2. • Renal transplantation is the organ
transplant of a kidney into a patient
with end-stage renal disease.
• Kidney transplantation is typically
classified as deceased-donor or livingdonor transplantation depending on
the source of the donor organ.
3. • Living-donor renal transplants are further
characterized as genetically related (livingrelated) or non-related (living-unrelated)
transplants, depending on whether a
biological relationship exists between the
donor and recipient.
4. INDICATIONS
•The indication for kidney transplantation
is end-stage renal disease (ESRD), regardless
of the primary cause.
•This is defined as a glomerular filtration rate
<15ml/min/1.73 sq.m.
5. CHRONIC KIDNEY DISEASE
•All individuals with a glomerular filtration
rate (GFR) <60 mL/min/1.73 m2 for 3 months
are classified as having chronic kidney disease,
irrespective of the presence or absence of
kidney damage.
•The rationale for including these individuals is
that reduction in kidney function to this level or
lower represents loss of half or more of the
adult level of normal kidney function, which
may be associated with a number of
complications.
6. • All individuals with kidney damage persisting for
3 or more months are classified as having
chronic kidney disease, irrespective of the level
of GFR.
• The rationale for including individuals with GFR >
60 mL/min/1.73 m2 is that GFR may be sustained
at normal or increased levels despite substantial
kidney.
7. STAGES OF CHRONIC KIDNEY DISEASE
Stage 1
•kidney damage with normal or relatively high GFR (≥90
mL/min/1.73 m2).
Stage 2
•Mild reduction in GFR (60–89 mL/min/1.73 m2) with kidney
damage.
Stage 3
•Moderate reduction in GFR (30–59 mL/min/1.73 m2).
Stage 4
•Severe reduction in GFR (15–29 mL/min/1.73 m2)
Stage 5
• End stage renal disease (ESRD) (GFR <15 mL/min/1.73 m2
8. • Sources of kidneys:
Deceased
Living related
Living unrelated
9. Organ trade
•In the developing world some people sell
their organs. Such people are often in grave
poverty or are exploited by salespersons.
• The people who travel to make use of
these kidneys are often known as
"transplant tourists."
•This practice is opposed by a variety of
human rights groups, including Organs
Watch, a group established by medical
anthropologists, which was instrumental in
exposing illegal international organ selling
rings.
10. RECIPIENT EVALUATION
• Must have established ESRD without any
potentially reversible component
• Recipient should have a life expectancy > 5 years
• No evidence of active infection
• No evidence of active malignant disease
• Psychiatric evaluation is very important to
establish motivation and likelihood of
compliance and absence of substance abuse
• Most transplant recipients are between 15 –
50yrs however age is no longer a barrier
11. RECIPIENT EVALUATION
•
Absolute contraindications
1. Presence of potentially harmful antibodies
against the donor kidney
2. Antibodies against the ABO blood group
antigens
3. Antibodies against HLA class 1 and class II
antigens
12. TISSUE TYPING
• HLA antigens are the major transplantation
antigens
• These genes are located in the short arm of
chromosome 6 at the site termed the MHC
• The genes code for 2 classes of HLA antigens
which are glycoproteins on the surface of all
cells
• Class 1 HLA antigens (HLA – A, B, C) can be
detected on most cells, they are target for
cytotoxic T lymphocytes (CD8+)
13. TISSUE TYPING
• Class II HLA antigens (HLA DR) are restricted
to B cells, monocytes/ macrophages. They
are involved in immune recognition and
regulation of immune responsiveness
• HLA typing is important in evaluating family
members as kidney donors
• The degree of match is an important
consideration in choosing an appropriate
donor among family members
14. TISSUE TYPING
• The concentration of HLA genes in one defined area
of chromosome are inherited as a packet or
haplotype
• Each individual inherits one haplotype of HLA genes
from each parent
• In clinical kidney transplantation, the HLA-A, B, and
DR antigens are regarded as important
• The remarkable degree of polymorphism of these
antigens accounts for the great difficulty in tissue
matching
• Inherited in a Mendelian codominant way
15. Inheritance of HLA antigens
Mother
A B DR
2 44 4
1 8 3
Sibling 1
A B DR
2 44 4
3 13 5
Father
A
B
3
13
29 44
Sibling 2
A B DR
2 44 4
29 44 7
Sibling 3
A B DR
1 8 3
3 13 5
DR
5
7
Sibling 4
A B DR
1 8 3
29 44 7
16. INHERITANCE OF HLA ANTIGENS
• Statistically there is 25% chance that the
siblings will share the same parental
haplotypes ( 2 haplotype match)
• 50% chance that they will share one
haplotype
• 25% chance that neither haplotype will be the
same (zero haplotype match)
17. RECIPIENT EVALUATION
• Check for antibodies against VZV, CMV, HBV, HCV,
HIV
• Check for strongyloides infection or schistosomiasis
• Patients blood group because recipient must receive
a transplant from a blood group compatible donor,
Rh factor not needed
18. RECIPIENT EVALUATION
• Panel reactive antibodies (PRA) done by
monthly screening of recipients serum; > 50%
patient is highly sensitized. Also important to
define the antigens to which recipient is
sensitized
Pregnancy
Blood transfusions
Previous failed kidney transplant
• White cell cross match: Mix donor white cells
with recipients serum & complement. A
positive cross- match is a contraindication to
transplant
19. DONOR EVALUATION
•
•
•
•
•
Not hypertensive
Diabetic
normal renal function
No infections; HIV, HBV, HCV
Psychiatric evaluation: psychologically sound,
no coercion
• Lab: CBC, FBS,LFT, Urine analysis, MC&S,
assess GFR, CXR, ECG, HLA screening, viral
screening, tuberculin skin test, IVU, renal
angiogram
20.
