Download Introducton to Kidney Transplantation

Introduction
to
Kidney Transplantation
Dr Natasha Cook
Renal Physician, Austin Health and Northern Health
September 2009
Treatment for Kidney Failure
Dialysis: Haemodialysis & Peritoneal
Transplantation
A kidney transplant is only one type of treatment for
End Stage Renal Failure.
It is NOT a cure
Where does my new kidney go?
Where does my new kidney go?
Kidney Transplant - Advantages
What are the benefits of a kidney transplant?
Quality of Life:
 normal life
 No dialysis
 Back to work, holiday etc.
 Food and fluid intake less restricted
 Improved sexual function and fertility
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Improved Medical Outcome:
 Increased longevity in the majority of patients
Short Term Risks of Transplantation
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Anaesthesia and surgical complications:
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including infection (wound, pneumonia, urine
infections),
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bleeding,
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clots in the legs and lungs.
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death
Donors are screened thoroughly for infections and
cancers, however unknown infectious agents and
microscopic cancers in the donor which are not detectable
may be transmitted to the recipient. This is very
uncommon.
Risks of Transplantation
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Complications from the anti-rejection medications
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Infections overall and includes infectious organisms which
the general population would not normally acquire
(“opportunistic infections” eg. Viral, fungal, atypical –
examples are Cytomegalovirus, Pneumocystis)
Cancers in general are increased in transplant recipients;
especially skin cancers and lymphoid cancers
Diabetes
High blood pressure
High cholesterol and other lipids
Osteoporosis
Specific side-effects of each anti-rejection medication
Kidney Transplant – Other
considerations
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Hospital stay is usually about 1 week but complications can lead to a
longer stay or coming back into hospital
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Delayed Graft Function : You may need dialysis for a while until
your kidney starts to work
Rejection
Infection
Technical Problems with Surgery at the blood vessel or the bladder
end
Frequent visits to clinic, frequent blood tests.
It may take some time before you feel the benefits.
Ongoing issues and changes to
Kidney Transplantation
Supply and Demand - increasing waiting time on deceased
donor waiting list (Currently about 3-6 years depending on
blood group and antibody level)
Changes to Practice due donor organ shortage
•Increasing Live Donor Transplantation
•Transplantation of patients with “positive cross-match”
•ABO incompatible transplantation
•Paired exchange
Significant changes to anti-rejection therapy
Types of Transplants
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Deceased Donor Transplants
Live Donor
 Related (genetic)
 Unrelated (“emotionally”)
Other
Live Non-directed donation
 Paired Exchange
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Number and Duration of Functioning
Grafts Australia 2005
All Functioning Grafts (6,269)
700
600
Deceased (4478)
Live (2061)
500
400
300
200
100
0
<1
2
4
6
8
10 12 14 16 18 20 22 24 26 28 30 >32
Duration in Years
Deceased Donor Transplants
How are the kidneys obtained?
The Donor Transplant Coordinator facilitates, coordinates and
assists in the procurement of donor organs 24 hours a day.
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Provides the link between the donor hospital and the transplant
hospital
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Receives referrals from Intensive Care Units who believe they
may have a potential donor
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Attends the referring hospital to assist in organising the donation
Who is eligible for a transplant?
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For people who are
 Near dialysis or dialysis dependent
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Medically & Surgically Fit
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Transplant is NOT a suitable treatment for everyone
Age
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It’s not the age in years that count but how worn your body is or
how many other disease you have.
The Transplant List
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There is only ONE Transplant List which is the “Active
Transplant List” – ready to be called for transplantation
Interim Patients under consideration or temporarily off the Active
List do NOT appear on the active transplant list
Transplant Waiting List
Requirements
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2nd Monthly blood test for antibodies
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Yearly Transplant Review
 Review recipients due to increasing waiting time
 Medical & Surgical fitness
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Education Seminar every 2 years
 Update on new developments
 Update on Risks/Benefits of Transplantation
Transplant “Work Up”
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Transplant Doctor & Transplant Nurse in
Transplant Outpatient Clinic
Detailed History and Examination
Blood tests
X rays
Heart Tests
Check up by Transplant Surgeon
Referrals to other specialists as needed- Cardiac,
Gastroenterology, Dermatology, Liver, Psychiatrists,
Vascular Surgeons
Tissue Typing and Cytotoxic antibodies
Tissue typing identifies Transplantation or Tissue antigens
 Must be completed before acceptance onto the
transplant list
 Cytotoxic Antibodies (antibody to “Transplantation or
Tissue” antigen)
 Monthly test
 Patient removed from the transplant list if blood is not
received regularly
Living Donor
Transplants
Donor Workup
Living Donor Transplants
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Who can donate?
