Renal Transplant Surgery

Allograft

transplant with non-identical individuals

failure, 10, lower, higher, dialysis, lower

Kidney Donor Profile Index (KDPI)

• Estimates the potential risk of graft ________ after kidney transplant based on __ donor factors

• The _______ the score, the higher the rate of survival

• Ranges from 0-100%

• Donated kidneys with score <20% → patients with _______ potential for survival

• Donated kidneys with score >85% → patients who will fare worse on _________ and need the benefit of transplant earlier, despite receiving potentially _____ quality organ

Hope Act

allows for organ donation from HIV (+) donors

yes

Can kidneys be used from donors after a cardiac death?

pericarditis, seizures, bleeding, diuretics, HTN, metabolic, malnutrition

Indications for Renal Replacement Therapy (transplant and/or dialysis)

• ______________ or pleuritis (urgent indication)

• Progressive uremic encephalopathy or neuropathy

  • _________ (urgent indication)

• Clinically significant _________ diathesis attributable to uremia (urgent indication)

• Fluid overload refractory to __________

• ___ poorly responsive to meds

• Persistent __________ disturbances refractory to medical therapy

• Persistent nausea and vomiting

• Evidence of _________

irreversible, CKD, dialysis, living, 30

Indications for Renal Transplant

• _____________ ESRD requiring renal replacement therapy

• Late ___ approaching need for renal replacement therapy

• Ideally the transplant should take place before ________ is required (pre-emptive transplant, requires _______ donor)

• Refer for initial eval with GFR < __ mL/min

2, malignancy, psychosocial, substance, immunologic, age

Absolute Contraindications for Renal Transplant

• Chronic illness that limits predicted survival < _ years

• Active glomerulonephritis

• Active ___________

• Active infection

• _____________ issues affecting adherence to medical care

• Active _________ abuse

• _____________ causes

• ___ is not an contraindication, majority on waitlist > 65 years old

psychiatric, non-compliance, myeloma

Relative Contraindications for Renal Transplant

• Severe ____________ disease

• Moderately severe degrees of comorbidity

• ___-__________ with dialysis or other medical therapy

• Primary renal diseases

  • Primary focal sclerosis with prior recurrence in transplant

  • Multiple ________

  • Amyloidosis

  • Oxalosis

antibodies, hyperacute, ABO, HLA, removal

Immunologic Contraindications

• presence of preformed __________ against the donor kidney at the time of anticipated transplant → __________ rejection

  • Natural antibodies against ___ blood group antigens

  • Natural antibodies against ___ class I or II

• Screening for this occurs routinely early in process

• ________ of antibodies directed at donor tissue now routinely performed with varying success

single, 6, target, polymorphic

Organ Selection - HLA Compatibility

• Match HLA major histocompatibility

  • Each mammalian species has a _______ chromosomal region that encodes the major histocompatibility antigens, this region on human chromosome _ codes the HLA genes

  • HLA can be immunologic _______ of organ rejection due to its highly ____________ properties

etiology, recurrence, familial, transplants, immunosuppressive, hypercoagulable

Recipient Evaluation → History: thorough medical and surgical history

• _________ of original kidney disease and risk of __________ with the transplanted kidney

• History of __________ or hereditary kidney disease, particularly if living, related donation is an option

• Potential sensitization risks, including history of blood or platelet transfusion, pregnancies, and previous ___________

• History of prior ________________ therapy

• History of _______________ state

• Medical co-morbidities: DM, CAD, CV disease, HTN

abdominal, P450, immunization, cause, complications

Recipient Evaluation → History: thorough medical and surgical history

• History of prior surgery, especially _____________

• Review of meds, especially those metabolized by cytochrome ____ system

• ___________ history

• Physical activity history to assess functional status

• In retra-transplantation candidates, prior transplantation courses and _____ of graft loss, medication adherence, and previous transplant ________________

BMI, infection, carotid, femoral, pedal, masses, dialysis

Recipient Evaluation → Physical: detailed physical exam

• Assessment of ___ and central adiposity

• Oral exam looking for advanced dental decay and signs of _________

• Auscultation for ________ bruits

• Assessment of bilateral _________ and ______ pulses and lower extremity integrity

