6Kidney Transplant - Advantages What are the benefits of a kidney transplant?Quality of Life:normal lifeNo dialysisBack to work, holiday etc.Food and fluid intake less restrictedImproved sexual function and fertilityImproved Medical Outcome:Increased longevity in the majority of patients
7Short Term Risks of Transplantation Anaesthesia and surgical complications:including infection (wound, pneumonia, urine infections),bleeding,clots in the legs and lungs.deathDonors 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.
8Risks of Transplantation Complications from the anti-rejection medicationsInfections 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 cancersDiabetesHigh blood pressureHigh cholesterol and other lipidsOsteoporosisSpecific side-effects of each anti-rejection medication
9Kidney Transplant – Other considerations Hospital stay is usually about 1 week but complications can lead to a longer stay or coming back into hospitalDelayed Graft Function : You may need dialysis for a while until your kidney starts to workRejectionInfectionTechnical Problems with Surgery at the blood vessel or the bladder endFrequent visits to clinic, frequent blood tests.It may take some time before you feel the benefits.
10Ongoing 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 shortageIncreasing Live Donor TransplantationTransplantation of patients with “positive cross-match”ABO incompatible transplantationPaired exchangeSignificant changes to anti-rejection therapy
11Types of Transplants Deceased Donor Transplants Live Donor Related (genetic)Unrelated (“emotionally”)OtherLive Non-directed donationPaired Exchange
12Number and Duration of Functioning Grafts Australia 2005 All Functioning Grafts (6,269)
14How 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 hospitalReceives referrals from Intensive Care Units who believe they may have a potential donorAttends the referring hospital to assist in organising the donation
15The Donor Transplant Coordinator Communicates with the coroner, the donor’s family, and the staff caring for the patientEnsures all the legal requirements have been metOversees the retrieval processAssists in theatre
16The Donor Transplant Coordinator Responsible for allocation of the donated kidneys according to the results of the tissue typingFollow up communication with the donor’s family and the staff involved with the donoradvising them of the results of the transplant operationsForwards thankyou letters/cards to the donor family from the transplant recipients
17Who is eligible for a transplant? For people who areNear dialysis or dialysis dependentMedically & Surgically FitTransplant is NOT a suitable treatment for everyone
18AgeIt’s not the age in years that count but how worn your body is or how many other disease you have.
19The Transplant ListThere is only ONE Transplant List which is the “Active Transplant List” – ready to be called for transplantationInterim Patients under consideration or temporarily off the Active List do NOT appear on the active transplant list
20Transplant Waiting List Requirements 2nd Monthly blood test for antibodiesYearly Transplant ReviewReview recipients due to increasing waiting timeMedical & Surgical fitnessEducation Seminar every 2 yearsUpdate on new developmentsUpdate on Risks/Benefits of Transplantation
21Transplant “Work Up”Transplant Doctor & Transplant Nurse in Transplant Outpatient ClinicDetailed History and ExaminationBlood testsX raysHeart TestsCheck up by Transplant SurgeonReferrals to other specialists as needed- Cardiac, Gastroenterology, Dermatology, Liver, Psychiatrists, Vascular Surgeons
22Tissue Typing and Cytotoxic antibodies Tissue typing identifies Transplantation or Tissue antigensMust be completed before acceptance onto the transplant listCytotoxic Antibodies (antibody to “Transplantation or Tissue” antigen)Monthly testPatient removed from the transplant list if blood is not received regularly
24Living Donor Transplants Who can donate?Parents, brothers, sisters, cousins, husbands, wives, friends.
25Live 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
26Individuals who may be excluded for living donation Age – the elderlyWomen who have not completed childbearing: preferably not usedDiabetes – complete contraindicationObesity/overweightRenal disease complete contraindicationAbnormal GFR (The volume of urine filtered by the kidney over a set time)Protein in the urineKidney stonesKidney surgeryRefluxHigh Blood PressureBlood in the urineHeart diseaseLung diseaseCancerInfectionInability to give consentThe donation must not be coerced and must be truly altruistic.
27Live Kidney Donor Workup Blood testsUrine tests: to check for blood and proteinSpecial Kidney XraysUltrasound of kidneys and urinary tractRenal ScanCT AngiogramReview by Transplant Surgeon, Psychiatrist and Independent Renal Physician
30Maximising Survival of the kidney Factors that we watch for, which may contribute to poor function:Kidney Rejection (Early and Late)Drug ToxicityProteinuriaPoorly controlled blood pressureBK virus infection
31Post Transplant Complications InfectionPCP pneumonia: Bactrim 3 times weekly or nebulised pentamadine for 6 moCMV: anti-viral treatment depending on exposure status of donor and recipientRecurrence of kidney diseaseDiabetic nephropathyGlomerulonephritis (Primary or Secondary)Cardiovascular diseaseDiabetes (prednisolone, tacrolimus)Cancer: Screening, Dermatology reviewOsteoporosis: 2 yearly DEXA scan
32Other Health IssuesObesitySmokingDietIssues relating to Fertility
34Transplantation is an Excellent Treatment for End Stage Renal Failure due to Alport Syndrome
35Anti-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
36Anti-Glomerular Basement Membrane Antibody disease The glomerular basement membrane in the kidney is made of Type 4 CollagenProduction of components of type IV collagen is reduced or defective in Alport SyndromeWhen normal components are encountered in the new kidney by a recipient with Alport Syndrome, they are seen as foreign and antibodies can be formedThis leads to glomerulonephritis and graft loss
37Anti-Glomerular Basement Membrane Antibody disease Men with deafness and kidney failure before 30 years of age are more susceptibleCOL4A5 deletions (The gene encoding α5 chain of Type IV collagen) are associated with higher riskHowever studies generally find the risk of anti-GBM nephritis is still less than predictedPlasma exchange, cyclophosphamide and more recently rituximab are treatment optionsDifficult to treat
38Anti-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 systemImmune cells do not react against the kidney transplant
39Use 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 sons3/6 new high blood pressure2/6 new protein in the urine4/6 decline in kidney function (but kidney function still about 40% or more of normal)
40Use of Alport ‘Carriers’ with isolated microscopic haematuria as Renal Donors Significant risk ofNew Onset ProteinuriaNew Onset HypertensionDecline in Renal functionHEARING LOSS, PROTEINURIA, HYPERTENSION, OR KIDNEY FAILURE PRIOR TO DONATION ARE ABSOLUTE CONTRAINDICATIONS
41Use of Alport ‘Carriers’ with isolated microscopic haematuria as Renal Donors Should be a rare eventClose follow up is requiredDonors should be given ACE inhibitors (which reduce protein leak into the urine as well as blood pressure)