Diskusi Kasus Modul TransplanTri Hadi Susanto.pptx

Tri Hadi Susanto
Pembimbing :
dr. Pringgodigdo Nugroho , SpPD-KGH
DELAYED GRAFT FUNCTION IN LIVING KIDNEY DONOR
PROGRAM PENDIDIKAN DOKTER SPESIALIS 2 DEPARTEMEN ILMU PENYAKIT DALAM
SUB DIVISI GINJAL HIPERTENSI FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA
RSUPN CIPTO MANGUNKUSUMO
DISKUSI KASUS MODUL TRANSPLANTASI GINJAL

BACKGROUND
• Delayed graft function (DGF) is commonly defined as the need for
dialysis during the first posttransplantation week.
• DGF incidence depends on its definition, risk profiles of the donor and
the recipient, and on the transplant center.
• There is clear evidence that DGF after deceased-donor kidney
transplantation (DDKT) is associated with inferior graft survival.
• Moreover, DGF may result in prolonged hospitalization, and it may
predispose to acute rejection and chronic graft dysfunction.
• DGF is rare in living donor kidney transplantation (LDKT), and there is
a paucity of studies on this issue.
Doc!! Why My
New Kidney is
Not Working ???

Laporan
Kasus
IDENTITAS PASIEN
Nama : Tn. AK
Umur : 31 tahun
Masuk RS : 10 Mei 2022
No. RM. : 4572402
Ruang Perawatan : 319 B

Riwayat Penyakit Sekarang
Keluhan Utama : Pro Transplantasi Ginjal
2020 :
 Pasien dirawat dengan keluhan mual
muntah, saat dirawat terdiganosa
hipertensi dan gagal ginjal tahap akhir,
dianjurkan untuk HD
 Pasien HD selama 3 bulan, Kemudian
berpindah ke CAPD , dengan 4x
pergantian cairan, UF harian 800-1000
ml
 Obat rutin : Candesartan 16mg 1x1,
Amlodipin 10 mg 1x1, Bisoprolol 5 mg
1x1, CaCo3 500 mg 3x1
10 Mei 2022:
 Pasien direncanakan transplantasi ginjal tgl 17 mei
2022 dengan donor ayah kandung
 Tidak ada keluhan saat perawatan sebelum
operasi
 Sebelum Pre op Regimen CAPD 4x Dianeal 2,5 %
lancar dan jernih, UF 1000 ml/hari
 BAK 200-400 ml/hari
 Dilakukan HD 3x sebelum operasi
 Tidak ada keluhan sebelum operasi
 Operasi transplantasi ginjal dilakukan dengan
implantasi kanan, perdarahan intra op 80 ml
 Terdapat laserasi pada ginjal, ginjal tampak
kebiruan, dilakukan reposisi ginjal Kembali
kemerahan

Riwayat Penyakit Sekarang
Hari 1 Operasi:
 Urin tidak keluar banyak , hanya 410 cc selama 14 jam dengan furosemide 10
mg/jam, warna urin kemerahan
 Produksi drain kemerahan 200 ml
 Tidak ada keluhan demam, sesak nafas, tekanan darah stabil 130-150/80-90 mmhg
 Dilakukan HD 4 jam dengan UFG 1000

Riwayat Penyakit Keluarga
• Ayah : Hipertensi
• Ibu : -
• Tidak ada keluarga
dengan penyakit seperti
pasien
Riwayat Penyakit Dahulu
Riwayat Auto imun :-
Riwayat diabetes : -
Riwayat sakit jantung : -
Riwayat Sosial dan kebiasaan
Pasien sudah menikah, bekerja swasta
Riwayat merokok saat ini sudah berhenti
Riwayat transfuse, minum alcohol, ivdu,prosmikuitas disangkal
Riwayat KB disangkal

KU : Tampak lemah,CM, Sakit sedang
• TD : 140/96 mmHg
• N : 100 x/menit,
• RR : 18 x/menit,
• Sat 02 : 100 %
• S : 36,7 oC (per axiller)
• TB : 163 CM
• BB : 80 KG
• IMT : 30,21 kg/m2 (Obese)
Tanda Vital :
PEMERIKSAAN FISIK
Kepala : Conjungtiva Anemis (+)
Leher : JVP tak meningkat
Jantung : Bunyi jantung reguler, bising (-)
Paru : Vesikuler N, rh (-), wh (-)
Abdomen : H/L tak teraba, ascites (-)
Ekstremitas : Oedema (-)

