5. The First Kidney Transplant – December 23, 1954
• performed in Boston between the identical Herrick twins at the Peter
Bent Brigham Hospital by a group of surgeons led by Dr. Murray.
• The recipient lived eight more years after the transplant.
6. CURRENT CKD NOMENCLATURE
USED BY KDIGO
• CKD is defined as abnormalities of kidney structure or function,
present for > 3 months, with implications for health. CKD is classified
based on Cause, GFR category (G1-G5), and Albuminuria category
(A1-A3), abbreviated as CGA.
7. • Transplantation is the kidney replacement therapy (KRT) of choice for
suitable patients with end-stage kidney disease (ESKD).
• However, not all patients are suitable candidates for transplantation,
and suitability is often determined by the perceived risks of
transplantation relative to the risks of not receiving a transplant.
8. • Patients with progressive CKD (e.g., CKD G4-G5) who are expected to
reach ESKD should be informed about all treatment options.
• This also includes the option of conservative management in cases
with limited life expectancy or severe comorbidities.
• Discussions regarding treatment options, including transplantation,
should occur regardless of the patient’s age, sex, socioeconomic
status or race/ethnicity.
9. ACCESS TO TRANSPLANTATION
• Potential candidates should begin the evaluation process at least 6 to
12 months before the anticipated start of KRT.
• Refer potential KTCs already on dialysis when medically stable and
kidney failure deemed irreversible.
• recommend pre-emptive transplantation (performed prior to the
need for dialysis) in adults when the eGFR is < 10 ml/min/1.73 m2 or
earlier with symptoms.
10. isn't recommended referring patients for transplant evaluation with
the following conditions
An active psychiatric or ongoing substance use disorder
Ongoing, health-compromising non adherent behaviour despite
education and adherence-based counseling
Multiple myeloma with cast nephropathy except for those
receiving potentially curative treatment or under stable
remission .
Light chain deposition disease (LCDD) or light and heavy
chain deposition disease (LHCDD
Active malignancy except for those with indolent and low-grade
cancers
Severe irreversible obstructive or restrictive lung disease
Systemic amyloidosis with cardiac amyloid
Non-healing extremity wounds with active infection until fully
resolved
Progressive neurodegenerative disease
11. • Document the reason(s) for not referring patients for transplant
evaluation
• Inform patients about the reason(s) for not referring for transplant
evaluation.
12. AGE
• Consider age when deciding about suitability for kidney
transplantation.
• < 60 years for non diabetic
• < 55 years for diabetic
• its recommend not excluding patients from kidney transplantation
because of advanced age alone
13. PSYCHOSOCIAL ASSESSMENT
It provides an opportunity to assess the patient’s
• economic or other forms of problem
• Presence of psychiatric problems that would impair ability to give
informed consent.
• Presence of adequate social support
14. ADHERENCE
• Non-adherence is defined as “deviation from the prescribed
medication regimen sufficient to adversely influence the regimen’s
intended effect.
15. TOBACCO
• Smoking is associated with poor outcomes in both the short and long term
after kidney transplantation.
• Its recommend that KTCs abstain from tobacco use, at a minimum 1
month prior to living donor transplantation.
• recommend that potential KTCs who are smoking tobacco products be
offered a tobacco cessation program.
• Chest CT for current or former heavy tobacco users (≥ 30 pack-year) to
screen for occult lung cancer.
16. SURGICAL ISSUES INCLUDING OBESITY
• Morbid obesity is a relative contraindication to kidney
transplantation.
• Patients with BMI > 35 kg/m2) should be adviced for dietary
counselling, physical fitness, or bariatric surgery.
17. Wound healing and hernia management
• All kidney transplant procedures have a risk of wound complications
including infection and hernia formation
• Patients with risk factors for hernia formation should be advised of
the potential need for surgical repair after transplant and tobacco
cessation should be strongly advised.
18. DIABETES
• Type 2 (T2DM) is the most common cause of ESKD globally.
• survival after kidney transplantation is superior to dialysis
for patients with ESKD due to diabetes.
