This document discusses a case presentation of a kidney transplant patient experiencing delayed graft function (DGF). It provides background information on DGF, including definitions, incidence, importance, and risk factors at various stages of the transplant process. These risk factors include characteristics of the donor, recipient, procurement techniques, and the perioperative period. The document then outlines the presenter's thought process and basic workup to consider for DGF cases.

1. I thought the new kidney will
work!!
Nephrology Grand round
Aug 2014
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2. Disclosure
• No financial holdings effect the content of the
presentation.
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3. Basic overview of the topic
 Sample case to identify risk factors
 Definition & incidence
 Importance
 Risk factors at various stages of Transplant
process
 Thought process and basic work up
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4. Case Presentation
• 53 yo male with h/o ESRD secondary to
hypertension, DM, HTN and BPH is post op
day 5, DBD/ECD renal transplant, KDPI 56%,
cPRA 25%.
• WIT 7hrs, CIT 24 hrs
• Patient has been on HD before transplant for 4
yrs through a left AVF. He makes little urine at
baseline
• Tacrolimus was started on day 2 at 4mg bid
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5. • Patient is on tapering dose of steroids and Cellcept.
• Prophylactic medications : Bactrim, Valgancyclovir
& Nystatin
• Additional medication includes Pantoprazole and
Ondansetron.
• During OR he was hypotensive briefly down to 80s
• His only complaint is mild RLQ abd pain and nausea
with dec PO intake
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6. Exam
• VSS stable except SBP 155/75
• AAO in NA
• S1+S2 no murmur
• Mild bibasilar crackles with no inc effort of
breathing
• Abd with RLQ scar, TTP at graft site, + BS, no foley
• Speech intact, moving all 4 limbs with intact
strength. ?asterexis
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7. Significant Labs
• WBC-normal, Hb 8.1 (7.5-9.5)
• Na 132, K 5.9, HCO3 17, BUN 98, Cr 7.6
• Cr has been slowly worsening since transplant
from 4.3 on arrival
• UA is 2+ blood, 1+ protein (1+ before Txp as
well) 1+LE, 19 WBCs and 10 RBCs, Few
granular casts on microscopy.
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8. Doc! Why my new Kidney is not
working?
Brief Differential
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9. Patient given a session of HD on
Day 5
He will be called to have
D_____ G____ F_____
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10. Soup Kitchen
• DGF: Delayed Graft Function
• DBD: Donation after Brain Death
• DCD: Donation after Cardiac Death
• ECD: Extended Criteria Donor
• SCD: Standard Criteria Donor
• KDPI: Kidney donor profile index
• cPRA: calculated Panel Reactive antibody
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11. Definitions
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12. Who Gets more DGF?
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13. Does it matter?
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14. Does it matter?
• Graft survival for DBD kidneys that fulfilled
the criteria for DGF, according to 9 of the 10
definitions, was associated with greater than
three times the risk of graft loss, whereas
none of the definitions of DGF were
associated with failure of DCD kidneys
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16. Does it matter?
• Associated with increased rate of rejection.
• Incidence has increased consistently in last 25
yrs. Likely because of using more DCD and
ECD.
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17. Risk Factors
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18. The Pre-Procurement Period
• Hypotension/Hypoxia/Anaerobic metabolism
• DBD:
– Loss of vascular tone
– Inflammatory state
– Complement activation
– Adhesion molecule upregulation
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19. • DBD factors:
– Use of Dopamine , agonist for HO-1(heme
oxygenase) , antagonizes free radicles
– Use of hormone replacement like steroids,
vasopressin, thyroxin.
– Length of ICU stay before withdrawal of care
– Anticoagulation
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20. DCD Factors
• Duration from withdrawal of care to cardiac
death (warm ischemia time)
– ATN, perivascular edema perpetuates ischemia at
corticomedullary junction
– <45 min , better outcomes
• Length of stay in ICU
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21. ECD Factors
The expanded criteria donor (ECD) is any donor
over the age of 60, or a donor over the age of 50
with two of the following: a history of high
blood pressure, a creatinine greater than or
equal to 1.5, or death resulting from a stroke
• Commonly ECD organ are avoided if >20%
glomeruli are sclerosed.
