1. Introduction to Kidney Transplantation
Dr Natasha Cook
Renal Physician, Austin Health and Northern Health
September 2009

2. Treatment for Kidney Failure
Dialysis: Haemodialysis & Peritoneal
Transplantation

3. A kidney transplant is only one type of treatment for End Stage Renal Failure.
It is NOT a cure

4. Where does my new kidney go?

5. Where does my new kidney go?

6. 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
Improved Medical Outcome:
Increased longevity in the majority of patients

7. Short Term Risks of Transplantation
Anaesthesia and surgical complications:
including infection (wound, pneumonia, urine infections),
bleeding,
clots in the legs and lungs.
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.

8. Risks of Transplantation
Complications from the anti-rejection medications
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

9. Kidney Transplant – Other considerations
Hospital stay is usually about 1 week but complications can lead to a longer stay or coming back into hospital
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.

10. 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

11. Types of Transplants Deceased Donor Transplants Live Donor
Related (genetic)
Unrelated (“emotionally”)
Other
Live Non-directed donation
Paired Exchange

12. Number and Duration of Functioning Grafts Australia 2005
All Functioning Grafts (6,269)

13. Deceased Donor Transplants

14. How are the kidneys obtained?
The Donor Transplant Coordinator facilitates, coordinates and assists in the procurement of donor organs 24 hours a day.
Provides the link between the donor hospital and the transplant hospital
Receives referrals from Intensive Care Units who believe they may have a potential donor
Attends the referring hospital to assist in organising the donation

15. The Donor Transplant Coordinator
Communicates with the coroner, the donor’s family, and the staff caring for the patient
Ensures all the legal requirements have been met
Oversees the retrieval process
Assists in theatre

16. The Donor Transplant Coordinator
Responsible for allocation of the donated kidneys according to the results of the tissue typing
Follow up communication with the donor’s family and the staff involved with the donor
advising them of the results of the transplant operations
Forwards thankyou letters/cards to the donor family from the transplant recipients

17. Who is eligible for a transplant?
For people who are
Near dialysis or dialysis dependent
Medically & Surgically Fit
Transplant is NOT a suitable treatment for everyone

18. Age
It’s not the age in years that count but how worn your body is or how many other disease you have.

19. The Transplant List
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

20. Transplant Waiting List Requirements
2nd Monthly blood test for antibodies
Yearly Transplant Review
Review recipients due to increasing waiting time
Medical & Surgical fitness
Education Seminar every 2 years
Update on new developments
Update on Risks/Benefits of Transplantation

21. Transplant “Work Up”
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

22. 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

23. Living Donor Transplants
Donor Workup

24. Living Donor Transplants
Who can donate?
Parents, brothers, sisters, cousins, husbands, wives, friends.

25. Live Donor Transplants
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

26. Individuals who may be excluded for living donation
Age – the elderly
Women who have not completed childbearing: preferably not used
Diabetes – complete contraindication
Obesity/overweight
Renal disease complete contraindication
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.

27. 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
Review by Transplant Surgeon, Psychiatrist and Independent Renal Physician

28. Donor Nephrectomy

29. Post Transplant Follow up

30. 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

31. Post Transplant Complications
Infection
PCP pneumonia: Bactrim 3 times weekly or nebulised pentamadine for 6 mo
CMV: anti-viral treatment depending on exposure status of donor and recipient
Recurrence of kidney disease
Diabetic nephropathy
Glomerulonephritis (Primary or Secondary)
Cardiovascular disease
Diabetes (prednisolone, tacrolimus)
Cancer: Screening, Dermatology review
Osteoporosis: 2 yearly DEXA scan

32. Other Health Issues
Obesity
Smoking
Diet
Issues relating to Fertility

33. Transplantation issues in Alport Syndrome

34. Transplantation is an Excellent Treatment for End Stage Renal Failure due to Alport Syndrome

35. Anti-Glomerular Basement Membrane Antibody disease
2-3% risk of graft loss due to formation of anti-Glomerular Basement Membrane Antibodies in male transplant recipients with Alport Syndrome

36. Anti-Glomerular Basement Membrane Antibody disease
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

37. Anti-Glomerular Basement Membrane Antibody disease
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

38. Anti-Glomerular Basement Membrane Antibody Disease
Bone marrow plus Kidney transplantation:
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

39. Use of Alport ‘Carriers’ with isolated haematuria as Renal Donors
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)

40. Use of Alport ‘Carriers’ with isolated microscopic haematuria as Renal Donors
Significant risk of
New Onset Proteinuria
New Onset Hypertension
Decline in Renal function
HEARING LOSS, PROTEINURIA, HYPERTENSION, OR KIDNEY FAILURE PRIOR TO DONATION ARE ABSOLUTE CONTRAINDICATIONS

41. Use of Alport ‘Carriers’ with isolated microscopic haematuria as Renal Donors
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)

42. Questions?