DGF

1. I thought the new kidney will
work!!
Nephrology Grand round
Aug 2014
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2. Disclosure
• No financial holdings effect the content of the
presentation.
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3. Basic overview of the topic
 Sample case to identify risk factors
 Definition & incidence
 Importance
 Risk factors at various stages of Transplant
process
 Thought process and basic work up
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4. Case Presentation
• 53 yo male with h/o ESRD secondary to
hypertension, DM, HTN and BPH is post op
day 5, DBD/ECD renal transplant, KDPI 56%,
cPRA 25%.
• WIT 7hrs, CIT 24 hrs
• Patient has been on HD before transplant for 4
yrs through a left AVF. He makes little urine at
baseline
• Tacrolimus was started on day 2 at 4mg bid
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5. • Patient is on tapering dose of steroids and Cellcept.
• Prophylactic medications : Bactrim, Valgancyclovir
& Nystatin
• Additional medication includes Pantoprazole and
Ondansetron.
• During OR he was hypotensive briefly down to 80s
• His only complaint is mild RLQ abd pain and nausea
with dec PO intake
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6. Exam
• VSS stable except SBP 155/75
• AAO in NA
• S1+S2 no murmur
• Mild bibasilar crackles with no inc effort of
breathing
• Abd with RLQ scar, TTP at graft site, + BS, no foley
• Speech intact, moving all 4 limbs with intact
strength. ?asterexis
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7. Significant Labs
• WBC-normal, Hb 8.1 (7.5-9.5)
• Na 132, K 5.9, HCO3 17, BUN 98, Cr 7.6
• Cr has been slowly worsening since transplant
from 4.3 on arrival
• UA is 2+ blood, 1+ protein (1+ before Txp as
well) 1+LE, 19 WBCs and 10 RBCs, Few
granular casts on microscopy.
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8. Doc! Why my new Kidney is not
working?
Brief Differential
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9. Patient given a session of HD on
Day 5
He will be called to have
D_____ G____ F_____
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10. Soup Kitchen
• DGF: Delayed Graft Function
• DBD: Donation after Brain Death
• DCD: Donation after Cardiac Death
• ECD: Extended Criteria Donor
• SCD: Standard Criteria Donor
• KDPI: Kidney donor profile index
• cPRA: calculated Panel Reactive antibody
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11. Definitions
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12. Who Gets more DGF?
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13. Does it matter?
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14. Does it matter?
• Graft survival for DBD kidneys that fulfilled
the criteria for DGF, according to 9 of the 10
definitions, was associated with greater than
three times the risk of graft loss, whereas
none of the definitions of DGF were
associated with failure of DCD kidneys
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16. Does it matter?
• Associated with increased rate of rejection.
• Incidence has increased consistently in last 25
yrs. Likely because of using more DCD and
ECD.
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17. Risk Factors
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18. The Pre-Procurement Period
• Hypotension/Hypoxia/Anaerobic metabolism
• DBD:
– Loss of vascular tone
– Inflammatory state
– Complement activation
– Adhesion molecule upregulation
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19. • DBD factors:
– Use of Dopamine , agonist for HO-1(heme
oxygenase) , antagonizes free radicles
– Use of hormone replacement like steroids,
vasopressin, thyroxin.
– Length of ICU stay before withdrawal of care
– Anticoagulation
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20. DCD Factors
• Duration from withdrawal of care to cardiac
death (warm ischemia time)
– ATN, perivascular edema perpetuates ischemia at
corticomedullary junction
– <45 min , better outcomes
• Length of stay in ICU
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21. ECD Factors
The expanded criteria donor (ECD) is any donor
over the age of 60, or a donor over the age of 50
with two of the following: a history of high
blood pressure, a creatinine greater than or
equal to 1.5, or death resulting from a stroke
• Commonly ECD organ are avoided if >20%
glomeruli are sclerosed.
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22. Composite Donor Risk
• The Kidney Donor Risk Index (KDRI) is an estimate of the relative risk of
post-transplant kidney graft failure, that combines ten dimensions of
information about a donor, including clinical parameters and
demographics, to express the quality of the donor kidneys relative to
other donors
• The Kidney Donor Profile Index (KDPI) is a numerical measure That is
derived by first calculating the Kidney Donor Risk Index (KDRI) for a
deceased donor
• http://optn.transplant.hrsa.gov/resources/allocationcalculators.asp?i
ndex=81
• Mapping: KDRI to KDPI :
• http://optn.transplant.hrsa.gov/ContentDocuments/KDRI_to_KDPI_M
apping_Table.pdf
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23. Composite Recipient Risk
• Dialysis prior to transplantation (duration)
• Diabetes
• Obesity
• Age >55
• Male sex
• Prolong wait period
• High cPRA
• Small for size kidney
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25. Procurement: Organ preservation Techniques
• Cold storage
• Preservation Fluids: Designed to reduce
osmotic injury and delay acidosis with H+
buffers
– UW (Uni of Wisconsin solution): Adenosine (reduces
re-perfusion injury) and allopurinol.
– HTK (Histidine-tryptophan-Ketoglutarate): Low K
Organs >24 hr CIT have less DGF risk when reperfused
with UW solution.
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26. Pulsatile machine perfusion
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Machine perfusion: perfusion flow <0.4ml/min/gm, resistance >80mmHg and resistive index
>0.5mmHg{ml/min/100gm of tissue} , protocols including directives for organ discard

27. Perioperative Period
• Hypotension
• Intraoperative fluid balance and ESRD pts with LVH
• Anesthesia effect/Vasodilation
• Reperfusion:
– Due to preceding ischemic injury, pathologic vasoconstriction
occurs with the activation of G protein coupled receptors.
– Innate immune response (Neutrophils and Macrophages)
signals from injured cell
– Adaptive immune response, inc MHC expression in IR injured
tissue through Ifγ, Cytokines and Chemokines, T-cell
mediated.
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28. Postoperative period
Day 1-7
• Surgical Complications:
– Vascular complications: Thrombosis ( pediatric
kidneys and pt with APLAS), hematoma
– Anatomic complications: urinary leak causing a
urinoma, tight fascia around the kidney
– Urologic complication: Urinoma, Ureteric Kinking
and stenosis, Evulsion
– Infection/Abscess
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29. • Drugs:
– CNI (Tacrolimus)
– Bactrim
– PPIs
• Urinary retention: After Foley is usually
removed on day 4.
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30. Rejection
• Acute Cell Mediated Rejection (ACR)
• Antibody mediated Rejection (AMR)
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31. Basic thought process
• Pre-Renal (Hypovolemic/Low renal blood
flow), Thrombosis)
• Renal (ATN, AIN, TMA, venous thrombosis &
congestion)
• Post renal (compression by fluid collection,
urologic problems)
• Rejection (ACR, AMR)
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32. Basic Workup to consider for DGF
• Donor information (KDPI, pre-procurement history,
available with UNOS)
• Operative report for hypotension
• Immunological risk: cPRA, cross match report
• Tacrolimus levels
• Allograft US with Doppler (?other imaging)
• Urine micro (not so informative as old kidneys still
make some urine) same problem with urine e-lytes
• Review other drugs
• Post void residuals & voiding trials
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33. • Biopsy provides the final differentiation (ATN,
AIN, Rejection, TMA) but sometime its difficult
to distinguish between AIN and Rejection
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34. Thank you!
DGF Risk Calculator
http://www.transplantcalculator.com/Transplant-Calculators/Delayed-
Graft-Function.aspx
Feedback appreciated…
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