Assessment of adult kidney transplant recipient

Dr Sunil kumar Prajapati

Purpose of evaluation

• Minimize the morbidity and mortality & maximize quality of life

• Protect living donors & scarce resource of deceased and living donor kidneys

• Survival advantage of transplantation –– any age, gender, ethnicity, with/without diabetic kidney

disease

Timing of evaluation

• If preemptively transplanted (before dialysis) - best outcomes

• GFR ≤20 mL/min• Rate of progression

– Patient with diabetes may progress relatively rapidly hence there is no sense in delaying transplantation if a living donor is available

– eGFR - 30 mL/min

• Clinically uremic

Interested in transplantation

Preliminary screening (no comorbidities)

ABO blood group, HLA typing

No obvious C/I

Judge case by case

Yes

Complete medical evaluation, history, examination & test

Optimize medical status No transplant

If no living donor place on waiting listProceed with living

donor transplant if available

Review every 2 years

Absoluet C/INo C/IRelative C/I

Relative/absolute Contraindications

• Not irreversible contraindications– life-threatening infections, cancer, unstable CVD,

noncompliance, psychatric illness– Not expected to survive >2 years with a kidney

transplant– ABO incompatibility, Positive T cell mismatch– Severe obesity BMI >40

Low risk(Age < 45 yrs, no

traditional risk factors)

History & examination

Medium risk (Age > 45 yrs or any traditional

risk factor)

High risk (angina +ve)CAG

Intensify conservative Management Proceed with listing &

review every 2 yrs

Appropriate intervention

Stress test

-ve +ve

Cardiovascular Disease

Cardiovascular Disease contd..

• Pre & perioperative βB reduces cardiac events in high-risk patients

• H/o stroke or TIA should be symptom free for at least 6 m before transplantation– Aspirin prophylaxis– Risk of perioperative bleeding is generally outweighed by

the benefits• History of PAD, or claudication symptoms

– examine for signs of lower extremity arterial insufficiency– Consider USG or MR angio to image the aorta and iliac

arteries

Obesity

• BMI ≥ 30 kg/m2 is associated with • death, graft failure, wound dehiscence, wound infections, HTN, ↑ risk

for developing DM after transplantation

• Generally not an absolute C/I - weight loss is required if BMI is > 40 kg/m2

• If diet is unsuccessful, bariatric surgery should be considered for BMI ≥40 kg/m2

Infections • Conditions that increases the chances of serious

post-transplant infections– Splenectomy– Immunosuppressive or chemotherapeutic agents– Prior organ/BMT– Acquired or inherited immunodeficiency syndromes– Malnutrition– Open wounds (including dialysis catheters), Poor dentition– Travel to endemic areas– Occupational exposure

Infections contd..

• Immunization may be less effective in stages 4 & 5 CKD, but there is little risk & potentially great benefit

• Asplenic patients - Hemophilus influenza & Meningococcus• live vaccines (VZV) should not be administered immediately before transplantation

HIV +ve pt. may be transplant candidates if…

• Adherent to a highly active antiretroviral therapy regimen• Undetectable virus load• Sustained CD4 count >200/mL• No opportunistic infections• No life-threatening malignancies• Appropriate expertise available

Infections contd..

• Hepatitis B– HBsAg, HBe-antigen, & viral load– Chronic active hepatitis, cirrhosis, & HCC - risks

aggravated by immunosuppression– HBV replicator – tt. with lamividine pre & post-

transplantation

Infections contd..

• HCV– liver disease & new-onset diabetes after kidney

transplantation– Patients with HBV, HCV, chronic active hepatitis,

cirrhosis are at high risk for developing HCC - baseline & follow-up levels of α-FP

HCV RNA -ve

Anti HCV +ve

HCV RNA +ve

Cirrhosis or precirrhosisNormal

Defer transplant or consider combined liver-

kidney transplant

Liver Bx

Normal LFT

List fro renal transplant

Hepatitis

HCV RNA -ve

Antiviral Rx

HCV RNA +ve

Pt by pt decision

Pulmonary Disease

• Smoking - 2.4 & 2.9 RR for the development of ESRD in men and women respectively

• Quit smoking prior to transplantation

• If history of cigarette smoking and/or shortness of breath do PFT & chest x-ray

Recurrent Kidney Disease

• Incidence of graft failure due to recurrent disease is probably not high enough to preclude transplantation in most cases

• Exceptions– ≥2 grafts loss due to recurrent idiopathic FSGS

(Plasmapheresis)

Recurrent Kidney Disease

Genitourinary Disorders

• Asymptomatic and absent history of bladder dysfunction do not usually require further evaluation

• Adequate urinary drainage prior to transplantation (at least 6wks)

• Chronic Kidney Disease Management • Anemia• Physiologic calcium, phosphorous, vit. D & PTH levels• Should not have a dialysis access infection or peritonitis (if

being treated with chronic peritoneal dialysis) at the time of transplantation.

