Kidney & Pancreas Transplantation Ernesto Pompeo Molmenti
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1KIDNEY TRANSPLANTATION
Section 1 Overview
  • Overview of Kidney Transplantation
  • Diagnoses and Diagnostic Categories for Kidney Transplantation
Section 2 Recipient Evaluation
  • Kidney Transplant Recipient Evaluation: Outcome Based Approach
  • Sample Recipient Evaluation Form
Section 3 Pre- and Post-Transplant Medical Considerations
  • Fluids and Electrolytes
  • Cardiac Evaluation
  • Pulmonary Evaluation
  • Hematologic Evaluation
  • Gastroenterology and Hepatology Evaluation
  • Nutritional Care
  • Obesity, Metabolic Surgery and Transplantation
  • Infections
  • Oral Health Evaluation Prior to Transplant Surgery
Section 4 Donor Evaluation
  • Deceased Donor Management
  • Donor Kidney Scoring Systems
  • Deceased Donor Considerations
  • Infectious Risks Associated with Donors
  • Live Donor Evaluation
  • Psychiatric Evaluation of Live Donors
Section 5 Immunology
  • Transplant Immunology
  • Immune Risk Profiling
  • HLA and ABO Desensitization
  • Kidney Paired Donation
2 Section 6 Pharmacology
  • Pharmacology
Section 7 Anesthesia
  • Anesthesia
Section 8 Operative Techniques: Donor
  • Live Donor Nephrectomy
  • Avoiding and Managing Hazards During Live Donor Nephrectomies
  • Deceased Donor Procurement
Section 9 Operative Techniques: Recipient
  • Back Table Preparation
  • Implantation
  • Minimally Invasive Kidney Transplantation
  • Implantation—Ureteroneocystostomy Techniques
  • Implantation—Ureteroureterostomy and Ureteropyelostomy
  • Implantation—Unilateral Dual Kidney Transplantation Technique
  • Implantation—Other Variants
  • Implantation—En Bloc Kidneys
  • Implantation—Complications
Section 10 Post-Transplant Considerations
  • Postoperative Guidelines
  • Allograft Function
  • Critical Care Considerations in the Management of Renal Transplant Patients
  • Rejection
  • Recurrent Glomerular Diseases after Kidney Transplantation
  • De Novo Glomerular Diseases Post-Transplantation
  • Neurologic Evaluation
  • Vascular Complications
  • Allograft Nephrectomy
  • Urologic Complications and Fluid Collections
  • Post-Transplant Malignancies
  • Vaccinations
  • Obstetric and Gynecologic Care
Section 11 Quality Management
  • The Role of Quality Management for Monitoring and Improving: A Transplant Program
3 Section 12 Basic Science
  • Epigenetics in Transplantation
  • Ischemia Reperfusion
Section 13 Pediatric Kidney Transplantation
  • Pediatric Kidney Transplantation
Section 14 Pathology
  • Renal Transplant Pathology
Section 15 Radiology
Pre-Transplant
  • Candidate Imaging
  • Donor Evaluation
Post-Transplant
  • Collections
  • Parenchymal Imaging
  • Urologic Imaging
  • Vascular Imaging
  • Infections and Malignancies
  • Various Findings
Section 16 Cutaneous Manifestations
  • Dermatologic Manifestations of Kidney Disease4

Overview of Kidney TransplantationCHAPTER 1

Christine Sardo Molmenti,
Ernesto P Molmenti,
Madhu Bhaskaran,
Nicole Ali,
Amit Basu,
Eric Siskind,
Viren Amin, and Collaborators
 
OVERVIEW
 
Benefits of Kidney Transplantation
The main benefits of transplantation (for those who qualify for the procedure) are:
  • Improved survival
  • Improved quality of life
  • From a public health financial perspective, kidney transplantation is cost-effective when compared to chronic dialysis
 
Other Observations
  • Pre-emptive (prior to starting dialysis) transplantation provides the best outcomes
  • Risk of death is directly proportional to time on dialysis
  • As in all medical and surgical procedures, no guarantees can be provided with respect to outcomes and/or results
  • Transplant candidate: Before transplantation
  • Transplant recipient: After transplantation
 
Transplantation: A Multidisciplinary Team Approach
Transplantation entails a multidisciplinary team approach that includes but is not limited to:
  • Transplant Center Director
  • Transplant Administrator
  • Transplant Coordinator
  • Transplant Financial Coordinator
  • Transplant Independent Living Donor Advocate/Team (at institutions performing live donor transplants)
  • Transplant Nephrologist
  • Transplant Pharmacist
  • Transplant Social Worker
  • Transplant Surgeon
  • Transplant Unit Staff Nurses
  • Consulting Specialists (cardiology, infectious diseases, psychiatry, endocrinology, others)
  • Referring Physicians
 
Evaluation
Medical, surgical, psychiatric, social and financial conditions are considered when determining candidacy.
 
