Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

KIDNEY TRANSPLANTATION PREPARATION AND CONSENTING

95 views

Published on

Kidney transplantation, if not contraindicated, is the most preferred renal replacement therapy for patients with end stage renal disease. Generally, live related transplantation is associated with longer term survival of the transplantated kidney as well as the patient. However, it is associated with great physical and psychological challenges for the donor. Therefore, an exhaustive physical workup as well comprehensive psychological counselling go a long way for a happy donor as well as recipient. Laparoscopic donor surgery has helped reduce surgical morbidity and improve acceptance. Moreover, to avoid medicolegal issues, exhaustive documentation is necessary.

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

KIDNEY TRANSPLANTATION PREPARATION AND CONSENTING

  1. 1. KIDNEY TRANSPLANTATION DONOR EVALUATION ​Dr Mayank Mohan Agarwal MBBS, MS, MRCS(Ed), ​DNB, MCh (PGIMER, Chandigarh) VMMF and IAUA Fellowships Uro-Oncology, Pelvic Floor Reconstruction (MSKCC, NY; UCLA, LA; WFUBMC, NC)​ Ex-Associate Professor of Urology (PGIMER, Chandigarh) Consultant and Head of Urology (Aster) Dr. Ramesh Cardiac and Multispecialty Hospitals Pvt. Ltd. Guntur (AP), India
  2. 2. Introduction • Why transplantation • Why living donor transplantation • Who can donate • General evaluation of donor • Urological evaluation of donor • Post-operative care of donor
  3. 3. WHY TRANSPLANTATION? Prolonged quantity of life Better quality of life - what one can eat / drink - what one feels (nausea, anorexia, weakness) Better control of co-morbidity - hypertension - dyselectrolytemia Reduced overall cost of healthcare - admissions for complications - monthly maintenance cost
  4. 4. WHY LIVING DONOR Deceased Living Primary non-function 2.7% 1.4% Delayed graft function 23.5% 3.4% 10 y graft survival 42.5% 59.6% Conditional t ½ of grafts 14.7 y 26.6 y
  5. 5. WHAT ARE THE RISKS TO DONOR Mortality 0.02–0.03 % End-stage renal failure 0.018 % / Y Hypertension 15–25 % Bleeding 2.2 % Bowel obstruction 1.0 % Vascular injury 0.2 % Open conversion 0.7–1.1 % Reoperation 0.2 % Blood transfusion 0.4 % Wound infection 2.1 % Urinary tract infection 4.5 % Readmission 0.9–2.0 % Hernia repair 0.8 %
  6. 6. TYPES OF LIVING DONORS • BLOOD RELATED • EMOTIONALLY RELATED • GOOD SAMARITAN • PAIRED DONORS
  7. 7. Legal Status in India: N.O.T.T.O • GRANDPARENTS • PARENTS • SIBLINGS • OFFSPRINGS • SPOUSE • EVERYBODY ELSE (including cousins)  “EMOTIONALLY RELATED” GENETIC RELATIONSHIP : FORM 5 SPOUSE : FORM 6 OTHER THAN NEAR RELATIVES : FORM 3
  8. 8. Donor evaluation • Communication • Documentation • Communication of documentation • Documentation of communication • Preservation of documentation
  9. 9. Donor evaluation • Communication • Documentation • Communication of documentation • Documentation of communication • Preservation of documentation
  10. 10. STEP 1a: BLOOD GROUP COMPATIBILITY
  11. 11. STEP 1b: EDUCATION AND COUNSELING • What is transplantation, why is it important to recipient and results of graft function • Quality of life of recipient • Quantity of life of recipient • Recipient’s death • Failure of graft
  12. 12. STEP 1: EDUCATION AND COUNSELING • What is transplantation, why is it important to recipient and results of graft function • What are the available alternatives • Continuation of dialysis • Wait on cadaveric donor list • Increased morbidity and death during waiting
  13. 13. STEP 1: EDUCATION AND COUNSELING • What is transplantation, why is it important to recipient and results of graft function • What are the available alternatives • What are the side effects and complications on the self • Generally very safe in short-term and long-term • Early recovery with laparoscopic procedure • Risk of identification of unknown malignancy, infection and lack of presumed blood relation • Risk of ESRD <0.02%/y Risk of death 0.03%
