1. Transplant 101

2.  Carol Broughton, RN, CCTC  Nancy Dawson, RN  Rhonda Jairam, RN, CCTC  Isaac Payne, RN  Lori Tummonds, RN, CCTC Transplant Nurse Coordinators

3. Transplant Team  Transplant Surgeons - Thomas Johnston, Dinesh Ranjan, Hoonbae Jeon, Roberto Gedaly  Transplant Nephrologists - Wade McKeown and Thomas Waid  Transplant Pharmacist - Tim Clifford  Social Workers - Mindy Murphy and Molly Patchell  Financial Counselors - Marybeth Henry and Angela Hernandez  Clinic Staff - Erica Lynch, Lisa Collett, Aimee Bishop, Marva Paris, and Amy Wright  Scheduling Coordinator - Mike Pelfrey

4.  AST = American Society of Transplantation  BMI = body mass index  CBC = complete blood count  CKD = chronic kidney disease  CMS = Centers for Medicare and Medicaid Services  CMV = cytomegalovirus  EBV = Epsein-Barr virus Acronyms and Abbreviations

5.  Transplant as treatment for ESRD  The pretransplant evaluation  Deciding on a donor Deceased Deceased Living Living  The referring nephrologist can be responsible for coordinating some of the pretransplant care Point person in coordinating care with transplant center, specialists (eg, cardiology) Point person in coordinating care with transplant center, specialists (eg, cardiology) Transplant 101: Overview

6. Recipient Evaluation Process

7. Adapted with permission from Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-95. Referred for transplant Initial information session Still a candidate? Potential barrier? Proceed with evaluation Evaluate Barrier removed? Dialysis when indicated No Yes No YesNo Kidney Transplant Evaluation Process

8.  Active malignancy or metastatic cancer Immunosuppression can enable tumor growth Immunosuppression can enable tumor growth  Cirrhosis  Severe myocardial dysfunction or peripheral vascular disease Unless due to potentially reversible ischemia, which should be corrected prior to transplant Unless due to potentially reversible ischemia, which should be corrected prior to transplant  Other severe, irreversible extrarenal disease  Active mental illness If patient cannot give informed consent or comply with drug regimens If patient cannot give informed consent or comply with drug regimens Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-15. Contraindications to Transplantation

9.  Chronic infection or untreated current infection  Irreversible limited rehabilitative potential  Persistent nonadherence to treatment  Active substance abuse Must be treated prior to transplant; drug screening may be required as proof of drug-free status Must be treated prior to transplant; drug screening may be required as proof of drug-free status  Primary oxalosis Unless combined liver/kidney transplant is an option Unless combined liver/kidney transplant is an option Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-15. Contraindications to Transplantation

10. Suggested malignancy wait time  Prostate – 2 years  Liver – Transplant not recommended with liver transplant  Multiple myeloma – Transplant not recommended  Lymphoma – 2 to 5 years  Leukemia – 2 years  Malignant melanoma – 5 years  In situ or superficial melanoma – 2 years  Squamous cell carcinoma – Surveillance  Basal cell carcinoma – None  Cervical/uterine – 2 to 5 years

11. Suggested malignancy wait time  Testicular – 2 years  Kaposi’s sarcoma – 2 years; second transplant contra-indicated  Breast cancer – 2 to 5 years  Lung cancer – 2 years  Bladder cancer – 2 years, In situ – None  Renal cell carcinoma small low-grade tumor – 2 years  Renal cell carcinoma large high-grade tumor – 5 years  Colon cancer stage 1 – 2 years  Colon cancer stage 2 or higher – 5 years

12. Pretransplant Recipient Evaluation  Full medical history and physical exam  CBC and chemistry panel  PT and PTT  Blood type  HBV and HBC serology  HIV screen  EBV  VZV  CMV test  Pelvic exam and Pap smear  Chest X-ray  ECG  HLA tissue typing and cytotoxic antibodies  VDRL screen  Lipid profile  Abdominal U/S Routine tests Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-95.

13. Pretransplant Recipient Evaluation  Voiding cystourethrogram  Pharmacologic or exercise stress test  Noninvasive vascular study  Barium enema and lower endoscopy  PSA test  Pap smear  Mammogram  Coronary angiogram  ECG Elective tests Siddqi N, et al. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 2005:169-192.

14.  When a living donor cannot be identified  Wait can exceed 2 years for blood types O and B  Administered by UNOS Patient can be listed when GFR <20 mL/min Patient can be listed when GFR <20 mL/min Transplant center will list the patient after evaluation Transplant center will list the patient after evaluation  Patients should ask the transplant center if their names are on the list Waiting List for a Deceased-Donor Kidney

15. Accruing Points on the UNOS List Points are awarded in accordance with this formula:  Time on waiting list  Quality of antigen mismatch—HLA-DR antigens only (no points for HLA-A or HLA-B matches)  PRA—points are assigned if PRA level is >80% with a negative preliminary donor/patient crossmatch  Pediatric patients (age <18) awarded additional points  Donation status—individuals who have donated a vital organ in the US receive preference  Medical urgency NOT a factor in points system except by local agreement United Network for Organ Sharing. Available at: http://www.unos.org.