Crossmatch
RESIPIEN :
Tn. Antoni (31thn)
O+
DONOR :
Tn. Rusyani(64 thn)
O+
Sel lisis : 10%
Hubungan: Related (Ayah-Anak)

Serologi
Resipien Donor
26/10/2021
Anti Toxoplasma IgG Non Reaktif
Anti Toxoplasma IgM Non Reaktif
Anti Rubella IgG
Anti Rubella IgM
Anti-CMV IgG Non Reaktif
Anti-CMV IgM Non Reaktif
Anti-HSV1 IgG Non Reaktif
Anti-HSV1 IgM Non Reaktif
Anti-HSV2 IgG Non Reaktif
VDRL Non Reaktif
TPHA Non Reaktif
HBsAg Non Reaktif
Anti-HCV Non Reaktif
Anti HIV Non Reaktif
Anti HBs Reaktif
26/10/2021
Anti Toxoplasma IgG Reaktif
Anti Toxoplasma IgM Non Reaktif
Anti Rubella IgG
Anti Rubella IgM
Anti-CMV IgG Reaktif
Anti-CMV IgM Non Reaktif
Anti-HSV1 IgG Reaktif
Anti-HSV2 IgG Reaktif
VDRL Non Reaktif
TPHA Non Reaktif
HBsAg Non Reaktif
Anti-HCV Non Reaktif
Anti HIV Non Reaktif
Anti HBs Reaktif

USG Abdomen (26/10/2021)
• Contracted kidney
bilateral
• Fatty liver
• KE, pancreas, limpa, buli
dan prostat dalam batas
normal

DONOR
Keadaan Umum : CM, TD 130/80, N 90x/menit
RR 20x/menit, T: afebris
BB 82 kg TB 176 cm IMT 26,4
Kepala : Conjungtiva Anemis (-)
Leher : JVP tak meningkat
Jantung : Bunyi jantung reguler, bising (-)
Paru : Vesikuler N, rh (-), wh (-)
Abdomen : H/L tak teraba, ascites (-)
Ekstremitas : Oedema (-)

HASIL LAB DONOR
26/10/2021 11/5/2022
Hb 15,6 15,8
Ht 44 46
MCV/MCH/MCHC 91/32/35,3 93,5
Trombosit 234 245
Leukosit 6,9 7,6
Diff Count (B/E/N/L/M) 1/8/38/47/6
LED 8 4
SGOT/SGPT 24/32 25/40
Albumin/Globulin 4,2/2,1 4,4/2,4
Kreatinin 0,9 0,9
eGFR 89,94 89,9
Ureum 26 23,5
As. Urat 7,1 7
Trigliserida/Kolesterol
Total/HDL/LDL
362/188/-/- 482/173/23/69
GDP/2JPP 96/127 93/-
Na/K/Cl/Phosphor/Ca/Mg 135/3,7/105,2/3,6/8,7/2,24
PT/APTT 10,9/42,4
Fibrinogen /D Dimer 197/320

URINALISIS
26/10/2021 11/5/2022
Warna Kuning Kuning
Kejernihan Jernih Jernih
Leukosit 1 0-2
Eritrosit 1 0-2
Silinder 0 0
Sel Epitel 0 0
Kristal 0
Bakteria 0 0
Berat Jenis <= 1,005 1,015
pH 6,5 6,0
Albumin Negatif Negatif
Glukosa Negatif Negatif
Keton Negatif Negatif
Darah/Hb Negatif Trace
Bilirubin Negatif Negatif
Urobilinogen 3,2 3,2
Nitrit Negatif Negatif
Leukosit
Esterase
Negatif Negatif

