1. Kidney Transplantation An Overview
Mark W. Johnson, MD,
Assoc. Professor of Surgery
Director of Liver Transplantation University of North Carolina
Chapel Hill

2. History of Transplantation
Hx of organ tx.

3. Kidney Transplantation Surgical Milestones
Ulman, 1902 – kidney to neck vessels
Carrel, 1912 – vascular techniques
Kolff, 1940’s – dialysis machine
Hume, 1947 – kidney to arm vessels
Murray, 1956 – identical twin transplant

4. Alexis carrel
Alexis Carrel 1912

5. Kolff, 1940’s :
Hemo-dialysis
machines
Dialysis machines

6. Hume, 1950’s – kidney to femoral vessels

7. Murray, 1956 – current transplant position

8. Murray, 1956 – current transplant position

9. Renal transplant:
Venous anastomosis

10. Renal transplant:
Arterial anastomosis

11. Renal transplant:
Reperfusion

12. Renal transplant:
Ureteral anastomosis

13. Kidney-Pancreas transplantation
Why?

14. Non-Uremic Patients
Sequellae of diabetes have to be considered worse than short term surgical risks and the long term risks of chronic immunosuppression.

15. History of Pancreas Transplantation
1913 Hedon: pancreas segment to neck of dog
1921 Banting & Best: extraction of insulin
1966 Kelly/Lillehei: 1st clinical pancreas tx
60 grafts/56 pts. 3% graft/39% 1 yr.
1978 Introduction of cyclosporin
295grafts/276 pts. 40% graft/77% 1 yr

16. History of Pancreas Transplantation (cont’d)
since 1984:
improved vascular techniques (“Y” graft)
drainage of exocrine function (bladder vs. enteric)
improved immunosuppression (FK506, MMF)
improved rejection therapy (OKT3)
improved antibiotics (anti-viral, fungal agents)

17. Pancreas transplant: Vascular anatomy

18. Lillehei 1966:
current transplant
position

19. Pancreas transplant:
enteric anastomosis

20. “You are about to experience something rare in your life, Stan – Rejection.”

21. P. B. Medawar, 1953:
“Actively Acquired
Tolerance of
Foreign Cells.”

22. Recognizing Non-self

23. Major Histocompatibility Complex
Class I MW 45k
single polymorphic chain
ß-2 microglobulin
A, B, and C loci
Expressed on all cells
Class II MW33k and 28k
two polymorphic chains
DP, DQ, and DR loci
Expressed on macrophages, B cells, activated T cells, dendritic cells, etc.

25. Varieties of Rejection
Type of Rejection
Time course
Cause
Hyperacute
Minutes-hours
Pre-formed antibodies (humoral)
Acute
Days - weeks
Cell mediated
chronic
Months - years
Humoral and cell mediated

26. Immunosuppression Evolution
Tacrolimus
Mycophenolate mofetil
Rapamycin
Brequinar
Leflunomide
IL2r antibodies
monoclonal antibodies
Cyclosporin
Azathioprine
OKT3
ATG
ALG
Steroids
?????

27. Progress in Immunosuppressionvs
Ready-Fire-Aim Ready-Aim-Fire

29. Renal Transplant Graft Survivals

30. Pancreatic Graft Survivals

31. The Solution