1. Transplantation “the art of the do-over”

2. Objectives Understand Identify Review
Understand the kidney transplant recipient selection process.
Identify
Identify donor and recipient factors that lead to successful transplant outcomes.
Review
Review standard transplant immunosuppression regimens.

8. Quantity or Quality
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9. Benefits of Kidney Transplantation
Longer Life
Improved Quality of Life
No Dialysis

10. Risks of Transplantation
Surgery
Bleeding
Urinary leak
Death
Debility
Anesthesia
Urine retention
Lymphocele
DVT
Pneumonia
Acute myocardial infarction
Immunosuppression
Opportunistic infections
Malignancy
Diabetes
Gout
Diarrhea
Insomnia
Tremor
Hypertension
Alopecia
Hypomagnesemia or hyperkalemia

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12. T cells
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13. HLA Proteins
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15. Lymphoid Organs
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18. Maintenance Immunosuppression
Tacrolimus (Prograf) – diabetes, hypertension, insomnia, tremor, diarrhea
Mycophenolate (Myfortic or Cellcept) – diarrhea, fatigue, bloating
Prednisone – fluid retention, weight gain, acne, fat redistribution, bruising

19. Drugs that raise CNI levels

20. Drugs that lower CNI levels

21. Calcineurin Inhibitor
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24. Donor Types Neurologic death criteria Cardiac death criteria Living
Deceased
Neurologic death criteria
Cardiac death criteria

26. Donor Factors POSITIVE OUTCOMES NEGATIVE OUTCOMES Younger age
Older age
Greater HLA match with recipient
HLA mismatched with recipient
Higher GFR
Lower GFR
Absence of diabetes or hypertension
Presence of diabetes or hypertension
Neurologic death
Cardiac death
Less ischemic
More ischemia

29. Post-Transplant Phase
Pre-Transplant Phase
Transplant Phase
Post-Transplant Phase

30. Transplant Candidate Evaluation
Multidisciplinary Team evaluation (Surgeon, Physican, Coordinator, Social Worker, Pharmacist, Dietitian, Independent Donor Advocate for donors)
Presented and approved at SELECTION COMMITTEE
Three outcomes – (a) UNOS listed, (b) sent back for further evaluation, (c) denied and given alternate referral options
Waitlist management – education and maintenance of health
Additional consents – (a) PHS elevated risk; (b) high KDPI donor

31. Recipient Factors POSITIVE OUTCOMES NEGATIVE OUTCOMES Older age
Younger age
Greater HLA match with recipient
HLA mismatched with recipient
Ideal BMI or non-diabetic
Under or 0verweight or diabetes
Good fitness
Poor fitness
Less sensitized
Highly sensitized
Disease with lower risk of recurrence
Disease with higher risk of recurrence

32. 1. Advanced kidney disease: Regulations for listing for transplantation state that candidates must either be on dialysis or have near loss of kidney function with a creatinine clearance < 20cc/min (normal is >80).
2. Adequate urinary tract:
3. Acceptable cardiovascular function: Contraindications to transplantation include significant un-correctible coronary artery disease and/or poor cardiac pump function.
4.  Acceptable vascular system:
5. Acceptable lung function: Smokers may be declined until they are able to quit (based on age and medical history).
6. Acceptable liver function: 
7. Active significant fungal or bacterial infection is a contraindication to transplantation.
8. Cancer screening:  Appropriate for age tests will be necessary including colonoscopy (age>50yo), prostatic specific antigen, etc.
9. Obesity:  Candidates must have a body mass index (BMI, weight/body surface area) of <38.
10. Functional status: Candidates must be able to walk short distances and perform activities of daily living without assistance.
11. Psychosocial status:  Candidates must be motivated, have demonstrated compliance with medical and dialysis regimens, not suffer from psychosis, live in a stable environment, capable of supporting compliance with the transplant regimen including transportation, and not be an active substance abuser, (+/- cannabis)
12. Financial considerations:

33. Transplant Phase Starts with donor offer – local donor vs import
Transplant center reviews the HLA match run and calls their potential recipients – each kidney has a primary candidate and backup candidate
Either admit potential recipient or have them provide blood for a final crossmatch
Medical suitability and final clearance
Dialysis coordination if necessary
Schedule surgery – time of day, cold ischemic time, surgeon “freshness”

37. Post-Transplant Phase
Conduct frequent lab tests and office visits
Review side effects of medication
Evaluate surgical healing and remove staples, tubes, and stent
Balance immune suppression medication
Screen for infection
Address psychological concerns

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42. Questions?