Pedi gu review transplantation

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Pedi gu review transplantation

  1. 1. Pediatric Transplantation Pediatric GU Review UCSD Pediatric Urology George Chiang MD Sara Marietti MD Outlined from The Kelalis-King-Belman Textbook of Clinical Pediatric Urology 2007 (not for reproduction, distribution, or sale without consent)
  2. 2. Advantages Over Dialysis <ul><li>Better growth after transplant </li></ul><ul><li>More cost-effective </li></ul><ul><li>Improved quality of life </li></ul>
  3. 3. Pediatric Transplantation <ul><li>Steady improvement in adult/pediatric pt survival and graft survival over last decade </li></ul><ul><li>Acute rejection rates (1 st 12 mo) at all time low </li></ul><ul><li>Because grafts/patients survive longer, increase in long-term complications </li></ul>
  4. 4. GU Involvement in Ped Transplant <ul><li>GU causes are responsible for 25% of childhood ESRD </li></ul><ul><li>MC Causes: </li></ul><ul><li>- obstructive uropathy </li></ul><ul><li>- aplastic/hypoplastic/dysplastic kidney </li></ul><ul><li>- focal segmental glomerulosclerosis </li></ul><ul><li>- reflux nephropathy </li></ul><ul><li>- polycystic disease </li></ul>
  5. 5. GU Involvement <ul><li>High number of pediatric transplant patients require adjunctive surgical procedures prior to transplant (ex. Augment, catheterizable channel) </li></ul><ul><li>More pt performing CIC than the adult population </li></ul>
  6. 6. Preparing For Transplantation <ul><li>Multidisciplinary approach – GU, neph, tx surgery, social worker, RN, dietician </li></ul><ul><li>Medical Evaluation </li></ul><ul><li>- as optimal as possible </li></ul><ul><li>- good physical fitness and weight control </li></ul><ul><li>- aggressive nutritional support </li></ul><ul><li>- possibly growth hormone therapy </li></ul><ul><li>- immunization status </li></ul>
  7. 7. Medical Eval (Cont.) <ul><li>- warts </li></ul><ul><li>- psychosocial stability </li></ul><ul><li>- frequent/comprehensive follow up </li></ul><ul><li>- access/compliance with immunosuppression </li></ul>
  8. 8. Goals of Urologic Evaluation <ul><li>Confirm adequate storage </li></ul><ul><li>Confirm adequate emptying </li></ul><ul><li>In pt with known GU problem (PUV, spina bifida) may need special void regimen, CIC or Ach prior to trasplant </li></ul><ul><li>If pt is fully diverted, must un-divert and cycle reservoir prior to transplant </li></ul>
  9. 9. Evaluation of Lower Urinary Tract <ul><li>Etiology of renal failure (ex valves) </li></ul><ul><li>History of lower urinary tract dysfunction </li></ul><ul><li>Voiding diary </li></ul><ul><li>Uroflow and PVR </li></ul><ul><li>VCUG </li></ul><ul><li>Urodynamics </li></ul><ul><li>Individualized approach </li></ul>
  10. 10. Indications for Pretransplant Nx <ul><li>Stones not cleared by minimally invasive techniques </li></ul><ul><li>Solid renal tumors </li></ul><ul><li>Polycystic kidneys, symptomatic, extend below iliacs, infections </li></ul><ul><li>Significant proteinuria </li></ul><ul><li>Recurrent pyelonephritis </li></ul><ul><li>High grade hydronephrosis </li></ul><ul><li>Infected stones </li></ul><ul><li>Severe hypertension </li></ul><ul><li>Infected reflux </li></ul><ul><li>Malignancy risk (Denys-Drash) </li></ul>
  11. 11. VUR Managment <ul><li>Controversial </li></ul><ul><li>Some studies have shown increased number of post-tx uti’s if not addressed prior to transplant </li></ul><ul><li>If recurrent infections with VUR (pretransplant) should do reimplant or bilateral N-U </li></ul>
  12. 12. Timing of Transplant <ul><li>Living donors allow for transplant prior to initiation of dialysis </li></ul><ul><li>However, deceased donors have now reached equivalent graft survival in the first few years of transplant </li></ul>
  13. 13. The Live Donor <ul><li>Many pediatric transplants are live donor – the parent </li></ul><ul><li>Need extensive information and medical work up </li></ul><ul><li>Newer – live donor exchange program (first done in 2001) </li></ul>
  14. 14. Living Donor Medical Evaluation <ul><li>Primary </li></ul><ul><li>- H&P </li></ul><ul><li>- blood type </li></ul><ul><li>- tissue type </li></ul><ul><li>- psych eval </li></ul><ul><li>- pregnancy test </li></ul>
  15. 15. Living Donor Medical Evaluation <ul><li>Secondary </li></ul><ul><li>- CBC, Coag, AMA-renal, Chol, LFT, UA, US, Renal Arteriography, CXR </li></ul><ul><li>- Infection screen: Epstein Bar, HIV, Hep B/C, PPD, ucx </li></ul><ul><li>- Pelvic exam, pap, if >40 then mammogram </li></ul><ul><li>- Rectal in male, if >40 then PSA </li></ul>
  16. 16. Living Donor Medical Evaluation <ul><li>Tertiary </li></ul><ul><li>- FMHx DM: 2 hr post-prandial glucose </li></ul><ul><li>- If cardiac risk factors: stress test, echo </li></ul><ul><li>- If pulm symptoms: PFT’s </li></ul>
  17. 17. Transplantation - Recipient <ul><li>Pt supine </li></ul><ul><li>Foley placed, antibacterial solution instilled </li></ul><ul><li>Central venous access </li></ul><ul><li>Second-generation cephalosporin </li></ul>
  18. 18. Transplantation <ul><li>>20kg retroperitoneal </li></ul><ul><li>10-20kg retroperitoneal if small kidney </li></ul><ul><li><10kg intraperitoneal </li></ul><ul><li>Retroperitoneal is ideal to preserve peritoneal cavity for PD if necessary </li></ul>
