kidney transplant

1. -
CHALLENGES IN LIFE OF
KIDNEY PATIENT
DR Y P SINGH RANA
UROLOGIST & KIDNEY TRANSPLANT SURGEON .

2. Background

3. Who is At Risk for CKD
• Hypertension
• Diabetes
• CAD
• Family History CKD
• Elderly
• Morbid Obesity

4. Two Screening Tests
•eGFR
•ACR
–Albumin/
Creatinine ratio

5. Classification of CKD

6. Classification of CKD by Diagnosis
• Diabetic Kidney Disease
• Glomerular diseases (autoimmune diseases, systemic
infections, drugs, neoplasia)
• Vascular diseases (renal artery disease, hypertension,
microangiopathy)
• Tubulointerstitial diseases (urinary tract infection, stones,
obstruction, drug toxicity)
• Cystic diseases (polycystic kidney disease)
• Diseases in the transplant (Allograft nephropathy, drug
toxicity, recurrent diseases, transplant glomerulopathy)

7. CKD IS A CORONARY DISEASE
EQUIVALENT
CKD
HYPERTENSION
DIABETES, hyperlipidemia
PROTEINURIA
SAVE YOUR KIDNEYS AND SAVE YOUR HEART
ANEMIABONE DISEASE

8. KEY POINTS IN:
• Diagnosis
• Recognition of
Complications
• Medication Safety
• Treatment
• Preparation for
Vascular Access
• When to Refer

9. Understanding eGFR
eGFR What to do
>60 and microalbumin< 30  Yearly surveillance with GFR (for hypertensive
patients) and both GFR and microalbumin (for
diabetic patients)
>60 and microalbumin > 30  ACE or ARB
>45 and < 60*  ACE or ARB
 Discontinue NSAIDS
 ? off Metformin**
 Check hemoglobin
 Check Calcium, Phosphorous, PTH and
Vitamin D yearly
>30 and < 45  The above plus
 Stop metformin**
 No PICC lines
 All blood draws from dominant arm (Save an
Arm)
< 30  Refer to Nephrologist
< 20  Refer for transplant evaluation

10. Clinical Practice Guidelines for Management
of Hypertension in CKD
Type of Kidney Disease Blood Pressure
Target
(mm Hg)
Preferred Agents
for CKD, with or
without
Hypertension
Other Agents
to Reduce CVD Risk
and Reach Blood
Pressure Target
Diabetic Kidney Disease
<130/80
ACE inhibitor
or ARB
Diuretic preferred,
then BB or CCB
Nondiabetic Kidney
Disease with Urine Total
Protein-to-Creatinine
Ratio 200 mg/g
Nondiabetic Kidney
Disease with Spot Urine
Total Protein-to-Creatinine
ratio <200 mg/g None preferred
Diuretic preferred,
then ACE inhibitor,
ARB, BB or CCB
Kidney Disease in Kidney
Transplant Recipient
CCB, diuretic, BB,
ACE inhibitor, ARB

11. VARIOUS CHALLENGES
• 1. ACCEPTANCE OF PROBLEM
• 2. Choosing RRT
• 3. DONOR AVAILABILITY
• 4. ISSUS OF IMMUNOSUPPRESSION.
• 5. LONG TERM COMPLIANCE & PRECAUTIONS
which determine outcome.

12. CHALLENGE -1
• Acceptance
• THE DAY OF DOOM
• ROLE of Family /Society/Health care providers
• Counselling, tell the figures (You are not
alone)

13. CHALLENGE -2
• CHOOSING THE RIGHT WAY OF RRT
• HD/CAPD/ RENAL TRANSPLANT
• FAQ- when I will need HD, What will be
frequency(IDEAL trial )

14. A-V fistula: vascular access for dialysis
• High flow rates 200ml/min
• Easy access
• So artery [flow]
anastomosed to
vein[lumen]

16. Tenckhoff Catheter

17. CHALLENGE -3
• HAVING SOME BODY TO DONATE KIDNEY
• Healthy related with compatible blood group
Governing Act for all organ transplants in India
Only live related transplants permissible .. First degree
relatives and grandparents
Authorisation by State Committee for all unrelated
transplants / foreign nationals
All Cadaver transplants.