Waiting List
  • Once approved for transplantation, candidates are placed on a waiting list
    • Regular re-evaluations are required, especially when approaching the top
  • Being in the waiting list for a deceased donor does not guarantee transplantation
    • Events such as strokes and myocardial infarctions may disqualify candidates
 
Donors
  • Kidneys can be obtained from live or deceased donors
  • Live donor kidneys are generally associated with better outcomes than those of deceased donors
 
Facts About Live Donation
  • 6Donor safety and well-being constitute the main priority when considering live donor transplantation
  • Communications between potential donors and the transplant center should always be kept confidential (unless otherwise authorized by the donor)
 
Positive Aspects of Living Donation
  • Short waiting time
  • Elective procedure
  • Improved graft and recipient outcomes
  • Potentially improved genetic compatibility
  • Psychological benefit for donors (and recipients)
 
Risks Involved in Living Donation
  • Donor surgical, medical, psychiatric, social and financial risks
  • Complications may be short and/or long lasting
 
Blood Typing
  • Donor and recipient must be ABO identical or compatible (unless otherwise addressed prior to transplantation) (Table 1)
  • Transplantation across incompatible blood types is possible but requires intensive preparation both before and after transplantation
 
Outcomes After Transplantation
  • Graft and patient survival rates vary from center to center
  • National and transplant center-specific outcomes are publically reported
 
Complications
The benefits of kidney transplantation may be diminished or totally obliterated by potential complications associated with the transplant surgery and/or with the transplant process.
Table 1   Blood type compatibility
Recipient ABO
Compatible donor ABO
O
O
A
A, O
B
B, O
AB
AB, A, B, O
 
Transfusion of Blood Products and Transplantation of an Organ
  • Exposure to biological products (such as an organ transplant and blood products) is associated with the potential for transmission of infections (such as hepatitis B, hepatitis C, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), West Nile virus, swine flu, Chagas’ disease, rabies, malaria), malignancies (such as cancers and lymphomas), and/or other pathologies
  • Receiving blood products may lead to sensitization, adversely affect receiving future transplants
 
Biopsies
  • Routinely obtained percutaneously under local anesthesia
  • Complications include but are not limited to bleeding, injury to blood vessels, injury to abdominal organs or other structures (such as bowel or nerves), hematuria, pain, infections, urinary leaks, arterio-venous fistulas, hematomas, loss of the kidney, death, etc.
 
Delayed Kidney (graft) Function (DGF)
  • Has been reported to be associated with:
    • Increased incidence of rejection
    • Diminished graft and patient survival
    • Increased costs
    • Prolonged hospitalization
    • Increased complexity of care (including but not limited to biopsies and dialysis)
  • Occasionally, the kidney may not function at all, requiring re-transplantation
 
Immunosuppression
  • Life-long immunosuppression (unless organ failure occurs prior to death) is required
  • Immunosuppression medications can have interactions with other medications (both prescription and over-the-counter medications) as well as with herbal medications, supplements, foods and beverages
  • Prior to starting or discontinuing any medications recipients should check with their transplant centers
 
Potential Side Effects of Immunosuppression
The potential side effects of immunosuppression include but are not limited to:
  • Acne
  • Adverse reactions to prolonged sunlight
  • 7Agitation
  • Anemia
  • Anxiety
  • Arthritis
  • Cardiovascular events
  • Cataracts
  • Cough
  • Cushingoid features (“moon-face” and “buffalo hump” among others)
  • Decreased ability of the blood to clot
  • Diabetes/hyperglycemia
  • Gastrointestinal complaints
  • Gout
  • Gingival hyperplasia
  • Hair loss/thinning
  • Headaches
  • Hirsutism
  • Hypertension
  • Hypercholesterolemia
  • Hyperglycemia
  • Increased appetite
  • Infections
  • Interactions with prescription, over-the-counter, and herbal medications as well as with foods and beverages
  • Joint and bone pain
  • Malignancies
  • Mood swings
  • Muscle weakness
  • Nephrotoxicity
  • Neurological events
  • Noncompliance
  • Osteoporosis
  • Pancreatitis
  • Paresthesias
  • Progressive multifocal leukoencephalopathy
  • Skin peeling on palms and feet
  • Swelling of feet, hands, abdomen or face
  • Tremors
  • Trouble sleeping
  • Unusual and/or unwanted fat deposits
  • Vascular disease
  • Weight gain
  • White cell count and platelet abnormalities
  • Other side effects
 
Long- and Short-Term Success
  • Long- and short-term success is dependent but not limited on:
    • Organ quality
    • Recipient medical condition
    • Patient compliance
    • Surgical and medical complications
    • Episodes of rejection
    • Age and health of the recipient
    • Quality of the allograft
  • Over half of recipients die with a functioning graft
    • Recipient mortality is frequently associated with:
      • Cardiovascular disease
      • Infections
 
Vaccines
  • Prior to receiving any vaccines (or being in close contact with children or adults who have recently received vaccines) recipients should consult with their transplant center
  • Attenuated pathogens that lead to immunity in immunocompetent individuals can be associated with full-blown disease in immunosuppressed ones
FURTHER READING
  1. Hariharan S, Johnson CP, Bresnahan BA, et al. Improved graft survival after renal transplantation in the United States, 1988 to 1996. N Engl J Med. 2000; 342 (9): 605-12. PMID: 10699159.
  1. National Kidney Foundation. Available from: http://www.kidney.org/index.cfm
  1. Organ Transplant Interpretive Guidelines Update. 8Center for Medicaid and State Operations/Survey & Certification Group.