RONTGEN THORAX
 Cor dan pulmo tak tampak kelainan

USG ABDOMEN
 Liver dengan gambaran fatty dan V. Porta terlihat sedikit
melebar yang sebabnya ?
 Gall bladder dengan dinding kurang rata, kemungkinan
adanya peradangan kronis dan intra luminal terlihat seperti
adanya gambaran sludge ball yang agak besar
 CBD tidak tampak melebar, ke distal terhalang oleh gas usus
 Pancreas dan spleen tidak tampak kelainan
 R – L kidneys dengan besar dan bentuk normal,
echogenisitas sedikit meningkat. RI kanan 0,56 dan kiri 0,57
 Urinary bladder tidak tampak kelainan
 Prostat membesar dengan volume 66,3 cc

USG DOPPLER VASKULAR ABDOMEN
13/5/2022

BNO-IVP
 Tak tampak urolithiasis radioopak / bendungan di
kedua ginjal dan ureter

MSCT AORTA RENALIS BILATERAL
 Ginjal kanan mendapatkan vaskularisasi dari 1 a.
renalis utama dan a. aksesoris serta
 Ginjal kiri mendapatkan vaskularisasi dari 1 a. renalis
utama disertai early branch menuju pole atas
 Tidak tampak kelainan pada system vena renalis saat
ini

PROTOKOL TRANSPLANTASI - RESIPIEN
H-6 H-5 H-4 H-3 H-2 H-1 H1 H2
Tanggal Rabu
11/5/22
Kamis
12/5/22
Jumat
13/5/22
Sabtu
14/5/22
Minggu
15/5/22
Senin
16/5/22
Selasa
17/5/22
Rabu
18/5/22
Prograf
2 x 1 mg 2 x 1 mg 2 x 1 mg 2 x 1 mg 2 x 1 mg - -
HD
• HD 4 jam
• UF 1 l
• Heparin
5000 unit
HD 4 jam
UF 1,5 L
Qb 200
Heparin
5000 u
HD 4 jam
UF 1,5 L
Heparin
minimal
Operasi
MP
1x500
mg
1x500 mg
Simulect
20 mg

OPERASI TRANSPLANTASI GINJAL - RESIPIEN
Transplantasi Ginjal Implantasi Kanan
Medikasi preop Cefoperazone 1 g IV
Jam mulai 10.00 WIB
Jam selesai 15.30 WIB
Lama tindakan 5 jam 30 menit
Tekanan darah 120-140/80-90 mmHg
Pendarahan 200 mL

OPERASI TRANSPLANTASI GINJAL
Warm ischemic time 1 7’42”
Cold ischemic time 23’51”
Warm ischemic time 2 28’12”
Time to urinate 0’3”
Biopsy Ya
TD pasca anastomosis 131/67
USG - RI 0,9

Pukul
TD
(mmHg)
HR
(x/menit)
Urin (ml)
Drain
(ml)
Keterangan
16.00 120/60 88 0 cc (dari OK) Dobutamin 2 mcg/kgBB/menit Norephinefrin 0.25 mcg/kgBB/menit;
17.00 131/67 106 80 Dobutamin 2 mcg/kgBB/menit Norephinefrin 0.25 mcg/kgBB/menit;
18.00 131/72 110 20
Dobutamin 2 mcg/kgBB/menit, Norephinefrin 0.3 mcg/kgBB/menit; Furosemid 2
mg/jam
19.00 130/65 110 0 100
mg/jam
20.00 128/68 116 30
mg/jam
21.00 125/70 125 0
Dobutamin 3 mcg/kgBB/menit, Norephinefrin 0.35mcg/kgBB/menit; Furosemid 4
mg/jam
22.00 128/70 128 0
mg/jam,
Cellcept 1000 mg
23.00 135/74 123 0
mg/jam
00.00 135/72 125 0
mg/jam
01.00 144/75 125 0
mg/jam
02.00 140/76 126 150
mg/jam
03.00 146/75 128 30
Dobutamin 2 mcg/kgBB/menit, Norephinefrin 0.4mcg/kgBB/menit; Furosemid
10mg/jam
04.00 150/72 118 0
10mg/jam
05.00 155/70 115 50 100
10mg/jam
06.00 154/78 118 50
10mg/jam
Total 410 cc 200 cc

0
500
1000
1500
2000
2500
3000
18 Mei (H1) 19 Mei (H2) 20 Mei (H3) 21 Mei (H4) 22 Mei(H5) 23 Mei (H6)
Urin Output
Urin Output
HD

