Priniciples of transplantation dr ahmed akl

1. Principles Of Transplantation
DR. AHMED AKL, MD, FISN
ISN EDUCATION AMBASSADOR,
Consultant Of Nephrology & Transplantation,
Urology & Nephrology Center,
Mansoura University,
Egypt

2. ADVANTAGES OF
TRANSPLANTATION
 Better quality of life - freedom from dialysis.
 Avoid long-term complications of dialysis.
 Higher energy levels.
 Less dietary and fluid restrictions.
 PATIENTS SURVIVAL:
• Chronic dialysis :
-mortality rate of 6-20% per year and as high as 11-25%. per year in diabetic
patients.
• Renal transplantation:
-Operative mortality rate of less than 2%.
-The 1-year survival for recipients of living related kidneys is better than 95%.
-The 5-year patient survivals are approximately 80% for nondiabetic recipients
and 60-70% for diabetic recipients.

3.  In 1954, the first successful kidney
transplantation was performed using a
kidney from a living donor: the identical twin
of the recipient.
HISTORY

4. HISTORY
• First Transplanted Patient in Mansoura
27 Mar 1976
ISN EDUCATION AMBASADORS Program,
PORT SAID, JULY 20-21, 2017

5. Preparation
(outpatient)
Inpatient ICU Inpatient Outpatient
Transplant Patient Flow Chart
Tx recipient
Operation
PatientDonor

6. ADMINSTRATION
Preparation
(outpatient)
Transplant Patient Flow Chart
PatientDonor

7. Kidney
Transplantation
Deceased/Cadaveric
Living
UnrelatedRelated
DONOR

8.  Blood group-(Rh).
 Cross-match.
 Tissue typing(HLA-DR).
ABO blood grouping and
cross-match testing
PatientDonor

9. PatientDonor
Medical Assessment
 History
 Clinical Examination

10.  Laboratory evaluation.
1- Urine:
- Analysis.
- Culture-TB (ZN and PCR).
- Protein (24h collection, creatinine/protein ratio).
2- Biochemistry.
3-Hematology (CBC, prothrombin time, concentration, INR).
4- Virological assessment (HCV, HBV, HIV, CMV).
Donor evaluation
• Serum creatinine ,Creatinine clearance.
• Serum uric acid.
• Fasting and 2HPP(OGTT).
• Lipid profile.
• Serum bilirubin ,TP, albumin ,alkaline phosphatase ,ALT ,AST.
• Serum electrolytes( calcium and phosphors ).

11.  Most transplant centers exclude donors with proteinuria that exceeds 300 mg/day, while others use a lower threshold of greater
than 150 mg/day.
 Some centers exclude everyone with >10 RBC/hpf as a possible transplant donor. Others will only accept a donor with
hematuria if the urologic evaluation and kidney biopsy are negative.
 Any donor with persistent hematuria should have a thorough urological evaluation and kidney biopsy.
EXCLUSION CRITERIA FOR DONATION
 Most centers require that donors have a glomerular filtration rate (GFR) of at least 80 mL/min.
 If renal function is evaluated via a creatinine clearance, the adequacy of the 24 hour urine collection should be carefully
assessed.
 Dietary intake of protein should be at least 1 g of protein /kg/body weight, since a low protein diet may decrease creatinine
clearance by as much as 10 mL/min.
-The MDRD equation also has to be used with caution.
-The CKD-EPI equation may estimate GFR more accurately than the MDRD equation among those with a true
GFR greater than 60 mL/min.
-However, estimation equations are frequently inaccurate when used for potential kidney donors.
 Difficulties inherent to the accurate measurement of the creatinine clearance, including variability in urine collections, may affect
results.
 Some centers therefore advocate the use of eGFR calculations such as the MDRD equation for the initial screen.
 Among those with a GFR < 80 mL/min by initial estimation, isotopic studies are subsequently performed to measure renal
function more accurately.

12. DM TESTING FOR LIVING DONORS
FBS<100
GTT<140
Proceed
Intermediate
FBS>126
GTT>140
Exclude
FBS<100
IGT
FBS100:110 FBS110:126
IGTNGT
Exclude
DM60%
Proceed
DM28%
IGTNGT
Proceed
DM19%
Proceed
DM31%
Proceed
DM9%

13.  The Amsterdam Forum on the Care of the Living Kidney Donor (2006)
individuals with a history of diabetes or fasting blood glucose ≥7 mmol/L on
at least two occasions (or 2 h glucose with OGTT ≥11.1 mmol/L should not
donate.
 The Canadian Council for Donation and Transplantation(2006)
We recommend . . . to refer to existing guidelines regarding the assessment
and eligibility of potential living kidney donors (e.g. Amsterdam Forum).
 European Renal Association-EDTA (2000) . . . exclusion criteria: . . . DM
UK Guidelines for Living Donor Kidney Transplantation (2005)
Diabetes mellitus is an absolute contraindication to living donation. Prospective
donors with an increased risk of type 2 diabetes mellitus because of family
history, ethnicity or obesity should undergo a glucose tolerance test and only be
considered further as donors if this is normal.
INTERNATIONAL GUIDELINES