• Palpation for abdominal ______ and assessment of prior abdominal procedure that may affect placement of the kidney transplant

• ___________ access location (in those receiving it)

CMV, simplex, varicella, EBV, B, C, syphilis

Recipient Evaluation → Serologic Tests

• Cytomegalovirus (___)

• Herpes ________ virus

• ___________-zoster virus

• Epstein Barr virus (___)

• HIV

• Hep _ and _ viruses

• Treponemia pallidum (__________)

• MMR

PPD, gamma, TB

Recipient Evaluation → Non-serologic Tests

• ___ or interferon-_____ release assay for __

• CXR

stress, CT, carotid

Recipient Evaluation → Cardiovascular Testing

• EKG

• Echocardiogram

• _______ Test

• __ abdomen/pelvis: evaluate vasculature

• _______ dopplers

smoking, lung

Recipient Evaluation → Pulmonary Function Testing

• If significant __________ history

• If chronic ____ disease

adherence, social worker, neuropsychiatric

Recipient Evaluation → Psychosocial Assessment

• Identify behavioral, social, and/or financial issues that may influence ________ and outcomes after transplant

• Performed by ________ _______ or psychologist trained in evaluation of transplant candidates

• Potential further eval with referral for ______________ assessment

immunosuppressive, cognitive, psychiatry, substance

Recipient Evaluation → Psychosocial Assessment

• Understanding of potential risks and benefits of transplant need for lifelong ________________ therapy, and need for adherence to medication regimen

• ___________ evaluation for decision-making capacity and ability to give informed consent

• Patients with mental health issues need to establish care with _____________ to improve access and success after surgery

• Patients with __________ abuse disorders

  • including alcohol, tobacco, recreational drugs

  • different centers have different contraindications but patient needs to be substance-free for certain period of time

contraindication, financial, insurance

Recipient Evaluation → Psychosocial Assessment

• Social support system in place, lack can be considered a _________________

• ____________ support given the high costs of immunosuppressive therapy and potential ____________ issues; make sure transplant and follow-up care is feasible

0, 3

Frailty Evaluation

• Assesses fatigue, resistance, ambulation, illness, and loss of weight

• Score _+ = frail

• Score _ = healthy

laparoscopic, living, robotic

The Surgery Process → Donor Kidney

• ________________ or open abdominal surgery

• Laparoscopic most common in ________ donors

• _________ becoming more common

hemodialysis, 48, potassium, arrhythmias

The Surgery Process → Kidney Recipient

• Adequate ______________ should be performed within __ hours prior to surgery as needed to control serum ___________ to prevent cardiac _________

open, iliac fossa, renal, external iliac, renal, external iliac, mucosa, 2

The Surgery Process

• Recipient: _____ abdominal surgery

• Kidney allograft is placed in recipient’s ________ ______ using retroperitoneal approach

• Anastomosis is made between donor ______ artery and recipient __________ ________ artery and donor ______ vein to recipient ________ _______ vein

• Anastomosis of donor ureter to the recipient bladder ________

• The kidney allograft starts to produce urine immediately after anastomosis

• Serum Cr should start to fall as allograft starts functioning, typically within _ weeks (can be as longa s 6 weeks though)

ischemia, diuresis, sodium, potassium, water, biopsy

The Surgery Process → Initial Issues

• Some degree of acute tubular injury due to ________ → Post-operative _________

• Large amounts of ________, ___________, and ______ may be lost post-op, requires close monitoring

• If slow urine recovery → allograft ________

immunosuppressive, steroids, antimetabolites

The Surgery Process

• _____________________ therapy, maintenance _________, and _____________ start on day of surgery

corticosteroids, thymoglobulins, IL2

The Surgery Process → Induction Meds

• _______________

• _______________

• ___ receptor antagonists (Basilizimab, Daclizumab)

corticosteroids, calcineurin, metabolites, mTOR

The Surgery Process → Maintenance Meds

• ______________

• ________________ inhibitors (cyclosporine, tacrolimus)

