +ve) (Age < 45 yrs, no yrs or any traditional CAGtraditional risk factors) risk factor) Stress test -ve +ve Intensify conservative Proceed with listing & Management review every 2 yrs Appropriate intervention
  7. 7. Cardiovascular Disease contd..• Pre & perioperative βB reduces cardiac events in high- risk patients• H/o stroke or TIA should be symptom free for at least 6 m before transplantation – Aspirin prophylaxis – Risk of perioperative bleeding is generally outweighed by the benefits• History of PAD, or claudication symptoms – examine for signs of lower extremity arterial insufficiency – Consider USG or MR angio to image the aorta and iliac arteries
  8. 8. Obesity• BMI ≥ 30 kg/m2 is associated with • death, graft failure, wound dehiscence, wound infections, HTN, ↑ risk for developing DM after transplantation• Generally not an absolute C/I - weight loss is required if BMI is > 40 kg/m2• If diet is unsuccessful, bariatric surgery should be considered for BMI ≥40 kg/m2
  9. 9. Infections• Conditions that increases the chances of serious post-transplant infections – Splenectomy – Immunosuppressive or chemotherapeutic agents – Prior organ/BMT – Acquired or inherited immunodeficiency syndromes – Malnutrition – Open wounds (including dialysis catheters), Poor dentition – Travel to endemic areas – Occupational exposure
  10. 10. Infections contd..• Immunization may be less effective in stages 4 & 5 CKD, but there is little risk & potentially great benefit• Asplenic patients - Hemophilus influenza & Meningococcus• live vaccines (VZV) should not be administered immediately before transplantation
  11. 11. HIV +ve pt. may be transplant candidates if…• Adherent to a highly active antiretroviral therapy regimen• Undetectable virus load• Sustained CD4 count >200/mL• No opportunistic infections• No life-threatening malignancies• Appropriate expertise available
  12. 12. Infections contd..• Hepatitis B – HBsAg, HBe-antigen, & viral load – Chronic active hepatitis, cirrhosis, & HCC - risks aggravated by immunosuppression – HBV replicator – tt. with lamividine pre & post- transplantation
  13. 13. Infections contd..• HCV – liver disease & new-onset diabetes after kidney transplantation – Patients with HBV, HCV, chronic active hepatitis, cirrhosis are at high risk for developing HCC - baseline & follow-up levels of α-FP
  14. 14. Anti HCV +ve HCV RNA -ve HCV RNA +ve Liver Bx Normal LFT Normal Hepatitis Cirrhosis or precirrhosis Antiviral Rx Defer transplant orList fro renal transplant consider combined liver- kidney transplant HCV RNA -ve HCV RNA +ve Pt by pt decision
  15. 15. Pulmonary Disease• Smoking - 2.4 & 2.9 RR for the development of ESRD in men and women respectively• Quit smoking prior to transplantation• If history of cigarette smoking and/or shortness of breath do PFT & chest x-ray
  16. 16. Recurrent Kidney Disease• Incidence of graft failure due to recurrent disease is probably not high enough to preclude transplantation in most cases• Exceptions – ≥2 grafts loss due to recurrent idiopathic FSGS (Plasmapheresis)
  17. 17. Recurrent Kidney Disease
  18. 18. Genitourinary Disorders• Asymptomatic and absent history of bladder dysfunction do not usually require further evaluation• Adequate urinary drainage prior to transplantation (at least 6wks)• Chronic Kidney Disease Management • Anemia • Physiologic calcium, phosphorous, vit. D & PTH levels • Should not have a dialysis access infection or peritonitis (if being treated with chronic peritoneal dialysis) at the time of transplantation.