14. ECG & Echocardiography

15. • Spiral NCCT.
Radiological Assessment
Renogram

16. CT Angiogram Or MR Angiogram

17. Psychological assessment
• Relationship to the recipient
• Motivation to donate
• Knowledge about donor surgery and risks of surgery
• Capacity to make decisions
• Knowledge about recipient surgery and alternatives to living donation.
• Psychiatric symptoms.
• Alcohol or substance abuse or dependence.
• Financial stressors and economic impact of surgery.
• Family support.
• Awareness of ability to decline to proceed with surgery.

18. Elements of securing informed consent
• Ensuring the participant’s understanding of the procedure
& sequelae.
• Confirming the participant’s medical & psychological
suitability.
• Educating the donor.
• Ensuring the absence of coercion and free choice.
• Documenting informed consent.

19. Mansoura Policy
‫عائلتها‬ ‫أفراد‬ ‫ألحد‬ ‫زوجة‬ ‫تبرع‬ ‫حالة‬ ‫فى‬
‫التبرع‬ ‫على‬ ‫الزوج‬ ‫وتوقيع‬ ‫موافقة‬ ‫يشترط‬

20. EXCLUSION CRITERIA FOR DONATION
• Hypertension or diabetes mellitus.
• Pregnancy or breast feeding.
• Positive serology for HCV, HBV, or HIV.
• Significant liver disease.
• Current or history of malignancy.
• Active systemic or localized major infection.
• Evidence of lung infiltrates, cavitation(s)or consolidation.
• Subjects with a screening baseline hemoglobin < 11gm/dl.
• Total white blood cell count ≤ 2,000/ mm3 .
• Platelet count ≤ 100000/ mm3 .
• Fasting triglycerides ≥ 400mg/dl or
• Fasting total cholesterol ≥ 300mg/dl.

21.  History of nephrolithiasis.
 Active peptic ulcer disease.
 Urological abnormalities (eg, multiple renal vessels).
 Morbid obesity, most commonly defined as BMI greater than 35.
 Age greater than 65 or less than 21 years.
 Strong family history of diabetes mellitus or hypertension.
 Family history of renal cell cancer.
 ABO or HLA incompatibility.
Relative
Contraindications

22. RISK OF
DONOR NEPHRECTOMY
• Atelectasis.
• Pneumothorax.
• Pneumonia.
• Urinary tract infection.
• Wound complication.
• Deep vein thrombosis.
• Pulmonary embolism.
IMMEDIATE RISK LONG TERM RISK
 Renal function.
 Hypertension.
 Maternal and fetal outcomes.
 Psychological consequences.
 Economic considerations.

23. RECIPINT EVALUATION
• CARDIAC
• CEREBROVASCULAR
• MALIGNANCY
• INFECTIONS
• GASTROINTESNAL
• PULMONARY
• UROLOGIC EVALUATION
• RENAL OSTEODYSTROPHY AND METABOLIC BONE DISEASE
ISN EDUCATION AMBASADORS Program,
PORT SAID, JULY 20-21, 2017

24. ECG & Echocardiography

25. HIGH CARDIOVASCULAR RISK RENAL TRANSPLANT
CANDIDATE
SYMPTOMATIC ISCHEMIC
HEART DISEASE
ASYMPTOMATIC
CORONARY
ANGIOGRAPHY
MYOCARDIAL
PERFUSION STUDY
POSITIVENEGATIVE
CAD WITH L MAIN
OR EQUIVALENT
STENOSIS
CAD >70% EXCLUDING
L MAIN OR EQUIVALENT
STENOSISCAD LESIONS
<70%
NORMAL CA
TRANSPLANT
REVASCULARIZE
PREFERENCE FOR
CABG
SUCCESSFUL
REVASCULARIZATION
SYMPTOMATIC
POSITIVE MPS
CARDIAC REVIEW
REVASCULARIZATI
ON BENEFICIAL
REVASCULARIZATIO
N NOT BENEFICIAL
ASYMPTOMATIC
NEGATIVE MPS
OPTIMIZE MEDICAL
MANAGEMENT
ASPIRIN BETA
BLOCKADE STATIN
CONSIDER ACEI
ISN EDUCATION AMBASADORS Program,
PORT SAID, JULY 20-21, 2017