Hasil Lab Resipien
16/5/22
(H-1)
17/5/22
(H1)
18/5/22
(H2)
19/5/22
(H3)
20/5/22
(H4)
22/5/22
(H5)
23/5/22
(H6)
27/5/22
(RJ)
14/6/22
Hb 13,2 12 12 11,2 10 7,6 6,8 8,5 11,9
Ht 37,4 34,6 35,3 32,8 31 22,5 19,3 24,3 35,8
Trombosit 312 339 359 336 337 190 193 382 445
Leukosit 12400 27240 25869 31130 20850 17850 13300 15320 13020
Kreatinin 6,9 9,4 6,7 6,7 6,8 5,8 3,6 1,7 1,4
eGFR 9,6 6,6 9,9 9,9 9,8 11 21 52 66
Ureum 25,7 49,2 47,1 50,4 96 119 109 62 47,1
Na/K/Cl/
134/4,2/
99
123/4,4/
91
134/3,7/
100
135/3,8/
101
137/4/10
5
136/3,7/
102
138/3,4/
104
139/4,2/
111
134/4,5/
110
Tacrolimus 8,7 8,3 9,8 16

Cor kesan dalam batas normal, elongasi aorta.
Tak tampak kelainan radiologis pada kedua paru.
Tip CVC di proyeksi atrium kanan
Tidak tampak gambaran pneumotoraks, pneumomediastinum
maupun emfisema subkutis
Rontgen Thoraks (17 Mei 2022 )

Daftar Masalah
• DGF pada CKD 5 Post Transplantasi Ginjal
• Hipertensi

1. DGF pada CKD 5 Post Transplantasi Target terukur Tata laksana
Anamnesis:
Urin keluar sedikit post transplantasi
Pemeriksaan fisik:
TD: 154/78, konjungtiva pucat +
Prod urine: 410 ml14 jam
Pemeriksaan penunjang:
Lab darah:
Sebelum Op:
Hb 13,2 ureum 25, kreat 6,9, eGFR 9,6
Setelah Op:
Hb 12 ureum 47, kreat 9,6, eGFR 6,9
Komplikasi intra op :
RI post Transplan: 0,9
Usg doppler
Peningkatan indeks arteri intrarenal disertai
gambaran inverted diastolic pada arteri
interlobaris media dan vaskularisasi ginjal
allograft yang tidak mencapai perifer, sesuia
gambaran severe ATN
Biopsi PA
Parekim ginjal yang mengalami iskemia
Urin Output > 100
ml/jam
Cr < 1,5
Rencana diagnosis:
- Evaluasi fungsi ginjal/hari, Balans cairan/ hari
- USG vaskuler dopler 3 minggu post evaluasi
Rencana terapi:
Prograf 2 x 4 mg tab  tunda bila urin output > 100
ml/jam
Cellcept 2x1000 mg tab
Metilprednisolon 1x500 mg iv (H1-3)
Simulect 1x20 mg iv
Cefoperazon 3x1 gram iv
Paracetamol 3x1 gram iv
Tramadol 200 mg drip/24 jam
Omeprazol 2x40 mg iv
HD, 4 jam, UFG 1000, Qb,200, QD 500, Heparin free
Rencana evaluasi:
Menjelaskan kondisi pasien saat ini dan rencana terapi.
Edukasi kepatuhan diet, minum obat dan kontrol
teratur.
Rencana edukasi:
menjelaskan kondisi px saat ini dan rencana tx
Dipikirkan: DGF pada CKD stage 5 post transplantasi ginjal

UNDERSTANDING DGF
• DGF), which is defined as the failure of the transplanted
kidney to function properly in the early phase after
transplant due to ischemia-reperfusion and immunological
injury.
• “Failure” after transplant has been conventionally
interpreted as the requirement of dialysis in the first week
after kidney transplant
• Alternative criteria that have recently been used include
temporally defined changes in serum creatinine levels,
rate of reduction in serum creatinine levels, and urine
output after transplant
• The main pathologic finding related to DGF is acute
tubular necrosis.
There is no
criterion
standard for DGF
Torki Al Otaibi et al/Experimental and Clinical Transplantation (2016)

Defining Delayed Graft Function after Renal Transplantation: Simplest Is Best.September 2013.Transplantation 96(10)
Ten commonly used definitions of DGF