18. STEPS FOR INCREASING DONOR
POOL
• CADAVER TRANSPLANT
• SWAP KIDNEY TRANSPLANT
• MARGINAL KIDNEY DONORS
• ABO Incompatible donors
• Brain Stem Death Concept
• Consent for donation
• Organ Allocation
• Maintenance of organ
viability
• Recipient operation
• Graft biopsy
• Conclusions

19. Brain stem death (BSD)
• Artificial window of opportunity between
Brain Stem Death and Cardiac standtstill
Duration variable . Usually about 24 -48 hrs
• Organs remain viable .. Harvest for
transplant. Beating heart harvest
• After cardiac arrest .. Non beating heart
harvest.. Not practiced in India

20. Declaration of BSD
• Mandatory declaration for all hospital ICUs
to monitor and declare BSD
• Brain Stem Death declaration committee
Medical Supdt
Intensivist
Physician in charge of case
Neurophysician or Neurosurgeon
• 2 sets of tests ,6 h apart
• Maintenance of organ viability from
declaration till harvest

21. Cadaver Donor Selection
• Age :-15-60 yrs
• Serum Creatinine < 1.5 mg /dl
• Absence of malignancy / viral infections /
septicaemia
• Contraindications: Diabetes Hypertension/CVA
in a younger patient
• Graft biopsy and frozen section assessment of
quality of kidney

22. Procurement of consent :
transplant coordinator
• Purely altruistic consent
• Religions sanction organ donation
Quran Ch 5-32 Whoever saves the life of one person would be as though he
saved all mankind.
Islamic jurisprudence Assembly Saudi Arabia, Iran, Egypt
HINDUS: Daan 3rd most important Niyam of life.
Lord Ganesh .. Xenotransplant . Belief of life after death .. Soul Sheds the
body for another body
(NDT 2011;26:437-44)
• Endorsement of Organ Donation by Religious Leaders
• Medico legal Cases: Governmental orders
information to Police Post / SHO
Post Mortem (PM) can be waived off if definittve cause of death established
Organ retrieval can be combined with PM

23. Icu care - donor
• Minimise duration from declaration of death
to organ retrieval
• “Catechol” storm
Haemodynamic Instability
Hypernatraemia
Hypothermia
Hyperglycaemia
• Usual course is cardiac instability and death in
2-3 days after BSD

24. Organ allocation--- transplant registry
• The backbone of cadaver transplant
• Fair /quick allocation of organs
• Recipients allocation based on seniority /
urgency / PRA status
• Registry at NOTTO / State / Institutional
inputs
• Local /regional distribution of organs

25. Procedure
• Donor blood samples for Grouping / Viral
Markers - Hep B/ HCV/HIV/ Cross Match
• Transplant Coodinator records consent …
Recipient teams activated
• Recipients summoned as per suitablility/
availability –

26. Preparation of recipient
• Blood group / cross match /Viral Screens
• Clinical surveillance for active infections
• 2-3 potential recipients screened ..best
selected
• Cross match turn around time 6-8 hrs …
dialysed and immunosuppressants started.

27. Where organ retrieval to be done
• All solid organs.. Authorised transplant centers
only
• For eyes and ear drum/ ossicles ..Domestic
harvest permitted
• Order of harvest
Heart Lungs …… Liver ….. Kidneys…. Cornea

28. Draping of patient

29. Midline laparotomy

30. Cattle’s manouvere

31. Catheter in aorta

32. Gall Bladder emptied of bile

33. Sternotomy

34. Multi organ donation .. Operative
steps

35. Isolation of Supra Coeliac Aorta

36. Cannulation of Sup Mes V

37. Ice slush.. Topical cooling of organs

38. Delivery of Liver

39. Retrieval of Kidney

42. Bench preparation of Renal Graft

43. Maintenance of organs
• Preservation of organ viability between
harvest to transplant
• Intracellular fluids: UW sol/ HTK sol
• Static versus Pumps
• Organ retrieval teams

44. KIDNEY PACKING
• Double packed
• Inner bag .. Kidney submerged in iced
Custodial solution , remove air , tie
• Outer bag … ice slush
• Outer carrier … Ice box with label

