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KIDNEY TRANSPLANTATION: AN OVERVIEW

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Presentation on theme: "KIDNEY TRANSPLANTATION: AN OVERVIEW"— Presentation transcript:

1 KIDNEY TRANSPLANTATION: AN OVERVIEW
Ahmed Donia, MD, MRCP (UK) Consultant of nephrology Urology and nephrology center Mansoura University, Egypt

2  Lawler et al First Successful Organ Transplant (cadaveric kidney), 1950

3 First successful living kidney transplant, 1954
 Lawler et al First Successful Organ Transplant (cadaveric kidney), 1950 J. Murray First successful living kidney transplant, 1954 Nobel prize winner 1990

4  Lawler et al First Successful Organ Transplant (cadaveric kidney), 1950  (April 1, 1919 – November 26, 2012)

5  Lawler et al First Successful Organ Transplant (cadaveric kidney), 1950  (April 1, 1919 – November 26, 2012)

6 PRE-OPERTATIVE PREPARATION

7 WHEN?

8 END STAGE RENAL DISEASE
WHEN? END STAGE RENAL DISEASE

9 WHEN?

10 WHEN TO REFER?

11 WHEN TO REFER? CKD SATGE IV

12 WHEN TO REFER? CKD SATGE IV Clearance < 30 ml/min

13 WHEN TO REFER? CKD SATGE IV Clearance < 30 ml/min
Age = 40 yr, weight = 72 kg

14 Refer when creatinine = 3.5 mg/dl !!
WHEN TO REFER? CKD SATGE IV Clearance < 30 ml/min Age = 40 yr, weight = 72 kg…… Refer when creatinine = 3.5 mg/dl !!

15 PRE-EMPTIVE kidney transplantation
WHEN TO REFER? PRE-EMPTIVE kidney transplantation

16 PRE-OPERTATIVE PREPARATION

17 BLOOD TRANSFUSION INDICATION? IMMUNOLOGIC EFFECT

18 HLA WBC

19 HLA HLA WBC Self organ

20 HLA HLA √ WBC Self organ

21 HLA HLA WBC Transplanted organ

22 HLA HLA REJECTION WBC Transplanted organ

23 HLA HLA REJECTION WBC

24 HLA HLA REJECTION WBC

25 HLA HLA PREFORMED ANTIBODIES WBC

26 HLA HLA REJECTION WBC Transplanted organ

27 HLA HLA PREFORMED ANTIBODIES WBC

28 PRE-OPERTATIVE PREPARATION

29

30 Transplantation Preparation Sheet Recipient
Name Sex: Age: y Wt: kg Ht cm TX NO Blood group: social state: offspring: Family history Evaluation: Nephrology Urology special Dialysis duration vascular access BP Compliance Original kidney disease: UOP: ML/day Immunology: CXM HLA % DR % PRA : I II Laboratory: Urine analysis culture ZN&PCR for TB RFT LFT BL.sugar Hematology sputum(zn>PCR) Viral profile HBV HCV CMV HIV Radiology: US UTP CXR MCUG others Endoscopies: FOGD Bladder Rectum Biopsy: Renal Liver Rectum Others ============================================================

31 CONTRAINDICATIONS

32 CONTRAINDICATIONS Absolute Reversible renal failure
Active infections (new DAA) Active malignancy Active substance abuse Uncontrolled psychiatric disease Documented active treatment nonadherence Severe unreversible systemic disease A significantly shortened life expectancy Primary oxalosis Severe bilateral iliac or lower-extremity arterial disease

33 CONTRAINDICATIONS Absolute Relative Age (centre-dependent) Abnormal UT
Reversible renal failure Active infections (new DAA) Active malignancy Active substance abuse Uncontrolled psychiatric disease Documented active treatment nonadherence Severe unreversible systemic disease A significantly shortened life expectancy Primary oxalosis Severe bilateral iliac or lower-extremity arterial disease Relative Age (centre-dependent) Abnormal UT Peripheral arterial disease Significant systemic disease Active systemic diseases that may caused renal failure Recurrent FSGS severe hyperparathyroidism Morbid obesity