  14. 14. IS THE DONOR STILL WILLING OBTAIN CONSENT FOR EVALUATION
  15. 15. STEP 2: PSYCHOSOCIAL EVALUATION • By psychiatrist or • Psychologist or • Specifically trained social worker PSYCHO SOCIAL Mental health issues High-risk behavior Pressure
  16. 16. • ELIGIBILE AND WILLING?
  17. 17. STEP 3: MEDICAL EVALUATION • IS HE / SHE APPARENTLY HEALTHY? • IS THERE ANY HIDDEN • INFECTION • MALIGNANCY • CHRONIC HEALTH CONDITION • UROLOGICAL DISEASE • IS IMMUNOCOMPATIBILITY ACCEPTABLE? • WHICH KIDNEY IS RETRIEVABLE / TRANSPLANTABLE? UROLOGIST NEPHROLOGIST REFERRALS
  18. 18. IS HE / SHE APPARENTLY HEALTHY? • Detailed H & E Medication - NSAIDS Allergy – medications, others Known medical comorbidity – HT, DM, HLP, CAD, CVA, thyroid, others Addictions – smoke, alcohol, others Symptoms – specific to heart, lung, brain, liver, kidney, genitourinary system, gastrointestinal system, psychological Family hx – metabolic syndrome Female hx – menstruation, pregnancies, etc. PROFORMA-BASED EVALUATION
  19. 19. IS THERE ANY HIDDEN infection / chronic disease / malignancy BASIC LABS • Anemia? – complete blood picture • Coagulopathy? – above + PT/INR + APTT • Hepatic function? – LFT with proteins • Renal function? – Na, K, creatinine, urea; 24H protein, creatinine • Endocrine function? – lipid profile, F/PP BS, GTT, HbA1c, TFT • Hypertensive? – 24h BP monitoring in high risk, else 3 measurements
  20. 20. IS THERE ANY HIDDEN infection / chronic disease / malignancy • Viral infection? – HIV, anti HCV, HBsAg, CMV, EBV • Tuberculosis? – Manteux test / Gold Quantiferon • Syphilis? – Rapid plasma reagin • Urinary tract infection? – urine analysis and culture • Stone disease? – uric acid, calcium, chloride / phosphorus, iPTH, 24H urine profile • Malignancy? – serum PSA, PAPs, mammography, colonoscopy
  21. 21. IS THERE ANY HIDDEN infection / chronic disease / malignancy BASIC RADIOLOGY • Lung? – chest X ray PA view, PFT • Heart? – ECG, Echo, TMT • Abdomen? – USG whole abdomen, X ray KUB
  22. 22. • PERFECTLY HEALTHY – STANDARD CRITERIA DONORS • SOME IMPREFECTIONS – EXPANDED CRITERIA DONORS • hypertension well controlled on one medication • single renal calculus • borderline renal function • microscopic hematuria • impaired glucose tolerance (but not a diabetic) • over 65y
  23. 23. • IF ELIGIBLE
  24. 24. IS IMMUNOCOMPATIBILITY ACCEPTABLE? • HLA TYPING (CERTAIN INDICATIONS) • CROSS MATCHING – • LYMPHOCYTE • ANTIBODY
  25. 25. IF ELIGIBLE
  26. 26. WHICH KIDNEY IS RETRIEVABLE / TRANSPLANTABLE? • Better one stays with the donor • Anatomical tests – CT KUB – triphasic MR KUB with urography • Functional tests for determining differential function – DTPA DMSA
  27. 27. DONOR SURGERY • LAPAROSCOPIC • OPEN LESS PAIN /BLEEDING EARLY AMBULATION LESS TISSUE TRAUMA EARLY HEALING COSMETIC ADVANTAGE PSYCHOLOGICAL ADVANTAGE
  28. 28. POSTOPERATIVE CARE • EARLY STOPPING ANTIBIOTICS (WITHIN 24 HOURS) • GOOD PAIN RELIEF • EARLY AMBULATION • EARLY ORALS • EARLY DISCHARGE POSTOPERATIVE LABS
  29. 29. Follow up protocol for donors after kidney donation • S. Creatinine on the day-1 post-surgery Urine output monitoring till the day of discharge. • Visits at 1 month, 6months, 12months, 24months, thereafter every two yearly. • Check blood pressure, weight, S.Creatinine, Urine RE, Hemoglobin and blood sugar in all visits. • At 6months, 12months, 24months and every 5years thereafter: 24 hour urine protein and creatinine for creatinine clearance
  30. 30. General Advice • Maintain healthy weight (BMI <25) • Do regular exercise • Eat healthy, balanced diet – avoid excessive salt, refined sugar, oily foods • Avoid smoking altogether • Alcohol intake should be limited • Avoid over the counter analgesics (NSAIDs) and other nephrotoxic medications • Drink plenty of fluids and avoid dehydration (replenish fluids promptly during excessive sweating, diarrhoea, etc.) • Inform your kidney donor status when you consult any doctor
  31. 31. CONCLUSION • Good selection • Good documentation • Good care • Good follow up
  32. 32. • THANK YOU

×