21. Phases of immunosuppression
• Induction immunosuppression: requires use of
powerful drugs that are specific for cells that
initiate & effect allograft directed immune
response
Antibodies ALG, ATGAM, OKT3, IL-2
receptor Abs
• Maintenance immunosuppression: steroids,
CNI, adjunctive agents AZT, MMF
• Treatment of acute rejection: Abs, pulsed
methyl prednisolone
22. KIDNEY DIALYSIS AND TRANSPLANT
PROS AND CONS
PROS
RENAL
TRANSPL
ANT
CONS
• Can be done prior to
start of dialysis
• Improved health with
more active lifestyle
• No longer need dialysis
• Higher long term
survival rate
• Psychological
stress of having a
family member
involved
• Time involved for
evaluation and
testing process
• May be
responsible for
travel expenses,
wages lost
23. PROS
CONS
HAEMODIALYSIS • Patient gets to know • Fistula or AV graft
other dialysis
surgically inserted
patients
• May have to travel to a
• Frequent access to
center
health care team
• Disrupts work schedule
due to fixed schedule
• Less privacy (Sleep with
other patients for
nocturnal)
• More ups and downs in
clinical condition
• Must maintain a strict
diet and fluid restriction
• Must follow center’s
rules regarding food,
visitors etc
24. Longer Life with a Transplant
•Patients who receive a kidney transplant typically
live longer than those who stay on dialysis.
•A living donor kidney functions, on average, 12 to
20 years, and a deceased donor kidney from 8 to
12 years.
•Patients who get a kidney transplant before
dialysis live an average of 10 to 15 years longer
than if they stayed on dialysis.
25. • Younger adults benefit the most from a kidney
transplant, but even adults as old as 75 gain
an average of four more years after a
transplant than if they had stayed on dialysis.
26. •
Average relative risk of death after renal transplantation in the time
periods 0 to 30 d, 31 to 365 d, and greater than 365 d in Ontario.
27. Data from US Renal Data System. USRD 2003 annual data
report: atlas of end stage renal disease in the United States.
29. The economics of kidney transplantation versus
hemodialysis
•Using 1998 data for 8 transplantation centers
located in New York City, this study found that
kidney transplantation was a more cost-effective
treatment than dialysis.
•The initially higher costs of transplantation were
fully recouped 2 years and 10 months after
surgery.
•Transplantation will also generate average
monthly savings of $3800 over dialysis for the 2
years following the break-even point.
32. Kidney donor selection and refusal criteria
•The physical condition of the donor, especially
of the organ to be donated, is more important
than age.
•Important risk factors for organ failure are a
prolonged history of diabetes mellitus or serious
hypertension with retinal vascular damage.
•Factors for excluding potential donors include
previous myocardial infarction, coronary bypass
angina, severe systemic vascular disease and
long-lasting hypotension, oliguria and a long
period in intensive care.
33. • Different circumstances apply when a
recipient is already infected with HIV or
hepatitis and transplant from infectious
donors is possible in certain situations.
• A previous history of malignancy is not usually
a contraindication for organ donation.
However, absolute contraindications are
active cancer or a history of metastatic cancer
(with a few exceptions, e.g. testicular cancer)
and cancers with high recurrence rates, e.g.
lymphoma.
34. CONCLUSION
Even though kidney transplant is a major
surgery with a phased recovery period, it can, in
comparison to dialysis, offer the opportunity for
a
LONGER AND MORE SATISFYING LIFE.