• Anti____________ (Azathioprine, MMF)

• ____ inhibitors (sirolimus, everolimus)

function, irreversible, swelling, creatinine, volume

Management of Rejection

• Early diagnosis of rejection → preserving allograft _________ and preventing lasting _____________ damage

• Rarely shown in patient with fever, _________, and tenderness over surgery site

• Frequently shows as a bump in serum __________ ± reduction in urine _______

ultrasound, vascular, obstruction, biopsy, T, antibody

Management of Rejection

• Doppler __________: shows allograft vascular changes, urinary ___________, or presence of perirenal urine collections, blood or lymph

• Allograft ________: gold standard for diagnosis of _ cell mediated and __________ mediated rejection

T, infiltration, steroids, antibody

Management of Rejection

• _ cell mediated rejection

  • Presence of immune cell ___________ in the interstitial, tubular, or vascular compartments

• Treatment: IV high-dose _________

  • If inadequate response to steroid → need to start __________ therapy

antibody, endothelial, complement, antibody, plasmapheresis, B, plasma

Management of Rejection

• ____________ mediated rejection

  • ____________ injury and deposition of ___________ component C4d is detected in peritubular capillaries

  • Detection of circulating donor-specific _________ in recipient’s blood

• Treatment

  • _____________

  • IVIG

  • Anti-CD20 monoclonal antibody to target _ lymphocytes (rituximab)

  • Bortezomib to target antibody-producing _______ cells

MI, steroid, CAD, age

Complications

• Increased incidence of death from __ and stroke

  • Worse risk in DM patients, high _______ use in immunosuppression

• High prevalence of ___ and PVD

  • Worsening with increased numbers of DM patients and increased average ___ of recipients

hypertension, native, stenosis, CCB, 120-130, 70-80

Complications

• _____________:

  • ________ kidney disease

  • Rejection of transplant

  • Renal artery _________

  • Renal CNI toxicity

• Treatment: ___ have been shown to reduce long-term mortality

• Goal Range: ___-___/__-__ mmHg

cultures, viral, US, reduction

Complications

• Opportunistic Infections

  • Blood, urine, drain fluid __________

  • ______ load in plasma

  • Imaging: __ and CT

• Goals

  • Adequate source control

  • Anti-microorganism therapy

  • _________ of immunosuppression

immunosuppressive, skin, lips, lymphoproliferative, EBV, reduction, chemotherapy, rejection

Complications → Malignancy

• 5-6% increase in incidence to tumors due to ___________ therapy

  • Cancer of ____ and ____ are most common

• Post-transplant __________________ disease within first year or around years 7-10 has increased risk with solid organ transplants

  • Associated with ___, poor prognosis

• Treatment

  • _________ of immunosuppression

  • Surgery

  • Conventional _____________

  • Radiotherapy

  • Cancer immunotherapy → 30-40% increased risk of allograft __________

1, antibody, HTN, CCB

Complications → Chronic lesions of transplanted kidney

• Chronic renal transplant dysfunction, typically starting _ year post-transplant

  • Chronic active _________-mediated rejection

  • Recurrent glomerular disease

  • ___

  • CNI nephrotoxicity

  • Secondary focal glomerulosclerosis

  • Combination of these pathophysiologies

• Control of systemic and intrarenal hypertension with ___ has been shown to slow rate of progression of dysfunction

parathyroid, parathyroidectomy, phosphorus

Complications → Hypercalcemia

• Potential indication of failure of hyperplastic __________ glands to regress

• May require subtotal _______________

• Incidence has improved with better management of calcium and __________ metabolism during chronic dialysis

bone marrow, steroids, B, B, HCV

Complications

• Anemia

  • ____ _______-suppressant meds

  • GI bleeding from long-term high dose ________

• Chronic Hepatitis

  • Hep _, higher risk if previously Hep _ surface antigen (+)

  • Due to immunosuppression

  • Direct-acting ___ antiviral meds have reduced this risk