Organ transplantation (kidney, pancreas)

Organ Transplantation

  • Presenter: Péter Szakály MD, PhD, Med. Habil

  • Affiliation: Universitas

  • Title: Associate Professor at Quinque

Problems of Transplantation

  • Organ Shortage:

    • Insufficient suitable organs due to factors such as:

      • Improved stroke prevention

      • Changes in head injury treatment

      • Advances in emergency and intensive care

      • Enhanced traffic safety from better cars

  • Immunosuppressive Therapy Limitations:

    • Not specific; challenges in managing recipient health.

  • Aging Population:

    • Average life expectancy is increasing, leading to older recipients and donors each year.

Kidney Transplantation Trends in the USA

  • Current Statistics:

    • Total patients: 120,000

    • Increase of +40,000 over 5 years

    • Increase of +20,000 over 11 years

  • Waiting List Trends:

    • Significant rise in kidney transplant candidates from 1998 to 2018.

Age Groups on the Waiting List

  • Age Distribution Changes Over Time (1998-2017):

    • Increasing percentages of older age groups:

      • Age 18-34 decreased

      • Age 35-49 stable

      • Age 50-64 and 65+ increased significantly.

Indications for Kidney Transplantation

  • Eligibility Criteria:

    • All end-stage kidney disease patients are suitable for transplantation unless there are contraindications.

      • Contraindications may include active infections, certain malignancies, or significant comorbidities that could impair the surgical outcome. Additionally, psychosocial factors such as non-compliance with medical regimens may also impact eligibility.

  • Common End-Stage Kidney Diseases:

    • Glomerulonephritis

    • Pyelonephritis

    • Diabetic nephropathy

    • Polycystic kidney disease

    • Hypertensive nephropathy

Transplantation Timing and Process

  • Initial Consultation:

    • Meeting with transplant surgeon before initiating dialysis.

  • Deceased Donor Transplantation Factors:

    • Allocation based on:

      • Blood type

      • HLA matching

      • Waiting time

      • Urgency (e.g., emergencies)

  • Waiting Time Variability:

    • Ranges from 0 months to 15 years, often influenced by luck.

Living Donor Kidney Transplantation

  • Advantages:

    • No waiting list; best short and long-term results.

    • Optimal timing for all parties involved (donor, recipient, surgeon).

    • Acceptably low risk for donors.

  • Surgical Techniques:

    • Open nephrectomy

    • Laparoscopic nephrectomy

      • Pure laparoscopic nephrectomy

      • Hand-assisted laparoscopic nephrectomy

Preoperative Preparation for living donor transplantation

  • Assessment Requirements:

    • Sufficient time for comprehensive medical evaluation.

    • Evaluation of donor's suitability and potential abnormalities in kidneys.

      • seen with CT angiography

Techniques of Laparoscopic Donor Nephrectomy

  • Preferred Technique:

    • Hand-assisted technique due to its safety and efficiency.

  • Incision Requirement:

    • Requires a small incision for kidney removal.

Organ Preservation Methods

  • Types:

    • Cold storage (common)

    • Pulsatile preservation (expensive)

  • Preservation Objectives:

    • Maintain cellular viability and minimize ex vivo ischemic injury.

    • Functions include washing out blood, cooling down organs, and equalizing the intra- and extracellular environment.

Ischemic Times

  • Warm Ischemic Time (WIT):

    • Duration without perfusion and storage, critical for kidney survival.

    • Acceptable up to 60 minutes; risk increases significantly after 20 minutes.

    • Only normal in cases of living donation, usually it is 0

  • Cold Ischemic Time (CIT):

    • Covers perfusion and storage periods; ideally less than 18 hours, however up to 24 hrs is acceptable

    • Different acceptable CIT for different organs

Techniques of Kidney Transplantation

  • Surgical Approach:

    • Retroperitoneal approach is highlighted for ease in accessing the transplanted kidney.

    • Vascular anastomosis conducted with iliac vessels.

  • Native Kidney Removal:

    • Decided case-by-case depending on the patient's condition.

  • Back table preparation of kidney

    • part of CIT

    • make the kidney ready for transplantation

Acute Rejection Post-Transplantation

  • Symptoms and Severity:

    • Symptoms can include malaise, decreased urine output, fever, and kidney tenderness.

    • Can be asymptomatic due to effective maintenance therapy.

    • every patients gets it

  • Management:

    • Regular immunosuppressive medication, hydration, and prompt assessment in transplant centers.

Prevention and Therapy

  • Common Practices:

    • Regular monitoring and quick response to signs of rejection can lead to successful management in over 90% of cases.

Future Considerations in Kidney Transplantation

  • Potential Complications:

    • Cardiovascular disease, infections, malignancy, and renal failure.

  • Long-Term Management Goals:

    • Focus on quality of life and minimizing complications associated with transplantation.

Diabetes and Transplantation

  • Rising Incidence:

    • Increased number of diabetes patients seeking transplants and associated complications.

    • Significant impact on treatment outcomes for kidney disease.