6/11/2018 Objectives TRANSPLANTATION Understand Identify Review - - PDF document

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6/11/2018 Objectives TRANSPLANTATION Understand Identify Review - - PDF document

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6/11/2018 Objectives TRANSPLANTATION Understand Identify Review THE ART OF THE Understand the Identify donor and Review standard DO- OVER kidney transplant recipient factors transplant recipient selection that lead to

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TRANSPLANTATION “THE ART OF THE DO-OVER”

Objectives

Understand

Understand the kidney transplant recipient selection process.

Identify

Identify donor and recipient factors that lead to successful transplant

  • utcomes.

Review

Review standard transplant immunosuppression regimens.

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Quantity

  • r

Quality

Benefits of Kidney Transplantation

Longer Life Improved Quality of Life No Dialysis

Risks of Transplantation

Surgery Bleeding Urinary leak Death Debility Anesthesia Urine retention Lymphocele DVT Pneumonia Acute myocardial infarction Immunosuppression Opportunistic infections Malignancy Diabetes Gout Diarrhea Insomnia Tremor Hypertension Alopecia Hypomagnesemia or hyperkalemia

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T cells

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HLA PROTEINS

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LYMPHOID ORGANS

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Maintenance Immunosuppression

  • Tacrolimus (Prograf) – diabetes, hypertension, insomnia,

tremor, diarrhea

  • Mycophenolate (Myfortic or Cellcept) – diarrhea,

fatigue, bloating

  • Prednisone – fluid retention, weight gain, acne, fat

redistribution, bruising

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Drugs that raise CNI levels Drugs that lower CNI levels Calcineurin Inhibitor

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Donor Types

Living Deceased

  • Neurologic death criteria
  • Cardiac death criteria
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Donor Factors

POSITIVE OUTCOMES NEGATIVE OUTCOMES Younger age Older age Greater HLA match with recipient HLA mismatched with recipient Higher GFR Lower GFR Absence of diabetes or hypertension Presence of diabetes or hypertension Neurologic death Cardiac death Less ischemic More ischemia

Pre-Transplant Phase Transplant Phase Post-Transplant Phase

Transplant Candidate Evaluation

  • Multidisciplinary Team evaluation (Surgeon, Physican,

Coordinator, Social Worker, Pharmacist, Dietitian, Independent Donor Advocate for donors)

  • Presented and approved at SELECTION COMMITTEE
  • Three outcomes – (a) UNOS listed, (b) sent back for further

evaluation, (c) denied and given alternate referral options

  • Waitlist management – education and maintenance of health
  • Additional consents – (a) PHS elevated risk; (b) high KDPI donor
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Recipient Factors

POSITIVE OUTCOMES NEGATIVE OUTCOMES Older age Younger age Greater HLA match with recipient HLA mismatched with recipient Ideal BMI or non-diabetic Under or 0verweight or diabetes Good fitness Poor fitness Less sensitized Highly sensitized Disease with lower risk of recurrence Disease with higher risk of recurrence

  • 1. Advanced kidney disease: Regulations for

listing for transplantation state that candidates must either be on dialysis or have near loss of kidney function with a creatinine clearance < 20cc/min (normal is >80).

  • 2. Adequate urinary tract:
  • 3. Acceptable cardiovascular function:

Contraindications to transplantation include significant un-correctible coronary artery disease and/or poor cardiac pump function.

  • 4. Acceptable vascular system:
  • 5. Acceptable lung function: Smokers may be

declined until they are able to quit (based on age and medical history).

  • 6. Acceptable liver function:
  • 7. Active significant fungal or bacterial infection is

a contraindication to transplantation.

  • 8. Cancer screening: Appropriate for age tests will

be necessary including colonoscopy (age>50yo), prostatic specific antigen, etc.

  • 9. Obesity: Candidates must have a body mass index

(BMI, weight/body surface area) of <38.

  • 10. Functional status: Candidates must be able to

walk short distances and perform activities of daily living without assistance.

  • 11. Psychosocial status: Candidates must be

motivated, have demonstrated compliance with medical and dialysis regimens, not suffer from psychosis, live in a stable environment, capable of supporting compliance with the transplant regimen including transportation, and not be an active substance abuser, (+/- cannabis)

  • 12. Financial considerations:

Transplant Phase

  • Starts with donor offer – local donor vs import
  • Transplant center reviews the HLA match run and calls their potential

recipients – each kidney has a primary candidate and backup candidate

  • Either admit potential recipient or have them provide blood for a final

crossmatch

  • Medical suitability and final clearance
  • Dialysis coordination if necessary
  • Schedule surgery – time of day, cold ischemic time, surgeon “freshness”
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Post-Transplant Phase

  • Conduct frequent lab tests and office visits
  • Review side effects of medication
  • Evaluate surgical healing and remove staples, tubes, and stent
  • Balance immune suppression medication
  • Screen for infection
  • Address psychological concerns

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QUESTIONS?