16.  During wait for a deceased-donor, routine medical evaluations should be conducted Social worker Social worker Surgeon Surgeon Vascular studies Vascular studies Cancer screening Cancer screening Pap smears and mammograms for womenPap smears and mammograms for women Digital rectal exam or PSA test for menDigital rectal exam or PSA test for men Cardiovascular examination as indicated Cardiovascular examination as indicated  The community nephrologist should advise the transplant center of changes in health that preclude transplantation  Patients who require medical intervention may remain on the UNOS list, but do not accrue “time of waiting” points Interim Medical Examinations

17. Living Donor Kidney Transplant Evaluation

18. Living and Deceased Kidney Donors, 1993-2002 2003 Annual Report of the United States OPTN/SRTR: Transplant Data 1993-2002.  Trend is toward living donation  Driven by longer waiting times  Can use donor that is not a close blood relative

19. Advantages and Disadvantages of Living- Donor Transplantation AdvantagesDisadvantages  Preemptive transplant option  Can select donor for haplotype match, age  Better outcomes  Minimal delayed graft function  No wait for deceased-donor kidney  Can time transplant for convenience  Immunosuppressive regimen may be less aggressive  Emotional gain to donor  Psychological stress to donor  Complete donor evaluation process  Operative donor mortality (~1/3000 patients)  Major complications (0.2%-2%)  Minor complications  Potential donor hypertension, proteinuria  Risk of trauma to remaining kidney  Risk of unrecognized covert renal disease Kendrick E, et al. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 2005:135-168.

20.  Donor’s risk must be considered separately from recipient’s need for transplant  Donor must be informed of the risks  ABO blood-type compatibility, tissue type, and crossmatch are initial screening steps  With multiple suitable donors, the transplant center will help determine the best donor Family to be included in this decision Family to be included in this decision For a younger recipient who may require a second transplant, a parent may be selected over a sibling, whose kidney may be needed in the future For a younger recipient who may require a second transplant, a parent may be selected over a sibling, whose kidney may be needed in the future Living Donor Evaluation

21.  Medical history and physical exam  Comprehensive lab screening Blood count/chemistry panel Blood count/chemistry panel HBV, HCV, HIV, and CMV tests HBV, HCV, HIV, and CMV tests Fasting glucose Fasting glucose  Urinalysis Spot urine for protein and creatinine ratio Spot urine for protein and creatinine ratio  Cardiovascular workup Chest X-ray Chest X-ray ECG ECG  Helical CT urogram  Psychosocial evaluation  Repeat crossmatch before transplant

22. Contraindications to Kidney Donation  Age 60-65 years 60-65 years  Hypertension >140/90 mm Hg or need for medication >140/90 mm Hg or need for medication May need 24-hour blood pressure monitor May need 24-hour blood pressure monitor  Diabetes  Proteinuria >250 mg/24 hours >250 mg/24 hours  GFR <80 mL/min by MDRD  Microscopic hematuria  Multiple renal vessels  Significant medical illness  History of thrombosis or thromboembolism  Strong family history of renal disease, diabetes, or hypertension  Psychiatric conditions or substance abuse  Pregnancy Kasiske BL, et al. J Am Soc Nephrol. 1996;7:2288-2313.

23. Donor/Recipient Matching  Three factors are involved in tissue matching and antibody production Human leukocyte antigen (HLA) antibodies Human leukocyte antigen (HLA) antibodies Crossmatch Crossmatch Panel-reactive antibody (PRA) Panel-reactive antibody (PRA)

24. HLA Matching  Three groups of HLA proteins: HLA-A HLA-A HLA-B HLA-B HLA-DR HLA-DR  One HLA in each group (haplotype) is inherited from each parent Example: Mother = A1, A2, B8, B44, DR3,4 Father = A3, A10, B7, B55, DR11,15 Child = A2, A10, B7, B44, DR4,15

25. Crossmatch  Crossmatch tests whether the recipient has antibodies to the potential donor Negative crossmatch is desired Negative crossmatch is desired Positive crossmatch increases risk of rejection Positive crossmatch increases risk of rejection Antibodies can develop, so repeat crossmatch testing is required immediately before transplant Antibodies can develop, so repeat crossmatch testing is required immediately before transplant