• Therefore, diabetes per se should not be seen as a
contraindication to transplantation, but rather an
indication to closely evaluate and manage associated
complications.
19. CAUSE OF END-STAGE KIDNEY DISEASE (ESKD)
• Many causes of ESKD can recur after transplantation and affect the
survival of the transplant and the patient.
• Primary disease can recur in up to 20% of transplants and has been
reported as the cause of graft loss in 8.4% grafts representing the
third most common cause of graft loss.
• Despite the risk of recurrence, transplantation is the treatment of
choice in eligible patients.
21. INFECTIONS
• Patients awaiting kidney transplantation are at risk for a
variety of infectious diseases due to underlying
immunologic abnormalities from CKD, diabetes, and the
process of dialysis itself.
• All infections should be treated and attempted to be cured
Clinical and radiologic improvement should occur before
transplantation.
• Microbiologic eradication should be documented in
situations where cultures can be obtained
22. • its recommend that kidney transplantation be delayed until active
infections (bacterial, fungal, viral, parasitic) are treated
25. Vaccinations
• Vaccine preventable diseases are an important cause of
morbidity after kidney transplantation.
• Vaccine immunogenicity is generally reduced in both CKD and
post transplant settings.
• However, data suggest that some vaccines are more
immunogenic when given pre-transplant rather than post-
transplant
• In addition, live-attenuated vaccines can be only be given prior
to transplantation
26. • Vaccines should be updated as per local guidelines for
• diphtheria,
• polio,
• tetanus,
• pertussis, and
• Hemophilus influenza,
• pneumococcal vaccine.
27.
28.
29. Cancer screening
• Cancer is common in patients with ESKD.
• two-fold increase in overall cancer incidence among patients
on dialysis, with kidney-related such as urogenital cancers,
• endocrine-related malignancy such as thyroid cancer and
• solid organ cancers such as colorectal cancer seen in excess
compared to the general population.
• Currently, there are no quality primary data to inform cancer
screening practices specifically in the ESKD population.
30. PULMONARY DISEASE
• There are very little data on pre-transplant evaluation of patients with
pulmonary disease.
• Its Suggested to have chest imaging prior to transplantation in all
KTCs.
• suggested to have chest CT for current or former heavy tobacco
users (> 30pack-year), as per local guidelines, and chest radiograph
for other KTCs.
31. • doing PFT in KTCs with impaired
functional capacity, respiratory symptoms, or known pulmonary
disease is recommended
• counselling all KTCs to avoid use of tobacco products, both before
and indefinitely after transplantation.
• candidates with severe irreversible obstructive or
restrictive lung disease be excluded from kidney transplantation.
32. CARDIAC DISEASE
• Cardiac disease is the most common cause of death in
dialysis patients
• incidence of cardiac events increases with worsening
stages of CKD.
• Kidney transplantation is generally classified as
intermediate risk surgery, however many patients have co-
morbidities that increase the risk for cardiac events
• For these reasons, assessment for cardiac disease is
important in the evaluation of KTCs.
33. • All patients evaluated for Ktc should undergo assessment for the
presence and severity of cardiac disease with history, physical
examination, and electrocardiogram (ECG).
• Asymptomatic KTCs who have been on dialysis for at least two years or
have risk factors for pulmonary hypertension undergo echocardiography
• suggest that kidney transplantation be delayed for at least one month
after myocardial infarction.
• kidney transplantation be deferred for at least one month
after placement of a bare metal stent and six months after insertion of a
drug eluting stent
34. NEUROLOGIC DISEASE
Its suggested to waiting at least 6 months after a stroke or
3 months after a TIA before kidney transplantation.
• Patients with progressive neurodegenerative disease
should not undergo kidney transplantation
35. GASTROINTESTINAL AND LIVER DISEASE
• recommend that candidates with symptoms suggestive of active
peptic ulcer disease undergo esophagogastroscopy and H. pylori
testing prior to kidney transplantation.
• Delay kidney transplantation in candidates with endoscopically
proven peptic ulcer disease until symptoms have resolved.