46. Recipient operation

47. Non beating heart donor
• Started in 50s-60s .. Poorer outcomes---
Beating Heart Donors …. Non beating heart
donors
• Consent .. Supports stopped… Cessation of
cardiac activity for 2 min..5 min or 10 min
• Systemic cold perfusion … organ harvest
• Early graft function poorer outcomes .
Equivalent results at 1-3 yrs
• 2 settings .. Controlled and Uncontrolled

48. Problems with Non beating Retrieval
• Getting familial consent
• Uncertainities of diagnosis
• Prolonged warm ischaemia
• Medico legal issues
• Strong local awareness and rules to support
this programme

49. Post op care
• Delayed graft function
• Prologed lymphatic drainage
• Functional outcomes Correlation with
Ischaemia time

50. Outcomes of cadaver
transplantation
• Deceased donor Renal Transplantation at Army Hospital RR : Our Experience
IJU 2013, 29 :105-109
• 44 cadaver renal transplants from 35 deceased donors including 37%
extended criteria donors
• Mean follow up 22 months
• Cold ischaemia time 6.25 hrs
• Delayed graft function 34 %
• Prolonged lymph drainage 31%
• Biopsy proven rejection 16%
• 1 yr graft survival 92 %
• 1 yr patient survival 83%
• 2 graft nephrectomies
• Counselling conversion rate 55%

51. Variations from live related
transplants
• Unplanned
• Multiple teams simultaneously operating
• Delays in identifying suitable recipients
• Minimal opportunity to screen donor and
recipients
• Walk the extra mile for good outcomes

52. ABO INCOMPATIBLE
TRANSPLANTATION

53. MARGINAL DONORS
• DONOR WITH KIDNEY STONE
• DONOR WITH OBESITY

54. challenge 4..Prevention of rejection
• IMMUNOSUPPRESSION
• INDUCTION-- administer medications that provide
marked suppression prior to and during the first week post
transplantation.
SIMULECT- 20MG ON DAY 0 & 4
ATG -1 MG/KG X 3 -5DAYS
MAINTENANCE

55. IMMUNOSUPRESSION
•STEROIDS
•TACROLIMUS
•CYCLOSPORIN
•MYCOPHENOLATE
•AZORAN
•SIROLIMUS/EVEROLIMUS

56. CHALLENGE - 5
compliance and Infection control
• TAILORING DRUG REGIMENS
• REFRACTORY REJECTION
CYCLOSPORIN TO TAC
• CARDIOVASCULAR DISEASE
CYA TO TAC
• HIGH CHOLESTEROL
SIROLIMUS TO CNI
• DIABETES
TAC TO CYA

57. CHRONIC GRAFT DYSFUNCTION

58. An analysis of first 250 transplants
at BLK Hopsital
• Duration Aug 12 – Aug 15
• 10 Cadaver Transplants
• HIV positive , HBSAg Positive ,HCV positive
• Dual virus HBV And HCV positive
• Redo transplants – 5 patients
• Sensitised recipients 2
• 3 pediatric transplants – Small neurogenic bladder ..
Augmented
• Foreign Nationals ; Afghansitan / Iraq/ Nepal/
Nigeria/ Kenya

59. Donor profile
• Parents : Father
Mother
• Spouse: Wife
Husband
• Sibling
• Children Son
Daughter
• Grandmother
• Unrelated
• Cadaver

60. Creatinine at Discharge
0
5
10
15
20
25
30
35
40
45
50
<0.5 0.5-0.9 1-1.4 1.5-1.9 2-2.4 2.5-2.9
no of patients
no of patients

61. Recipient Data
• 6 deaths
• 5 Sepsis from Pneumonia , UTI
• 1 – bleed after graft nephrectomy
• Funcitonal grafts at 1 yr 97%

62. CONCLUSIONS
• Surgical accuracy is critical
• Cadaver transplant is possible key to match
supply demand gap
Not an operation to be taken lightly –
kidneys are precious and hard to come by
Meticulous surgical technique
TEAM EFFORT

63. RENAL TRANSPLANT IS LIKE A MARRIAGE
BLESSING FOR MOST
CURSE FOR SOME
BUT A RISK FOR ALL

64. • In my end is my beginning
- T.S.Eliot, Four Quartets
So begin now