26. RECOMMENDATIONS FOR MINIMUM TUMOUR–FREE WAITING
PERIODS FOR COMMON PRETRANSPLANTATION MALIGNANCIES
RENAL
WILMS TUMOR 2 YEARS
RENAL CELL CARCINOMA NONE (INCIDENTAL TUMORS)
BLADDER
IN SITU NONE
INVASIVE 2 YEARS
UTERUS
CERVIX (IN SITU) NONE
CERVICAL INVASIVE 2-5 YEARS
UTERINE BODY 2 YEARS
BREAST 2-5 YEARS
COLORECTAL 2-5 YEARS
LYMPHOMA 2-5 YEARS
SKIN (LOCAL)
BASAL CELL NONE
SQUAMOUS CELL SURVEILLANCE
MELANOMA 5 YEARS
TUMOR TYPE MINIMAL WAIT TIME
ISN EDUCATION AMBASADORS Program,
PORT SAID, JULY 20-21, 2017

27. RISK FOR RECURRENT DISEASE AFTER RENAL
TRANSPLANTATION
FSGS 30-50
IgA NEPHROPATHY 40-60
MPGN-I 30-50
MPGN-II 80-100
MEMBRANOUS NEPHROPATHY 10-30
DIABETIC NEPHROPATHY 80-100 (BY HISTOLOGY)
HUS/TTP 50-75
OXALOSIS 80-100
WEGENER DISEASE <20
FABRY DISEASE <5
SLE 3-10
RECURRENT DISEASE RISK (%)
ISN EDUCATION AMBASADORS Program,
PORT SAID, JULY 20-21, 2017

28. INDICATIONS FOR PRE-TRANSPLANTATION NATIVE
NEPHRECTOMY
 Chronic renal parenchymal infection.
 Infected stones.
 Polycystic kidney disease.
 Infected reflux.
ISN EDUCATION AMBASADORS Program,
PORT SAID, JULY 20-21, 2017

29. MAJOR CONTRAINDICATIONS TO KIDNEY
TRANSPLANTATION
 RECENT OR METASTATIC MALIGNANCY.
 UNTREATED CURRENT INFECTION.
 SEVERE IRREVERSIBLE EXTRARENAL DISEASE.
 PSYCHIATRIC ILLNESS IMPAIRING CONSENT AND ADHERENCE.
 CURRENT RECREATIONAL DRUG ABUSE.
 AGGRESSIVE RECURRENT NATIVE KIDNEY DISEASE.
 PRIMARY OXALOSIS
ISN EDUCATION AMBASADORS Program,
PORT SAID, JULY 20-21, 2017

30. TRANSPLANTATION
• 2800 living donor transplant recipients [90-100 per year].
Donor nephrectomy
Kidney graft perfusion
Transplantation

31. ICU ward
Daily Laboratory
Daily Graft Doppler
Transplant Patient Flow Chart

32. IMMUNOSUPPRESSION

33. Conventional Protocol (very old not used now)
Immunosuppression protocols
Days post transplantation
CyclosporinA
Azathioprine
-2 -1 0 1 2 3 4 5 6 7 8 129 10 11 13 14 15 16 17
1 mg/dl
12.5
0.8 mg/dl
12.5
8.5
mg/dl
12.5
5 mg/dl
1.5 mg/dl
Steroids
Endoxan

34. Tripple Therapy (FK based) for high risky patients
Immunosuppression protocols
Days post transplantation
Tacrolimus
MMF
Anti-
CD25
Anti-
CD25
-2 -1 0 1 2 3 4 5 6 7 8 129 10 11 13 14 15 16 17
Steroids
3.5 3.5
0.75 mg/dl
1.5 mg/dl
3.5
8
mg/dl

35. Steroid Avoidance for low risky patients
Immunosuppression protocols
Days post transplantation
500 mg
Tacrolimus
MMF
Anti-
CD25
Anti-
CD25
-2 -1 0 1 2 3 4 5 6 7 8 129 10 11 13 14 15 16 17
250mg
100mg
Steroids

36. Rapamun based Protocol
Immunosuppression protocols
Days post transplantation
Sirolimus
MMF /Or Tacrolimus
Anti-
CD25
Anti-
CD25
-2 -1 0 1 2 3 4 5 6 7 8 129 10 11 13 14 15 16 17
Steroids
3.5 3.5
0.75 mg/dl
1.5 mg/dl
3.5
8
mg/dl

37. Preparation
(outpatient)
Inpatient ICU Inpatient
Transplant Patient Flow Chart
Operation
PatientDonor

38. INPATIENT WARD & CLINICAL ASSESSMENT BEFORE DISCHARGE

39. Radiographic Assessment
of the graft before discharge (Basal Study )
Renogram MRA

40. Transplant Subfile and
Statistical processing
Transplant Patient Flow Chart

41. Outpatient Follow up
Waiting reception
Outpatient Follow up Laboratory

42. Outpatient Follow Up Clinic

43. Outpatient
Pharmacy

44. 76 - 8485 - 8990 - 9495 - 9900 - 0506 - 10
91
315
395
418
460440
‫السنوات‬
‫الكلى‬ ‫زرع‬ ‫حاالت‬ ‫معدل‬

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