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Parents, brothers, sisters, cousins, husbands,
wives, friends.
Live Donor Transplants
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The Donor is the very important person in this
situation and every possible care is taken to
make sure any potential risk is minimised to
acceptable levels
Individuals who may be excluded for living
donation
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Age – the elderly
Women who have not completed childbearing: preferably not used
Diabetes – complete contraindication
Obesity/overweight
Renal disease complete contraindication
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Abnormal GFR. (The volume of urine filtered by the kidney over a set time)
Protein in the urine
Kidney stones
Kidney surgery
Reflux
High Blood Pressure
Blood in the urine
Heart disease
 Lung disease
 Cancer
 Infection
 Inability to give consent
The donation must not be coerced and must be truly altruistic.
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Live Kidney Donor Workup
 Blood
tests
 Urine tests: to check for blood and protein
 Special Kidney Xrays
Ultrasound of kidneys and urinary tract
 Renal Scan
 CT Angiogram
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 Review
by Transplant Surgeon, Psychiatrist
and Independent Renal Physician
Donor Nephrectomy
Post Transplant Follow up
Maximising Survival of the kidney
Factors that we watch for, which may
contribute to poor function:
 Kidney Rejection (Early and Late)
 Drug Toxicity
 Proteinuria
 Poorly controlled blood pressure
 BK virus infection
Post Transplant Complications
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Infection
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Recurrence of kidney disease
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PCP pneumonia: Bactrim 3 times weekly or nebulised pentamadine
for 6 mo
CMV: anti-viral treatment depending on exposure status of donor
and recipient
Diabetic nephropathy
Glomerulonephritis (Primary or Secondary)
Cardiovascular disease
Diabetes (prednisolone, tacrolimus)
Cancer: Screening, Dermatology review
Osteoporosis: 2 yearly DEXA scan
Other Health Issues
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Obesity
Smoking
Diet
Issues relating to Fertility
Transplantation issues in Alport
Syndrome
Transplantation is an Excellent
Treatment for End Stage Renal Failure
due to Alport Syndrome
Anti-Glomerular Basement
Membrane Antibody disease
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2-3% risk of graft loss due to formation of antiGlomerular Basement Membrane Antibodies in
male transplant recipients with Alport Syndrome
Anti-Glomerular Basement
Membrane Antibody disease
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The glomerular basement membrane in the
kidney is made of Type 4 Collagen
Production of components of type IV collagen
is reduced or defective in Alport Syndrome
When normal components are encountered in
the new kidney by a recipient with Alport
Syndrome, they are seen as foreign and
antibodies can be formed
This leads to glomerulonephritis and graft loss
Anti-Glomerular Basement
Membrane Antibody disease
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Men with deafness and kidney failure before 30 years
of age are more susceptible
COL4A5 deletions (The gene encoding α5 chain of
Type IV collagen) are associated with higher risk
However studies generally find the risk of anti-GBM
nephritis is still less than predicted
Plasma exchange, cyclophosphamide and more recently
rituximab are treatment options
Difficult to treat
Anti-Glomerular Basement Membrane
Antibody Disease
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Bone marrow plus Kidney transplantation:
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Recipient’s immune system is a mixture of cells from the
native and donor immune system
Immune cells do not react against the kidney transplant
Use of Alport ‘Carriers’ with isolated
haematuria as Renal Donors
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One recently published study with very small
numbers but follow up for 2-14 years:
Gross et al NDT May 2009:
6 “Carrier” mothers donating to sons
 3/6 new high blood pressure
 2/6 new protein in the urine
 4/6 decline in kidney function (but kidney function
still about 40% or more of normal)
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Use of Alport ‘Carriers’ with isolated
microscopic haematuria as Renal
Donors
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Significant risk of
New Onset Proteinuria
 New Onset Hypertension
 Decline in Renal function
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HEARING LOSS, PROTEINURIA,
HYPERTENSION, OR KIDNEY FAILURE
PRIOR TO DONATION ARE ABSOLUTE
CONTRAINDICATIONS
Use of Alport ‘Carriers’ with isolated
microscopic haematuria as Renal
Donors
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Should be a rare event
Close follow up is required
Donors should be given ACE inhibitors (which
reduce protein leak into the urine as well as
blood pressure)
Questions?