26. Panel-Reactive Antibody (PRA)  PRA is the amount of HLA antibody present in the recipient’s serum (expressed as a percentage) Determined by testing the recipient’s serum against a panel of cells from 60 people with different HLA proteins Determined by testing the recipient’s serum against a panel of cells from 60 people with different HLA proteins HLA antibodies can change, especially in response to blood transfusion, prior transplant, or pregnancy HLA antibodies can change, especially in response to blood transfusion, prior transplant, or pregnancy Higher % PRA makes finding a donor more difficult Higher % PRA makes finding a donor more difficult

27. Laparoscopic Nephrectomy  Advantages Less postoperative pain Less postoperative pain Minimal surgical scarring Minimal surgical scarring Rapid return to work (~4 weeks) Rapid return to work (~4 weeks) Shorter hospital stay Shorter hospital stay Magnified view of renal vessels Magnified view of renal vessels  Disadvantages Impaired early graft function Pneumoperitoneum may compromise renal blood flow Longer operative time Tendency to have shorter renal vessels and multiple arteries Kendrick E, et al. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 2005:135-168.

28. Discharge

29. After surgery, return to Transplant wing (8 East) After surgery, return to Transplant wing (8 East) Incision will be closed with staples Incision will be closed with staples May have small drain placed in the incision called a “Jackson- Pratt” drain May have small drain placed in the incision called a “Jackson- Pratt” drain Will have catheter in bladder a few days Will have catheter in bladder a few days Post-Operative Care

30. (continued) Will be out of bed walking in room and hallway in first 24 hours Will be out of bed walking in room and hallway in first 24 hours Discharge information will be reviewed with you frequently by your floor nurse and Transplant nurse coordinator Discharge information will be reviewed with you frequently by your floor nurse and Transplant nurse coordinator Written discharge information and instructions will be provided to take home with you Written discharge information and instructions will be provided to take home with you Much emphasis will be placed on teaching you your medications, their doses, and their purpose. A medicine list will be provided. Much emphasis will be placed on teaching you your medications, their doses, and their purpose. A medicine list will be provided. Post-Operative Care

31. (continued) Discharge topics that will be discussed include signs and symptoms of rejection, dietary and activity guidelines, and clinic routine. Discharge topics that will be discussed include signs and symptoms of rejection, dietary and activity guidelines, and clinic routine. Average length of stay is 4-10 days Average length of stay is 4-10 days May return home at discharge May return home at discharge Clinic appointments are twice a week for 4-6 weeks Clinic appointments are twice a week for 4-6 weeks Once a week for 4-6 weeks Every other week for 4-6 weeks Post-Operative Care

32. (continued) Approximately 3 months after discharge, you will be referred to primary care doctor or nephrologist. Will alternate visits a few times between local doctor and us, and then most of follow-up will be with referring or primary care physician. Approximately 3 months after discharge, you will be referred to primary care doctor or nephrologist. Will alternate visits a few times between local doctor and us, and then most of follow-up will be with referring or primary care physician. Post-Operative Care

33.  Home Medication Review  Inpatient medication recommendations  Coordinate with nurses and social worker for discharge medications  Availability in hospital and clinic  Involved pre- and post-transplant  Facilitate education Pharmacist

34.  Medications After Transplant Anti-rejection drugs Anti-rejection drugs Prograf (tacrolimus)Prograf (tacrolimus) Cellcept (mycophenolate mofetil)Cellcept (mycophenolate mofetil) PrednisonePrednisone Anti-infective drugs Anti-infective drugs Take all medications as prescribed Take all medications as prescribed Pharmacist

35. 1. Call with any insurance changes. 2. Call with any changes in employment of you or your spouse if it will affect your insurance coverage. 3. If you are in the process of obtaining Medicaid please notify us for further assistance. 4. Insurance benefits are monitored every month by our office. 5. Approval for transplant will be obtained through our office. Financial Counselor

36. Social Worker  Support System / Caregiver  Substance Abuse Policy  Insurance / Medication Coverage Post- Transplant  Transportation

37. For More Information  UK Transplant Center (859) 323-6544http://www.mc.uky.edu/transplant http://www.mc.uky.edu/transplant  Kentucky Organ Donor Affiliates (KODA) (800) 525-3456http://www.kyorgandonor.org http://www.kyorgandonor.org  National Kidney Foundation (800) 622-9010 http://www.kidney.org http://www.kidney.org

38. For More Information  Transplant Patient Partnering Program (800) 893-1995http://www.tppp.net http://www.tppp.net  National Foundation for Transplants (800) 489-3863http://www.transplants.org http://www.transplants.org  United Network for Organ Sharing (UNOS) (888) 894-6361http://www.unos.org http://www.unos.org

39.  Relatively unrestricted diet  Freedom to travel  Ability to become pregnant and bear children  Can engage in training for athletic competition  Lifestyle free of dialysis constraints Transplant-Related Quality-of-Life Benefits

40. Questions?