34 PRE-OPERTATIVE PREPARATION
HISTRORY TAKING

35 PRE-OPERTATIVE PREPARATION: RECIPIENT
HISTRORY TAKING

36 Transplantation Preparation Sheet Recipient
Name Sex: Age: y Wt: kg Ht cm TX NO Blood group: social state: offspring: Family history Evaluation: Nephrology Urology special Dialysis duration vascular access BP Compliance Original kidney disease: UOP: ML/day Immunology: CXM HLA % DR % PRA : I II Laboratory: Urine analysis culture ZN&PCR for TB RFT LFT BL.sugar Hematology sputum(zn>PCR) Viral profile HBV HCV CMV HIV Radiology: US UTP CXR MCUG others Endoscopies: FOGD Bladder Rectum Biopsy: Renal Liver Rectum Others ============================================================

37 PRE-OPERTATIVE PREPARATION: RECIPIENT
CLINICAL EXAMINATION

38 PRE-OPERTATIVE PREPARATION: RECIPIENT
CLINICAL EXAMINATION

39 Transplantation Preparation Sheet Recipient
Name Sex: Age: y Wt: kg Ht cm TX NO Blood group: social state: offspring: Family history Evaluation: Nephrology Urology special Dialysis duration vascular access BP Compliance Original kidney disease: UOP: ML/day Immunology: CXM HLA % DR % PRA : I II Laboratory: Urine analysis culture ZN&PCR for TB RFT LFT BL.sugar Hematology sputum(zn>PCR) Viral profile HBV HCV CMV HIV Radiology: US UTP CXR MCUG others Endoscopies: FOGD Bladder Rectum Biopsy: Renal Liver Rectum Others ============================================================