• Delay kidney transplantation in candidates with active diverticulitis
until symptoms have resolved.
36. • Delay kidney transplantation in candidates with acute pancreatitis a
minimum of three months after symptoms have resolved.
• Delay kidney transplantation in patients with symptomatic gallstone
or gallbladder disease until symptoms have resolved.
• Delay kidney transplantation in candidates with active symptomatic
inflammatory bowel disease
37. Liver disease
• Screen KTCs for evidence of liver disease with appropriate history
and physical exam, total bilirubin, alanine aminotransferase (ALT),
INR, and albumin
• Delay kidney transplantation until acute hepatitis, of any cause, has
resolved,.
38. HEMATOLOGICAL DISORDERS
• Acute leukemia and high-grade lymphoma
• avoidance of kidney transplantation until patient has
received curative therapy, achieved remission and
remained cancer free
39. • Myelodysplasias, chronic leukemia and chronic/low-grade
lymphoma
• Decisions about kidney transplantation in patients with
myelodysplasia should be made in collaboration with a
haematologist.
40. . Peripheral Vascular disease
• Peripheral vascular disease is an important cause of allograft
ischemia, lower-extremity amputation and poor patient survival.
• Indication for screening;
- Diabetes
- History of Claudication
- History of ischemic ulceration in the lower
limbs/amputation
- Absence of femoral pulse
41. IMMUNOLOGICAL ASSESSMENT
• Sensitizing events including pregnancy, blood transfusion and prior
transplant can lead to the formation of HLA antibodies in transplant
candidates.
• These antibodies, depending on donor HLA typing and donor rates,
may significantly limit a candidate’s access to donors.
• The goal of HLA testing during candidate evaluation and while wait
listed is to estimate the risk of reduced access to potential donors
based upon HLA antibodies/HLA typing.
42. Communicate all sensitizing events e.g., blood product transfusion,
Including platelets
pregnancy or miscarriage or
clinical events that can impact panel reactive antibody (PRA) e.g.,
vaccination,
withdrawal of immunosuppression,
transplant nephrectomy,
significant infection to the human leukocyte antigen (HLA)
laboratory.
43. • Perform HLA antibody testing at transplant evaluation, at regular
intervals prior to transplantation and a minimum of 2 weeks after a
sensitizing event or a clinical event that can impact PRA.
• its suggested informing KTCs about their access to transplantation
based on blood type and histocompatibility testing results.
45. INTRODUCTION
• The number of patients awaiting kidney transplantation has steadily
increased over time.
• The gap between allograft supply and demand continues to widen.
• The use of organs from living donors is one strategy to address the
need for transplants.
• However, rates of living kidney donation declined 15 percent from
2004 to 2012 .
46. • most donors experience good outcomes and have good quality of life
after donation, kidney donation is associated with short- and longer-
term risks .
• Risks of donation include surgical, medical, psychosocial, and financial
complications
47. DONOR EVALUATION
• — The Organ Procurement and Transplantation Network (OPTN)
requirements specify that the following be performed and
documented prior to living kidney donation
• Blood typing (performed on two separate occasions before the
recovery).
• A medical evaluation
• A psychosocial evaluation
48. Blood typing and cross match
• The evaluation begins with an assessment of the donor and recipient
blood groups and a cross match compatibility.
• The blood type and cross match compatibility are the primary criteria
for biological compatibility of the donor and recipient.
• The cross match between potential donor and recipient is done to
detect preformed anti-donor antibodies in recipient blood that would
cause early failure of the allograft
49. • Donor candidates who are ABO blood group or cross match
incompatible with their intended recipient should be informed of the
availability, risks, and benefits of treatment options, including kidney
paired donation and incompatibility management strategies.
50. • Most kidney transplant programs routinely perform HLA typing
• However, HLA matching between a particular donor and recipient is
not required for successful transplantation.
• In some centres, HLA typing is not performed for most donors,
because outcomes are acceptable even without HLA matching in the
current era of improved immunosuppressive regimens.