  19. 19. Thrombophilias• ≈ 2% allografts are lost to thrombosis• Perioperative anticoagulation can prevent – Screen if h/o venous thrombosis, including recurrent hemodialysis access thromboses – Factor V Leiden, prothrombin G20210A mutation, Antiphospholipid antibodies – If any of these are positive, perioperative anticoagulation could be given – Other indications • Recipient is younger • Donor is < 2 yrs age
  20. 20. Malignancies• life-threatening - C/I• Same cancer screening as recommended for the general population – Colonoscopy every 5 years for > 50 years – Mammography for > 50 years , younger if family h/o breast cancer – Annual pelvic examination with cervical cytology testing – >50 years - DRE & PSA testing for prostate cancer (controversial) – Cystoscopy for high-risk patients screening for bladder cancer • Analgesic nephropathy, chronic exposure to cyclophosphamide.
  21. 21. Patients with a history of prior malignancy, how long to wait?
  22. 22. Noncompliance and Cognitive Impairment• Substance abuse – substance free for at least 6 months before being accepted for transplantation.• Patients with cognitive impairment should probably not undergo transplantation
  23. 23. Immunologic Evaluation• Preformed antibodies – prior transplantations – Pregnancies – blood transfusions• Test measures Ab induced lysis of a panel of lymphocytes from different individuals in the population.• The higher the panel reactive antibody (PRA; range 0%–100%) titer, the more difficult it will be to find a donor, that the potential recipient will not reject with an antibody-mediated rejection
  24. 24. Immunologic Evaluation contd..• The PRA is generally measured at the time of transplant evaluation and then periodically (every 3 mth)• PRA declines with time, especially if blood transfusions are avoided• Still may have an anamnestic Ab response if re-exposed to an antigen - wise to avoid• HLA - graft survival is better with fewer mismatches (range 0-6)• Generally, the donor and the recipient must be blood group- compatible (Except when donor is BG A2)• Whether a particular kidney can be transplanted is determined by a final cross-match that measures whether the recipient has an antibody to the donor kidney
  25. 25. Special situations…
  26. 26. Children– Body weight > 11kg,– Infant donors – high chances of graft thrombosis– Best result when donor is young adult
  27. 27. Diabetic nephropathy– Most common cause of death is MI, CHF– Special attention to bladder emptying & foot ulcers– Early transplant– Combined pancreas and kidney transplant is beneficial for nephro & neuropathy, while effect on retinopathy & vasculopathy is unclear
  28. 28. Oxalosis– ESRD before 30 years– Aggressive preoperative dialysis, forced diuresis– Pyridoxine, orthophosphates, thiazides post transplantation– Combined liver and kidney transplant is better– Isolated kidney transplant in late onset form only– Transplant when GFR – 25ml
  29. 29. Nephrectomy• Large renal stone• Gross abnormalities of urinary tract• Persistent infection• PCKD – Persistent infection – Very large kidney hindering graft placement – Drug resistant HTN
  30. 30. Dialysis• Dialysis immediately preceding transplantation only if hyperkalemia or unacceptable fluid overload. Increased risk of bleeding.• If dialysis is done than pt should be adequately hydrated• Pt on PD should continue dialysis until the time of transplantation, peritoneal cavity should be drained before surgery
  31. 31. Take home message..
  32. 32. Assesment of patient before transplantation• History & physical examination – General • Cause of CRF, duration, HTN • Infection • Previous transplantation – Other disease • CVD, malignancies(prev. or current), respiratory, GIT • DM – Previous operations • Nepherectomy, splenectomy, parathyredectomy, appendectomy etc. – Family history – Current clinical data and tt • Mode & duration of dialysis • BP • Urine – volume • Sign & symptoms of neuropathy • Previous BT & pregnancies • Diet Drugs
  33. 33. Assesment of patient before transplantation contd..• Laboratory examinations – Hct, TLC, DLC, absolute lecocyte count, plt. Count – Ca, phosph, Alk phosph, PTH – LFT – CMV Ab, HBs Ag, HB Ab, HCV Ab, EBV Ab, HIV Ab – Urine C/S – Radiological exam – CXR, USG – Others • ECG, Fundus, Urological exam• Immunological exam • Blood grouping • Tissue typing, family typing • Antibody screening
  34. 34. Thankyou