40 PRE-OPERTATIVE PREPARATION: RECIPIENT

41 PRE-OPERTATIVE PREPARATION: RECIPIENT

42 PRE-OPERTATIVE PREPARATION: RECIPIENT

43 PRE-OPERTATIVE PREPARATION: RECIPIENT

44 PRE-OPERTATIVE PREPARATION: RECIPIENT

45 PRE-OPERTATIVE PREPARATION: DONOR

46 PRE-OPERTATIVE PREPARATION: RECIPIENT

47 PRE-OPERTATIVE PREPARATION

48 PRE-OPERTATIVE PREPARATION: DONOR

49 PRE-OPERTATIVE PREPARATION: DONOR
CONTRAINDICATIONS

50 PRE-OPERTATIVE PREPARATION: DONOR

51 PRE-OPERTATIVE PREPARATION: DONOR

52 PRE-OPERTATIVE PREPARATION: DONOR

53 PRE-OPERTATIVE PREPARATION: DONOR

54 PRE-OPERTATIVE PREPARATION: DONOR

55 PRE-OPERTATIVE PREPARATION: DONOR

56 PRE-OPERTATIVE PREPARATION: DONOR

57 PRE-OPERTATIVE PREPARATION: DONOR
HISTRORY TAKING

58 PRE-OPERTATIVE PREPARATION: DONOR
CLINICAL EXAMINATION

59

60 PRE-OPERTATIVE PREPARATION: DONOR

61

62 PRE-OPERTATIVE PREPARATION: IMMUNOLOGY

63 PRE-OPERTATIVE PREPARATION: IMMUNOLOGY

64 PRE-OPERTATIVE PREPARATION: IMMUNOLOGY
HLA HLA WBC Transplanted organ

65 PRE-OPERTATIVE PREPARATION: DONOR

66 PRE-OPERTATIVE PREPARATION: DONOR

67 PRE-OPERTATIVE PREPARATION: DONOR

68 PRE-OPERTATIVE PREPARATION: DONOR

69 PRE-OPERTATIVE PREPARATION: DONOR

70 PRE-OPERTATIVE PREPARATION: DONOR

71 KIDNEY TRANSPLANTATION: AN OVERVIEW

72 PERI-OPERTATIVE PERIOD

73 PERI-OPERTATIVE PERIOD

74 PERI-OPERTATIVE PERIOD

75 PERI-OPERTATIVE PERIOD

76 PERI-OPERTATIVE PERIOD

77 PERI-OPERTATIVE PERIOD

78 PERI-OPERTATIVE PERIOD

79 PERI-OPERTATIVE PERIOD

80 POST-OPERTATIVE IMMUNOSUPPRESSION

81 WHY NEEDED? HOW DOES IT WORK? WHICH PROTOCOL TO USE? WHAT DOES IT COST?

82 WHY NEEDED? HOW DOES IT WORK? WHICH PROTOCOL TO USE? WHAT DOES IT COST?

83 WHY NEEDED?

84 WHY NEEDED?

85 WHY NEEDED? HLA

86 WHY NEEDED? HLA

87 WHY NEEDED? HLA WBC

88 WHY NEEDED? HLA HLA WBC Self organ

89 WHY NEEDED? HLA HLA √ WBC Self organ

90 WHY NEEDED? HLA HLA WBC Transplanted organ

91 WHY NEEDED? HLA HLA REJECTION WBC Transplanted organ

92 WHY NEEDED? IMMUNOSUPPRESSION HLA HLA REJECTION WBC Transplanted organ

93 WHY NEEDED? HOW DOES IT WORK? WHICH PROTOCOL TO USE? WHAT DOES IT COST?

94 HOW DOES IT WORK?

95 HOW DOES IT WORK?

96 HOW DOES IT WORK?

97 HOW DOES IT WORK?

98 HOW DOES IT WORK? HLA HLA IMMUNOSUPPRESSION REJECTION WBC
Transplanted organ

99 HOW DOES IT WORK?

100 HOW DOES IT WORK? Signal 1

101 HOW DOES IT WORK? Signal 1 Signal 2

102 HOW DOES IT WORK? Signal 3 Signal 1 Signal 2

103 HOW DOES IT WORK?

104 HOW DOES IT WORK? PLASMA EXCHANGE RITUXIMAB IV Ig

105 WHY NEEDED? HOW DOES IT WORK? WHICH PROTOCOL TO USE? WHAT DOES IT COST?

106 WHICH PROTOCOL TO USE?

107 TIME AFTER TRANSPLANTATION
WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION

108 TIME AFTER TRANSPLANTATION
WHICH PROTOCOL TO USE? INDUCTION TIME AFTER TRANSPLANTATION

109 WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION INDUCTION
MAINTENANCE IMMUNOSUPPRESSION INDUCTION TIME AFTER TRANSPLANTATION

110 WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION INDUCTION
MAINTENANCE IMMUNOSUPPRESSION GRAFT FUNCTION INDUCTION TIME AFTER TRANSPLANTATION

111 WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION INDUCTION
MAINTENANCE IMMUNOSUPPRESSION ANTIREJECTION ANTIREJECTION GRAFT FUNCTION INDUCTION TIME AFTER TRANSPLANTATION

112 MAINTENANCE IMMUNOSUPPRESSION
WHICH PROTOCOL TO USE? MAINTENANCE IMMUNOSUPPRESSION ANTIREJECTION ANTIREJECTION INDUCTION

113 WHICH PROTOCOL TO USE?

114 THE OPTIMAL IMMUNOSUPPRESSION PROTOCOL IS UNCLEAR
WHICH PROTOCOL TO USE? THE OPTIMAL IMMUNOSUPPRESSION PROTOCOL IS UNCLEAR

115 WHICH PROTOCOL TO USE? THE OPTIMAL IMMUNOSUPPRESSION PROTOCOL IS UNCLEAR CENTER/PATIENT-ADAPTED PROTOCOLS

116 WHICH PROTOCOL TO USE? THE OPTIMAL IMMUNOSUPPRESSION PROTOCOL IS UNCLEAR CENTER/PATIENT-ADAPTED PROTOCOLS DRUG DOSES ↓GRADUALLY WITH TIME