51. • As rhesus (Rh) antigens are not expressed on kidney tissue cell
surfaces, this antigen system does not play a major role in allograft
rejection, and matching for Rh antigens is not relevant in most
settings.
• However some ,evidence suggests that Rh antigen mismatching may
be associated with decreased allograft survival.
• In addition, female Rh-negative recipients of childbearing age may be
at risk for sensitization when the donor is Rh positive
52. History and physical examination
• A personal history of significant medical conditions
• hypertension, coronary artery disease,
• lung disease, heart disease,
• gastrointestinal disease, genitourinary disease
• autoimmune disease, neurologic disease
• hematologic disorders, bleeding or clotting disorders,
• history of cancer including melanoma,
• history of infections, and allergies.
• Women should be asked about gestational hypertension,
preeclampsia, or eclampsia and future childbearing plans
53. • Physical exam should include vital signs,
• examination of all major organ systems,
• measurement of height and weight, and
• computation of body mass index (BMI).
• Blood pressure must be measured on at least two occasions or by 24-hour
or overnight ambulatory blood pressure monitoring (ABPM).
54. Laboratory and imaging tests
• Complete blood count with platelet count;
• blood type and subtype determination
• PT , INR,PTT,
• metabolic testing including BUN ,serum creatinine; FBS
• electrolytes; calcium and phosphorous;
• albumin, transaminase levels, and alkaline phosphatase;
• fasting lipid profile .
55. • Urinalysis with microscopy; urine culture (if clinically indicated).
• Measurement of urinary protein and albumin excretion.
• Measurement of GFR
• Donor candidates with a history of nephrolithiasis (>3 mm) must have a 24-hour urine
stone panel including calcium, oxalate, uric acid, citric acid, creatinine, and sodium.
• HCG quantitative pregnancy test in premenopausal women
• Electrocardiogram.
• Chest radiograph.
56. Infectious disease tests
• Cytomegalovirus (CMV) antibody.
• Epstein-Barr virus (EBV) antibody.
• HIV antibody (anti-HIV) testing or HIV antigen/antibody (Ag/Ab) combination test as
close as possible but within 28 days prior to organ recovery.
• Hepatitis B surface antigen (HBsAg) testing as close as possible but within 28 days prior
to organ recovery.
• Hepatitis B core antibody (anti-HBc) testing as close as possible but within 28 days prior
to organ recovery.
• Hepatitis C antibody (anti-HCV) testing as close as possible but within 28 days prior to
organ recovery.
• Syphilis testing
57. The following are the minimum absolute exclusions
• Age <18 years and mentally incapable of making an informed
decision.
●Uncontrolled hypertension or history of hypertension with end-organ
damage.
●HIV infection
●Evidence of acute symptomatic infection (until resolved).
●High suspicion of donor coercion.
●Uncontrolled, diagnosable psychiatric conditions.
• Active or incompletely treated cancer
58. Possible contraindications to living kidney
donation
• ABO or HLA incompatibility without a planned management protocol
and informed consent.
• Proteinuria and/or haematuria.
• Impaired renal function.
• Any chronic, active viral infection ( HTLV, HBV, and HCV).
• History of malignancy, especially lung, breast, renal or urologic, Gl, or
hematologic cancers and melanoma.
59. • Current pregnancy.
• Chronic illness, particularly pulmonary, liver, autoimmune, neurologic,
or cardiac disease.
• Uncontrolled hypertension or hypertension in higher-risk candidates.
• Nephrocalcinosis, bilateral kidney stones, or recurrent nephrolithiasis.
60. • Disorders requiring anticoagulation.
• History of sickle cell trait .
• Morbid obesity, most commonly defined as BMI >35 kg/m2 .
• Family history of renal cell cancer.
• Active substance or alcohol abuse disorder.
61. FOLLOW-UP AFTER KIDNEY DONATION
• follow-up clinical and laboratory data at discharge (or at six weeks
after donation, whichever comes first) and then at six months, one
year, and two years after donation.
• 2017 KDIGO recommended to check BP, BMI, EGFR, albuminuria @
least annually
• Healthy life style should be promoted.