  19. 19. Transplantation <ul><li>Infant/toddler – aorta or aorto-iliac junction </li></ul><ul><li>Young child – common iliac </li></ul><ul><li>Adolescent/adult – external iliac </li></ul><ul><li>Aggressively avoid hypotension </li></ul><ul><li>Expand blood volume to CVP of 12-16 </li></ul><ul><li>Adult allograft can sequester 200-300 ml of blood from the circulation </li></ul>
  20. 20. Transplantation <ul><li>Reimplant can be either intra/extravesical </li></ul><ul><li>Extravesical advantages – shorter OR time, less obstruction, less hematuria, less urinary extravasation </li></ul>
  21. 21. Post-Op Care <ul><li>Fluid and electrolyte management </li></ul><ul><li>Fresh transplant has decreased concentrating ability so may have excessive uop first few days </li></ul><ul><li>1:1 replacement </li></ul>
  22. 22. Early Graft Dysfunction <ul><li>Mostly preventable </li></ul><ul><li>Signs – oliguria, Cr does not fall </li></ul><ul><li>No uop – concern for arterial thrombosis, most centers do immediate doppler US after closure </li></ul><ul><li>Most have native kidneys so uop as measure can be challenging </li></ul>
  23. 23. Initial Good UOP, then Drop <ul><li>Low intravascular volume – bolus </li></ul><ul><li>CI toxicity - >20 ng/ml </li></ul><ul><li>Rejection – dx by biopsy </li></ul><ul><li>Venous thrombosis </li></ul><ul><li>Urine leak </li></ul>
  24. 24. Post-Op Fluid Collection <ul><li>Lymphocele – intervene if symptomatic, expanding or obstructive </li></ul><ul><li>Urine leak </li></ul><ul><li>Hematoma </li></ul>
  25. 25. Immunosuppression <ul><li>Very individualized but usually triple therapy with CI, antimetabolite, steroids </li></ul><ul><li>Target ranges based on estimated rejection risk balanced against side effects of the medications </li></ul>
  26. 26. Immunosuppressive Therapy <ul><li>LESS </li></ul><ul><li>First-time caucasian recipient </li></ul><ul><li>Live donor kidney </li></ul><ul><li>No evidence of pre-sensitization </li></ul><ul><li>MORE </li></ul><ul><li>Repeat transplant </li></ul><ul><li>Deceased donor </li></ul><ul><li>Evidence of pre-sensitization </li></ul><ul><li>Recipients who are african-american </li></ul>
  27. 27. Prophylaxis <ul><li>Bacterial: peri-op for wound infection, then targeted toward uti and pneumocystis carinii (Bactrim) </li></ul><ul><li>CMV – determined by risk (recipient and donor history of CMV exposure and strength of immunosupp) </li></ul><ul><li>Epstein Barr virus – no effective prophylaxis, many peds recipients are neg, adult donors are positive </li></ul><ul><li>Antifungals – first few months while immunosupp is highest </li></ul>
  28. 28. Prophylaxis <ul><li>If pt has acute rejection and need to increase immunosuppressive therapy, recycle the full spectrum of prophylactic meds as well </li></ul><ul><li>GI – H2 blocker for steroid-induced gastritis and ulcers </li></ul>
  29. 29. Urologic Complications <ul><li>5.6% of all cases </li></ul><ul><li>- urinary extravasation </li></ul><ul><li>- ureteral anastomotic obstruction </li></ul><ul><li>- ureteral necrosis </li></ul><ul><li>- symptomatic VUR </li></ul><ul><li>Urologic problems result in allograft loss 31% of the time </li></ul>
  30. 30. Renovascular Complications <ul><li>5.5% of all cases </li></ul><ul><li>- technical (3.2%):anastomotic defect, vascular angulation, vascular compresseion </li></ul><ul><li>86% of all vascular complications result in allograft loss </li></ul>
  31. 31. Urolithiasis <ul><li>6% of adults, 5% of pediatric tx kidneys </li></ul><ul><li>Etiology </li></ul><ul><li>- low uop </li></ul><ul><li>- elevated calcium excretion </li></ul><ul><li>- disturbance in uric acid metabolism secondary to CI therapy </li></ul><ul><li>- increased frequency of uti </li></ul><ul><li>- hypocitraturia, hypomagnesuria, hypophosphaturia </li></ul><ul><li>- suture material present </li></ul>
  32. 32. Post-transplant VUR <ul><li>Post-tranplant VUR without pyelonephritis has not been linked to allograft loss in either adult/kids </li></ul><ul><li>Post-transplant VUR with pyelonephritis has been linked to allograft loss, these should be corrected </li></ul><ul><li>Attempts at deflux have failed to correct it </li></ul><ul><li>In kids, VUR can be from incompletely managed bladder…may need Ach or CIC </li></ul>
  33. 33. Long-term <ul><li>Transition to adult can be hard </li></ul><ul><li>Decreased compliance in teenage years is an issue </li></ul><ul><li>Need long term follow up of donors who may develop htn/proteinuria </li></ul><ul><li>Attempting to create Donor Database to better follow these pt </li></ul><ul><li>If donor loses solitary kidney, placed at top of transplant list </li></ul>
  34. 34. Summary <ul><li>33% of pediatric tx pt require urologic surgery prior to transplant </li></ul><ul><li>No pt is transplanted while diverted </li></ul><ul><li>Living donors have better graft survival long term </li></ul><ul><li>Improvements in immunosuppression have significantly improved graft survival, specifically in the first few years </li></ul>

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