117 WHICH PROTOCOL TO USE?

118 WHICH PROTOCOL TO USE?

119 TIME AFTER TRANSPLANTATION
WHICH PROTOCOL TO USE? INDUCTION TIME AFTER TRANSPLANTATION

120 TIME AFTER TRANSPLANTATION
WHICH PROTOCOL TO USE? INDUCTION TIME AFTER TRANSPLANTATION

121 TIME AFTER TRANSPLANTATION
WHICH PROTOCOL TO USE? INDUCTION TIME AFTER TRANSPLANTATION

122 TIME AFTER TRANSPLANTATION
WHICH PROTOCOL TO USE? High risk patients High PRA Donor specific antibodies 5-6 HLA mismatch Multiple previous transplants Previous transplant lost due to immunologic cause INDUCTION TIME AFTER TRANSPLANTATION

123

124

125

126

127 WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION INDUCTION
MAINTENANCE IMMUNOSUPPRESSION INDUCTION TIME AFTER TRANSPLANTATION

128 WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION INDUCTION
MAINTENANCE IMMUNOSUPPRESSION INDUCTION TIME AFTER TRANSPLANTATION

129

130

131 WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION INDUCTION
MAINTENANCE IMMUNOSUPPRESSION INDUCTION TIME AFTER TRANSPLANTATION

132 WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION INDUCTION
MAINTENANCE IMMUNOSUPPRESSION INDUCTION TIME AFTER TRANSPLANTATION

133

134 WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION INDUCTION
MAINTENANCE IMMUNOSUPPRESSION INDUCTION TIME AFTER TRANSPLANTATION

135 WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION INDUCTION
MAINTENANCE IMMUNOSUPPRESSION INDUCTION TIME AFTER TRANSPLANTATION

136

137

138

139 WHICH PROTOCOL TO USE? TIME AFTER TRANSPLANTATION INDUCTION
MAINTENANCE IMMUNOSUPPRESSION ANTIREJECTION ANTIREJECTION GRAFT FUNCTION INDUCTION TIME AFTER TRANSPLANTATION

