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

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Presentation on theme: "Introduction to Kidney Transplantation Dr Natasha Cook Renal Physician, Austin Health and Northern Health September 2009."— Presentation transcript:

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

6 Kidney Transplant - Advantages What are the benefits of a kidney transplant? Quality of Life: J normal life J No dialysis J Back to work, holiday etc. J Food and fluid intake less restricted J Improved sexual function and fertility J Improved Medical Outcome: J Increased longevity in the majority of patients

7 Short Term Risks of Transplantation Anaesthesia and surgical complications: Anaesthesia and surgical complications: including infection (wound, pneumonia, urine infections), including infection (wound, pneumonia, urine infections), bleeding, bleeding, clots in the legs and lungs. clots in the legs and lungs. death 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. 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 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) 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 Cancers in general are increased in transplant recipients; especially skin cancers and lymphoid cancers Diabetes Diabetes High blood pressure High blood pressure High cholesterol and other lipids High cholesterol and other lipids Osteoporosis Osteoporosis Specific side-effects of each anti-rejection medication 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 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 Delayed Graft Function : You may need dialysis for a while until your kidney starts to work Rejection Rejection Infection Infection Technical Problems with Surgery at the blood vessel or the bladder end Technical Problems with Surgery at the blood vessel or the bladder end Frequent visits to clinic, frequent blood tests. Frequent visits to clinic, frequent blood tests. It may take some time before you feel the benefits. 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 Deceased Donor Transplants Live Donor Live Donor Related (genetic) Related (genetic) Unrelated (emotionally) Unrelated (emotionally) Other Other Live Non-directed donation Live Non-directed donation Paired Exchange 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 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 Receives referrals from Intensive Care Units who believe they may have a potential donor Attends the referring hospital to assist in organising the donation Attends the referring hospital to assist in organising the donation

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

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

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

18 Age Its not the age in years that count but how worn your body is or how many other disease you have. Its 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 2 nd Monthly blood test for antibodies 2 nd Monthly blood test for antibodies Yearly Transplant Review Yearly Transplant Review Review recipients due to increasing waiting time Review recipients due to increasing waiting time Medical & Surgical fitness Medical & Surgical fitness Education Seminar every 2 years Education Seminar every 2 years Update on new developments Update on new developments Update on Risks/Benefits of Transplantation Update on Risks/Benefits of Transplantation

21 Transplant Work Up Transplant Doctor & Transplant Nurse in Transplant Outpatient Clinic Transplant Doctor & Transplant Nurse in Transplant Outpatient Clinic Detailed History and Examination Detailed History and Examination Blood tests Blood tests X rays X rays Heart Tests Heart Tests Check up by Transplant Surgeon Check up by Transplant Surgeon Referrals to other specialists as needed- Cardiac, Gastroenterology, Dermatology, Liver, Psychiatrists, Vascular Surgeons 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 Must be completed before acceptance onto the transplant list Cytotoxic Antibodies (antibody to Transplantation or Tissue antigen) Cytotoxic Antibodies (antibody to Transplantation or Tissue antigen) Monthly test Monthly test Patient removed from the transplant list if blood is not received regularly 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? Who can donate? Parents, brothers, sisters, cousins, husbands, wives, friends. 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 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 Age – the elderly Women who have not completed childbearing: preferably not used Women who have not completed childbearing: preferably not used Diabetes – complete contraindication Diabetes – complete contraindication Obesity/overweight Obesity/overweight Renal disease complete contraindication Renal disease complete contraindication Abnormal GFR. (The volume of urine filtered by the kidney over a set time) Abnormal GFR. (The volume of urine filtered by the kidney over a set time) Protein in the urine Protein in the urine Kidney stones Kidney stones Kidney surgery Kidney surgery Reflux Reflux High Blood Pressure High Blood Pressure Blood in the urine Blood in the urine Heart disease Heart disease Lung disease Lung disease Cancer Cancer Infection Infection Inability to give consent Inability to give consent The donation must not be coerced and must be truly altruistic.

27 Live Kidney Donor Workup Blood tests Blood tests Urine tests: to check for blood and protein Urine tests: to check for blood and protein Special Kidney Xrays Special Kidney Xrays Ultrasound of kidneys and urinary tract Ultrasound of kidneys and urinary tract Renal Scan Renal Scan CT Angiogram CT Angiogram Review by Transplant Surgeon, Psychiatrist and Independent Renal Physician 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) Kidney Rejection (Early and Late) Drug Toxicity Drug Toxicity Proteinuria Proteinuria Poorly controlled blood pressure Poorly controlled blood pressure BK virus infection BK virus infection

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

32 Other Health Issues Obesity Obesity Smoking Smoking Diet Diet Issues relating to Fertility 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 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 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 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 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 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 Men with deafness and kidney failure before 30 years of age are more susceptible COL4A5 deletions (The gene encoding α 5 chain of Type IV collagen) are associated with higher risk COL4A5 deletions (The gene encoding α 5 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 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 Plasma exchange, cyclophosphamide and more recently rituximab are treatment options Difficult to treat Difficult to treat

38 Anti-Glomerular Basement Membrane Antibody Disease Bone marrow plus Kidney transplantation: Bone marrow plus Kidney transplantation: Recipients immune system is a mixture of cells from the native and donor immune system Recipients immune system is a mixture of cells from the native and donor immune system Immune cells do not react against the kidney transplant 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: One recently published study with very small numbers but follow up for 2-14 years: Gross et al NDT May 2009: Gross et al NDT May 2009: 6 Carrier mothers donating to sons 6 Carrier mothers donating to sons 3/6 new high blood pressure 3/6 new high blood pressure 2/6 new protein in the urine 2/6 new protein in the urine 4/6 decline in kidney function (but kidney function still about 40% or more of normal) 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 Significant risk of New Onset Proteinuria New Onset Proteinuria New Onset Hypertension New Onset Hypertension Decline in Renal function Decline in Renal function HEARING LOSS, PROTEINURIA, HYPERTENSION, OR KIDNEY FAILURE PRIOR TO DONATION ARE ABSOLUTE CONTRAINDICATIONS 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 Should be a rare event Close follow up is required Close follow up is required Donors should be given ACE inhibitors (which reduce protein leak into the urine as well as blood pressure) Donors should be given ACE inhibitors (which reduce protein leak into the urine as well as blood pressure)

42 Questions?


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