Thrombophilias

• ≈ 2% allografts are lost to thrombosis• Perioperative anticoagulation can prevent– Screen if h/o venous thrombosis, including recurrent

hemodialysis access thromboses– Factor V Leiden, prothrombin G20210A mutation, Antiphospholipid

antibodies

– If any of these are positive, perioperative anticoagulation could be given

– Other indications• Recipient is younger • Donor is < 2 yrs age

Malignancies

• life-threatening - C/I• Same cancer screening as recommended for the

general population– Colonoscopy every 5 years for > 50 years– Mammography for > 50 years , younger if family h/o breast

cancer– Annual pelvic examination with cervical cytology testing– >50 years - DRE & PSA testing for prostate cancer (controversial)

– Cystoscopy for high-risk patients screening for bladder cancer• Analgesic nephropathy, chronic exposure to cyclophosphamide.

Patients with a history of prior malignancy, how long to wait?

Noncompliance and Cognitive Impairment

• Substance abuse – substance free for at least 6 months before being accepted for transplantation.

• Patients with cognitive impairment should probably not undergo transplantation

Immunologic Evaluation

• Preformed antibodies – prior transplantations– Pregnancies– blood transfusions

• Test measures Ab induced lysis of a panel of lymphocytes from different individuals in the population.

• The higher the panel reactive antibody (PRA; range 0%–100%) titer, the more difficult it will be to find a donor, that the potential recipient will not reject with an antibody-mediated rejection

Immunologic Evaluation contd..

• The PRA is generally measured at the time of transplant evaluation and then periodically (every 3 mth)

• PRA declines with time, especially if blood transfusions are avoided • Still may have an anamnestic Ab response if re-exposed to an

antigen - wise to avoid• HLA - graft survival is better with fewer mismatches (range 0-6)• Generally, the donor and the recipient must be blood group-

compatible (Except when donor is BG A2)• Whether a particular kidney can be transplanted is determined by a

final cross-match that measures whether the recipient has an antibody to the donor kidney

Special situations…

Children

– Body weight > 11kg, – Infant donors – high chances of graft thrombosis – Best result when donor is young adult

Diabetic nephropathy

– Most common cause of death is MI, CHF– Special attention to bladder emptying & foot ulcers– Early transplant– Combined pancreas and kidney transplant is beneficial for

nephro & neuropathy, while effect on retinopathy & vasculopathy is unclear

Oxalosis

– ESRD before 30 years– Aggressive preoperative dialysis, forced diuresis– Pyridoxine, orthophosphates, thiazides post

transplantation– Combined liver and kidney transplant is better – Isolated kidney transplant in late onset form only– Transplant when GFR – 25ml

Nephrectomy

• Large renal stone• Gross abnormalities of urinary tract• Persistent infection• PCKD– Persistent infection– Very large kidney hindering graft placement– Drug resistant HTN

Dialysis

• Dialysis immediately preceding transplantation only if hyperkalemia or unacceptable fluid overload. Increased risk of bleeding.

• If dialysis is done than pt should be adequately hydrated

• Pt on PD should continue dialysis until the time of transplantation, peritoneal cavity should be drained before surgery

Take home message..

Assesment of patient before transplantation

• History & physical examination– General

• Cause of CRF, duration, HTN• Infection• Previous transplantation

– Other disease• CVD, malignancies(prev. or current), respiratory, GIT• DM

– Previous operations• Nepherectomy, splenectomy, parathyredectomy, appendectomy etc.

– Family history– Current clinical data and tt

• Mode & duration of dialysis• BP• Urine – volume• Sign & symptoms of neuropathy• Previous BT & pregnancies• Diet Drugs

Assesment of patient before transplantation contd..

• Laboratory examinations– Hct, TLC, DLC, absolute lecocyte count, plt. Count– Ca, phosph, Alk phosph, PTH– LFT– CMV Ab, HBs Ag, HB Ab, HCV Ab, EBV Ab, HIV Ab– Urine C/S– Radiological exam– CXR, USG – Others

• ECG, Fundus, Urological exam

• Immunological exam• Blood grouping• Tissue typing, family typing• Antibody screening

Thankyou