N16- Renal transplantation and CKD

What are the treatment choices in CKD stage 5

What are renal replacement therapies

• kidney transplant

• haemodialysis

• peritoneal dialysis

What is the indication of kidney transplantation

• CKD if eGFR <20ml

• best results with transplantation without starting dialysis

• limit of eGFR for getting on waiting list

What are the absolute contraindications of transplantation

• active malignant disease

  • if sustained disease free state cannot be reached

• instable, irreversible CV disease

  • severe, irreversible- peripheral atherosclerosis

  • “ “ coronary vascular disease

  • “ “ progresive vitium

  • “ “ instable cardiac failure, high pulmonary artery BP

• decompenssated hepatic cirrhosis

  • simultaneous transplant should be considered

• severe irreversible respiratory failure

• psychosocial instability

• if temporary contraindication becomes sustained

• if expected survival <2years

What are relativve contraindications of transplant

• ABO incompatibility- in Hungary

• severe obesity BMI>40- relative if BMI >35

• optimal age:<75

• HIV seropositivity is not a contraindication if HAART successful

Temporary contraindications of transplantation

• surgical/ technical cause

  • arterial occlusion, stenosis, urological malformation or disorder

• increased peri and early postoperative risk

  • MI, stroke

• increased risk of immunosupression

  • infections, malignancies

• if an active disease is directly harmful for kidney graft

  • immunologiclaly active recurring GN

What are the types of donors

• living

• dead

What are the types of living donors

• Living unrelated

  • emotional relative- spouse, mate, friend

• Living related

What are the types of deceased donors

• heart beating donor

  • donation after brain death

• non heart beating donot

  • donation after circulatory death

What do you need to check before transplantation

• screen for malignancy

  • (chest Xray, abdomen US, gyne/uro evaluation, mammography, repeated faecal occult blood negativity)

• infections

  • (viral HEP, HIV, EBV, CMV, VZV, toxoplasma, treponema)

• otolaryngology and dental check-up

• artery check-ups, atherosclerosis, ECG

• surgical and anaesthetic consultation,

• HLA status

What are the donor organ allocations- conditions

• negative crossmatch

  • no antibody in recipient’s serum against donor HLA antigens

• blood group compatibility

• other factors

  • HLA match

  • urgency, level of immunisation, waiting time

What are the advantages of living kidney donation for the recipient

• better graft survival vs deceased after 1 year

• “half life” of kidney is better 20 vs 13 years

• no need for dialysis in the postop period due to immediate kidney function

• shorter waiting time, preemptive transplantation

What are the advantages of living kidney donation for the donor

• surgically safer, quick healing

• donor discharge after 4 days

• after 4 weeks they live their normal life

Who can be a living donor?

• competent adult with disposing capacity (no children)

• near genetic relatives

• emotional relatives (after approval by ethics committee)

• adequate function of both kidneys

• donor can revoke consent at any time

What is the location of transplantation

Heterotopic- iliacal fossa, extraperitoneal

What are the possible anastomoses of grafts

• common iliac artery + vein

• external iliac artery + vein

• internal iliac artery + vein

• ureter: neoimplantation or end-to-end anastomoses

What are the complciations in early postoperative period- 2 weeks

• delayed graft function

• surgical

  • arterial, venal- technical failure

  • ureter- leakage,- reanastomosis

  • wound healing

  • peri graft fluid, lymphocele

• immunonlogical

  • acute infection, T cell or/ and antibody mediated

• infections

  • respiratory, urinary tract

When is the follow up after Tx

What is the alloreactive immune response

• innate immunity

  • ischemic reperfusion injury at the time of resuming circulation

• adaptive immunity

  • cell mediated- T cell mediated rejection

  • antibody mediated rejection

What is the induction therapy

• IL2R antibody monoclonal

  • Basiliximab

• Anti CD52 monoclonal antibody

  • Alemtuzumab

• anti thymocyte polyclonal antibody immunoglobulines

  • thymoglobulin

  • ATG fresenius- grafalon

What is the maintenance immunosuppression

• steroids

  • prednisolone, methylprednisolone

• calcineurin inhibitors- CNI

  • cyclosporin, tacrolimus

• proliferation inhibitors mTOR

  • everolimus, sirolimus

• lymphocyte proliferation inhibitors

  • selective- mycophenolate- mofetil, Na

  • non selectiev- Azothioprine

What is the combination maintenance immunosuppression

• be careful for CAVE rug interactions

• without steroids only 15-20%

• CNI + mycophenolate

• CNI + mTOR

• mycophenolate + mTOR

  • CAVE- myelosuppression, anaemia, GI SE

• azothioprine

  • CAVE- allopurinol

What are the side effects of immunosuppressants

What are the renal consequences of transplantation

• rejection

• surgical complications

• DGF

• baseline disease relapse

• de novo kidney disease

• nephrolithiasis

• graft failure

What are the extrarenal consequences of transplantation

• HT

• glucose metabolic disturbances

• lipid abnormalities

• CV disease

• haematological complications

  • post transplant lymphoproliferative disorder

• bone disorders

• infections

• tumours

• psychological, psychiatric disorders

What are the types of non transplant related predictors of long term outcome

• traditional

• non tranditiona

What are the traditional non transplant related predictors of long term outcome

• age, gender, ethnicity

• BMI

• ESRD cause

• ESRD tratment, duration

• comorbidities

  • diabetes

  • HT

  • dyslipidemia

  • smoking habits

  • CV

What are the non traditional non transplant related predictors of long term outcome

• graft function- GFR

• proteinuria

• anaemia

• Ca-P metbaolic disturbances

  • FGF23, PTH, Vit D

• malnutrition inflammation complex syndrome

• ADMA

• homocystein

• angiopoietin 2

• depression, mood disorders

• OSAS

What are the transplant related predictors of long term outcome

• donor, allocation and surgical consequences

• native and adaptive immunity

  • delayed graft function

  • rejection

• methods for preserving graft function and their consequences

  • immunosuppression- efficiency vs toxicity, infections, malignancies

  • immunological tolerance

What are the avantages of transplantation

• QoL is better

• life expectancy is double

• shorter dialysis the better outcome

• living kidney is best

• cost benefit