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22. Composite Donor Risk
• The Kidney Donor Risk Index (KDRI) is an estimate of the relative risk of
post-transplant kidney graft failure, that combines ten dimensions of
information about a donor, including clinical parameters and
demographics, to express the quality of the donor kidneys relative to
other donors
• The Kidney Donor Profile Index (KDPI) is a numerical measure That is
derived by first calculating the Kidney Donor Risk Index (KDRI) for a
deceased donor
• http://optn.transplant.hrsa.gov/resources/allocationcalculators.asp?i
ndex=81
• Mapping: KDRI to KDPI :
• http://optn.transplant.hrsa.gov/ContentDocuments/KDRI_to_KDPI_M
apping_Table.pdf
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23. Composite Recipient Risk
• Dialysis prior to transplantation (duration)
• Diabetes
• Obesity
• Age >55
• Male sex
• Prolong wait period
• High cPRA
• Small for size kidney
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25. Procurement: Organ preservation Techniques
• Cold storage
• Preservation Fluids: Designed to reduce
osmotic injury and delay acidosis with H+
buffers
– UW (Uni of Wisconsin solution): Adenosine (reduces
re-perfusion injury) and allopurinol.
– HTK (Histidine-tryptophan-Ketoglutarate): Low K
Organs >24 hr CIT have less DGF risk when reperfused
with UW solution.
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26. Pulsatile machine perfusion
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Machine perfusion: perfusion flow <0.4ml/min/gm, resistance >80mmHg and resistive index
>0.5mmHg{ml/min/100gm of tissue} , protocols including directives for organ discard

27. Perioperative Period
• Hypotension
• Intraoperative fluid balance and ESRD pts with LVH
• Anesthesia effect/Vasodilation
• Reperfusion:
– Due to preceding ischemic injury, pathologic vasoconstriction
occurs with the activation of G protein coupled receptors.
– Innate immune response (Neutrophils and Macrophages)
signals from injured cell
– Adaptive immune response, inc MHC expression in IR injured
tissue through Ifγ, Cytokines and Chemokines, T-cell
mediated.
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28. Postoperative period
Day 1-7
• Surgical Complications:
– Vascular complications: Thrombosis ( pediatric
kidneys and pt with APLAS), hematoma
– Anatomic complications: urinary leak causing a
urinoma, tight fascia around the kidney
– Urologic complication: Urinoma, Ureteric Kinking
and stenosis, Evulsion
– Infection/Abscess
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29. • Drugs:
– CNI (Tacrolimus)
– Bactrim
– PPIs
• Urinary retention: After Foley is usually
removed on day 4.
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30. Rejection
• Acute Cell Mediated Rejection (ACR)
• Antibody mediated Rejection (AMR)
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31. Basic thought process
• Pre-Renal (Hypovolemic/Low renal blood
flow), Thrombosis)
• Renal (ATN, AIN, TMA, venous thrombosis &
congestion)
• Post renal (compression by fluid collection,
urologic problems)
• Rejection (ACR, AMR)
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32. Basic Workup to consider for DGF
• Donor information (KDPI, pre-procurement history,
available with UNOS)
• Operative report for hypotension
• Immunological risk: cPRA, cross match report
• Tacrolimus levels
• Allograft US with Doppler (?other imaging)
• Urine micro (not so informative as old kidneys still
make some urine) same problem with urine e-lytes
• Review other drugs
• Post void residuals & voiding trials
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33. • Biopsy provides the final differentiation (ATN,
AIN, Rejection, TMA) but sometime its difficult
to distinguish between AIN and Rejection
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34. Thank you!
DGF Risk Calculator
http://www.transplantcalculator.com/Transplant-Calculators/Delayed-
Graft-Function.aspx
Feedback appreciated…
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