36
What happened ?
In kidney transplantation, Ischemia/ReperfusionInjury(IRI) is known to underlie the clinical entity of
delayed graft function (DGF)
IRI is a multifactorial inflammatory condition with underlying factors :
• hypoxia,
• metabolic stress,
• leukocyte extravasation,
• cellular death pathways,
• and activation of the immune response

37
• Both ischemia and reperfusion in ischemically-damaged kidneys
following prolonged periods of hypothermic preservation are
involved in the development of delayed graft function (Koo et al.,
1998).
• The generation of reactive oxygen species (ROS), release of
inflammatory cytokines and adhesion and margination of
leukocytes are all cellular events that result in renal injury and
subsequent generation of DGF (Schroppel and Legendre, 2014).
• Extended cold ischemia time is an independent risk factor for the
development of delayed graft function (Quiroga et al., 2006).
Prolonged cold ischemia promotes DGF and acute immune
rejection which, in turn, can shorten long-term graft survival.
Why IRI is important?

38
Severity of ischemia-
reperfusion injury is positively
associated with the frequency of acute
rejectionepisodes
The relationship between DGFand
acuterejectionremains controversial
• Sert et al. (2014) : no association
between cold ischemia time and
the incidence of acute rejection.
• Perez Valdivia et al. (2011) :
confounding results that
indicated that longer cold
ischemia time was associated
with poorer early graft function,
independent of donor and
recipient age.
Why IRI is important?

39
Ischemic Time
Pathophysiology

Delayed Graft Function risk calculator
• Donor, recipient, and surgical
factors are included in a functional
nomogram.
• (A) continuous and categorical
variables that have the highest
likelihood of contributing to the
development of DGF.
• (B) Patient characteristics are
additive and correlate with a risk of
DGF between 10–90%.
• The most widely used, with about 70% accuracy, is the
Irish risk calculator
• However, there is still disagreement about its ability to
predict clinical events, in part, due to the limitations of
granularity in registry data.

Risk factors for delayed graft function in living- donor kidney transplant

Treating risks associated with DGF in LKDT
• In kidney transplant, careful matching of donor and recipient characteristics has been
suggested to have an effect on DGF after transplant.
• Because living- donor transplants are not dictated by the exigencies of immediate organ
availability, these transplants are better suited for donor-recipient matching.
• Age- and gender-matched donor-recipient pairs are less likely to display DGF after
transplant.
• Another important factor that facilitates the reduction of DGF risk is matching patients
with respect to graft volume in relation to recipient body weight.
• Transplants with higher graft weight-to-donor body weight ratio (> 4.5) show better
graft function after living-donor kidney transplant than those with lower ratios (< 3.0).

Treating risks associated with DGF in LKDT
• In addition to screening donors and recipients to establish the right match, clinical
interventions can also help to reduce DGF risk after living-donor kidney transplant.
• In a randomized controlled study from the Middle East that compared graft outcome of
laparoscopic donor nephrectomy with open donor nephrectomy, laparoscopic donor
nephrectomy was not only associated with greater donor satisfaction and less
morbidity67 but also with a 5% (89.5% vs 84.3%) better graft survival in a 5-year follow-
up.
• Immunologic factors play a crucial role in determining graft function after transplant;
therefore, immunomodulation has been used extensively to improve renal function
posttransplant.
• Immuno- suppression with thymoglobulin has shown promise in studies of patients undergoing living-
donor kidney transplant. Thymoglobulin has been shown to have zero incidence of DGF in 214 living-donor
transplant recipients in one single-center retrospective study

Management of established delayed graft
function
• After competing pre-renal, renal and post-renal diagnoses are excluded,
patients suspected should be biopsied to determine the presence of acute
rejection and ATN
• Post-transplant hemodialysis should be offered when clinically indicated)
• Hemodynamic instability and nephrotoxins should be avoided in any
patient diagnosed with AKI.
• Delaying the introduction of the CNI or replacing it with sirolimus or
everolimus is not warranted.
• Use of anti-lymphocyte therapy after DGF is established may not treat the
DGF, but use of antilymphocyte therapy will reduce the rejection rate and
minimize the negative impact of acute rejection in association with DGF

Diskusi Kasus Modul TransplanTri Hadi Susanto.pptx

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