140 WHICH PROTOCOL TO USE? TYPES OF REJECTION

141 WHICH PROTOCOL TO USE? ACUTE CHRONIC TYPES OF REJECTION CELLULAR
HUMORAL CELLULAR HUMORAL

142 WHICH PROTOCOL TO USE? TYPES OF REJECTION ACUTE CELLULAR HUMORAL

143 ANTI-REJECTION PROTOCOL
WHICH PROTOCOL TO USE? ANTI-REJECTION PROTOCOL ACUTE CELLULAR HUMORAL

144 ANTI-REJECTION PROTOCOL
WHICH PROTOCOL TO USE? ANTI-REJECTION PROTOCOL ACUTE CELLULAR HUMORAL

145 WHICH PROTOCOL TO USE? DRUG MONITORING

146 WHICH PROTOCOL TO USE? DRUG MONITORING

147 WHICH PROTOCOL TO USE? DRUG MONITORING

148 WHICH PROTOCOL TO USE? DRUG MONITORING

149 WHICH PROTOCOL TO USE?

150 WHICH PROTOCOL TO USE?

151 WHY NEEDED? HOW DOES IT WORK? WHICH PROTOCOL TO USE? WHAT DOES IT COST?

152 WHAT DOES IT COST?

153 WHAT DOES IT COST? IMMUNE SYSTEM

154 WHAT DOES IT COST? IMMUNE SYSTEM

155 WHAT DOES IT COST? INFECTION IMMUNE SYSTEM

156 WHAT DOES IT COST? INFECTION MALIGNANCY IMMUNE SYSTEM

157 Transplantation. 2008 Oct 27;86(8):1139-42. doi: 10. 1097/TP
Transplantation. 2008 Oct 27;86(8): doi: /TP.0b013e318187ccb3. Postkidney transplant malignancy in Egypt has a unique pattern: a three-decade experience. Donia AF, Mostafa A, Refaie H, El-Baz M, Kamal MM, Ghoneim MA. Source Urology and Nephrology Center, Mansoura University, Egypt. Abstract The pattern of posttransplant malignancy varies among transplant units. We report on our single-center experience. Between 1976 and 2007, 1866 kidney transplantations were carried out (1390 males and 476 females, mean age / years). Recipients who developed posttransplant malignancy were evaluated (74 patients, 3.97%). Furthermore, their data were compared with those of the malignancy-free recipients (1792 patients). Kaposi sarcoma was the commonest type (36.8%) and had the shortest transplant-to-malignancy period (mean 2.84 years). The lesions were only cutaneous in 75% of cases. Skin cancers were the fourth among posttransplant malignancies (9.2%) and 85.7% of cases were basal cell carcinoma. In our series, age and prior blood transfusion were identified as independent risk factors for the development of posttransplant malignancy. In conclusion, the prevalence and type of posttransplant malignancy vary because of many factors including environmental and genetic factors. In our series, Kaposi sarcoma was the commonest type and, therefore, needs further evaluation.

158 WHAT DOES IT COST? HYPERTENSION

159 ELECTROLYTE DISTURBANCES
WHAT DOES IT COST? ELECTROLYTE DISTURBANCES

160 NEUROPSYCHIATRIC PROBLEMS
WHAT DOES IT COST? NEUROPSYCHIATRIC PROBLEMS

161 WHAT DOES IT COST? NEPHROTOXICITY

162 WHAT DOES IT COST? COSMETIC CHANGES

163 WHAT DOES IT COST? DIABETES MELLITUS

164 WHAT DOES IT COST? GIT PROBLEMS

165 WHAT DOES IT COST? DELAYED HEALING

166 WHAT DOES IT COST? DYSLIPIDEMIA

167 WHAT DOES IT COST? MYELOSUPPRESSION

168 WHAT DOES IT COST? TERATOGENICITY

169 WHAT DOES IT COST? HEPATOTOXICITY

170 WHAT DOES IT COST? BONE DISEASE EYE PROBLEMS

171 KIDNEY TRANSPLANTATION: AN OVERVIEW

172 POST-OPERTATIVE FOLLOW UP

173 POST-OPERTATIVE FOLLOW UP

174 POST-OPERTATIVE FOLLOW UP

175 POST-OPERTATIVE FOLLOW UP

176 POST-OPERTATIVE FOLLOW UP
Figure 1: Actuarial patient and graft survival. Patient survival was 89.7±0.7% and  778±1.2% years at 5 and 10 years, respectively. Graft survival was  86.7±0.8% at 5 years and dropped to 65.5±1.3% at 10 years

177 POST-OPERTATIVE FOLLOW UP

178

179 Transplantation Preparation Sheet Recipient
Name Sex: Age: y Wt: kg Ht cm TX NO Blood group: social state: offspring: Family history Evaluation: Nephrology Urology special Dialysis duration vascular access BP Compliance Original kidney disease: UOP: ML/day Immunology: CXM HLA % DR % PRA : I II Laboratory: Urine analysis culture ZN&PCR for TB RFT LFT BL.sugar Hematology sputum(zn>PCR) Viral profile HBV HCV CMV HIV Radiology: US UTP CXR MCUG others Endoscopies: FOGD Bladder Rectum Biopsy: Renal Liver Rectum Others ============================================================

180 TAKE HOME MESSAGE Immunosuppression is permanently needed post-kidney transplantation to prevent/treat rejection. Doses gradually ↓ with time Combined protocol (usually triple) is used Infection and malignancy are general potential untoward effects in addition to drug-specific side effects Judicious handling is ,therefore, needed

181 UROLOGY AND NEPHROLOGY CENTER
MANSOURA CITY UROLOGY AND NEPHROLOGY CENTER MANSOURA UNIVERSITY THANK YOU

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