KIDNEY TRANSPLANTATION ULKEM CAKIR, MD PROFESSOR OF MEDICINE/NEPHROLOGY WOMEN IN KIDNEY TRANSPLANTATION 722 KIDNEY TX

Outline What is chronic kidney disease? Why kidney transplantation? Who is a kidney transplant recipient candidate? Timing? Donor source? Pretransplant evaluation? Posttransplant follow-up? Prognosis? Women in kidney transplantation

What is chronic kidney disease (CKD)? Irreversible damage in both kidneys Characterized by disorders in structural and functional abnormalities Lasts more than 3 months Glomerular filtration rate (GFR) decreases eventually Can be diagnosed by blood, urine and imaging studies

CKD-Staging

Approach to CKD StageGFR (mL/min/1.73 m2)Approach 1 90 Diagnosis/monitoring progression Slowing progression Detection and treatment of the complications Preparation for renal replacement therapy 5<15Renal replacement therapy

Renal replacement therapies (RRT) Hemodialysis Peritoneal dialysis Kidney transplantation

First kidney transplantation in the world Prof. Joseph E. Murray1954 Nobel Prize (1990)

1975 Living-related 1978 Cadaveric Prof. Mehmet Haberal First kidney transplantation in Turkey

Kidney transplantation in Turkey 2010: : 3000

Why transplantation? Gold standart in treatment of ESRD Better quality of life Better life expectancy Lower cost

RRT-Mortality Dialysis: 6.3% / year Kidney tx from a cadaveric donor: 3.8% / year Kidney tx from a living donor: 2% / year

- Hemodialysis Peritoneal Dialysis Kidney Tx (1) Kidney Tx (2) Cost of renal replacement therapies (USD/ year) * *Erek E et al. NDT, 2002.

Life Expectancy (Years) AGE HEALTHY PERSON DIALYSIS PATIENTRENAL TX PATIENT

Who is a kidney transplant recipient candidate? Everyone who has been diagnosed as ESRD should be evaluated for kidney transplantation

Severe cardiovascular and peripheral vascular disease* Active infection Malignancy* HIV* Drug addiction Insufficient social support Insufficient financial support Contraindications to kidney transplantation (?)

Timing? The sooner the better…

Timing? The sooner the better…

Preemptive kidney transplantation Positive impact on patient and graft survival The rate of preemptive kidney tx in USA – Living: %25 – Deceased: %7-8 In Turkey: % 20

Living – Related – Related-Paired – Unrelated Deceased Donor source

Living kidney transplantation Waiting lists inrease enormously Insufficient cadaveric donation

Advantages of living kidney transplantation Timing of the operation Optimal evaluation of the recipient and donor Better short and long term results

Relationship between donor and recipient Related Patient/ Patient’s wife’s relatives 1.Degree : Father, Mother, Children 2.Degree : Brother,Sister,Grandfather/mother 3.Degree : Uncle,Aunt, Nephew, Niece 4.Degree : Children of 3rd degree

Relationship between donor and recipient Related-Paired Kidney paired donation (KPD) is a transplant option for candidates who have a living-related donor who is medically able, but cannot donate a kidney to their intended candidate because they are incompatible.

Paired Kidney Transplantation DONOR 1 (A) RECIPIENT 1 (B) DONOR 2 (B) RECIPIENT 2 (A)

Relationship between donor and recipient Unrelated Candidates who have a living-unrelated donor who is medically able, but the legal procedure should be investigated by 'Local Ethical Commitee of Ministry of Health'

Pretransplant evaluation Potential contraindications Basic immunological studies Expected success rate

Evaluation for kidney transplantation-I Examination of documents by organ coordinators (legal procedure) Evaluation by Nephrology Evaluation by Surgery Immunologic evaluation ( HLA antibodies, Cross Match )

Evaluation for kidney transplantation-II Routine Laboratory Tests Radiologic Imaging Consultations

Blood type and tissue matching Blood type matching is still a must. We need tissue typing only for deciding which type of the immunsuppression protocol to use.

Blood Type Matching O BLOOD TYPE B BLOOD TYPE AB BLOOD TYPE A BLOOD TYPE

Contraindications for donation? Infection and cancer Every donor candidate has to be evaluated by the transplant team(s) in order to avoid rejecting due to wrong reasons We need every organ in such donor shortage

Women in Kidney Transplantation As Donors-Courage in Donation One of the greatest barriers to a receiving a living-donor transplant is difficulty in asking others to donate a kidney. Patients are often concerned that family and friends will be angry with them for asking, they feel they will be bothering their family members, or they have concerns that they will be jeopardizing the health of others by asking for them to donate a kidney. Women are better at asking others to donate to a loved one as opposed to asking someone to donate a kidney on their own behalf.

Kidney Transplantation As Donors-Surgical Approach Being associated with similar graft function, a similar graft loss rate, similar surgical complications, similar graft survival and a similar mortality rate while having significantly lower analgesic use, a quicker recovery, and a shorter hospital stay than open nephrectomy, laparoscopic living-donor nephrectomy (LLDN) has been widely accepted as a gold-standard method for kidney procurement.

Women in Kidney Transplantation As Donors-Surgical Approach Minimally invasive new laparoscopic techniques, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS), have recently been described as aiming at reducing morbidity further by avoiding surgical incisions and external scars. Transvaginal natural orifice transluminal endoscopic surgery– assisted living-donor nephrectomy seems to be a feasible and reproducible alternative to conventional laparoscopic living- donor nephrectomy in female donors provided the viability of the vagina as an organ retrieval route.

Kidney Transplantation Operation Donor operation Recipient operation

Donor Operation Open Surgery (Donor Nephrectomy)

Donor Operation Laparascopic Surgery (Donor Nephrectomy)

Donor Operation Laparascopic Surgery (Transvaginal Donor Nephrectomy)

Donor Operation Laparascopic Surgery (Single Port Transvaginal Donor Nephrectomy) PeroperativePostoperative 1 st month

Recipient Operation

Prognosis Graft survival rates for 1 year change from 80 to 95%

Acibadem University International Hospital Transplant Center Kidney transplant program (Oct 11, 2010) 722 transplants (98% living donor) Female Donors: 415 Female Recipients: 223

Acibadem University International Hospital Transplant Center Kidney transplant program (Oct 11, 2010) 722 transplants (98% living donor) Graft survival rate: 99% 1st year, 94% 5th year Patient survival rate: 99% 1st year, 95% 5th year

KIDNEY TRANSPLANTATION WHY US? Ethics & Academical environment Internationally approved and experienced transplant team High standards in medicine Plasmapheresis for highly sensitized patients Laparascopic donor nephrectomy, transvaginal route for women 722 KIDNEY TX