KIDNEY

TRANSPLANTATION
JOHN CHRISTOPHER A. ASILO, RPH
Masters of Science in Pharmacy with specialization in Clinical
Pharmacy and Research

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 Kidney Transplantation

■ It is the renal replacement therapy of choice for suitable patients with advanced Chronic
Kidney Disease or END-Stage Renal Disease.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Kidney Transplantation: Timing of
Referral
■ Survival after transplant is worse the longer a patient is on dialysis.
■ Patient and Graft survival are improved in patients transplanted preemptively.
■ The pretransplant evaluation and testing can take several months to complete,
potentially delaying addition to the waiting list, and therefore especially in diabetics,
early referral is essential.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Pre-Transplant Evaluation

■ The goal of the evaluation:

– To identify any contraindications to transplantation
– To determine immunologic factors impacting donor kidney options
– To screen for comorbid conditions that need to be identified and managed prior to
transplantation
– To assess psycosocial factors that could affect the success of the transplant

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Pre-Transplant Evaluation

■ The greatest morbidity and mortality from transplantation occurs in the first year after
transplant and consist both cardiovascular and infectious complications.
■ Patients with high near term mortality
■ Patients with histories of medication non-adherence or psychiatric illness that may limit
their ability to adhere to post-transplantation care need to properly address these
concerns prior to transplantation.
■ Patients with primary oxalosis should be considered carefully.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Pre-Transplant Evaluation

■ Immunology
■ Panel Reactive Antibody
■ Cardiovascular Disease
– Ischaemic Heart Disease
– Structural Heart Disease
– Peripheral Vascular Disease
– Tobacco Use
– Hypercoagulable State

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Pre-Transplant Evaluation

■ Infection
– Hepatitis B Virus
– Hepatitis C Virus
– HIV
– Tuberculosis
– Bacterial Infection
– Prophylactic Vaccination

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Pre-Transplant Evaluation

■ Malignancy
– Depending on the malignancy, a disease-free period of between 2 to 5 years is
generally accepted as adequate.
– All transplant candidates must undergo appropriate cancer screening prior to
transplantation.
■ If the cancerous lesion is less than 3 cm, the patient can proceed to transplantation. For
lesions greater than 3 cm, transplantation should be deferred for the requisite 2- 5 years
period to ensure remission prior to transplantation.
■ Urologic Disease

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 TRANSPLANTATION OPTIONS FOR
HIGHLY SENSITIZED INDIVIDUALS
■ Human Leukocyte antigen is performed in response to exposure to foreign HLA
molecules.
■ Options include:
– Paired- Donations Program
– Acceptable mismatch Programs
– Desensitization

** In order for optimal treatment to be offered to highly sensitized patients, all three in
combination probably provide the optimal solution.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Liver Donor Kidney Donation

■ Patients with CKD need to make two important decisions:

– Whether to proceed with transplantation or dialysis as primary therapy
– Whether to proceed with living donation or to go on the waiting list for a deceased
donor transplant
■ Transplant results are significantly better for recipients who undergo transplant before
initiating dialysis or after a short course of dialysis versus recipients who undergo
transplant after a prolonged dialysis course.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Kidney Transplantation

■ Regarding on choosing between living donation or deceased donor transplantation,

there is no doubt that a living donor transplant is the best option.
■ However, donation from living and deceased donor is almost identical.
■ Note that living unrelated transplant have the same olutcome as non identical living
related transplant.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Donor Surgical Risk

■ Laparoscopic Donor Nephrectomy has been associated with less pain and a faster
recovery for the donor than conventional open nephrectomy.
– As a result, laparoscopic nephrectomy has become the procedure of choice at many
transplant centers.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Donor Quality of Life

■ In general, Living donor report a similar or better quality of life.

■ Donors negative effects on recovery and future health:
– The amount of time to return to routine daily activities and commitment
– The financial consequences and implications
– The potential penalization by life or health insurance companies

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Surgical Procedure

■ Procedures:
– Cadaveric Donor Nephrectomy (En Bloc Technique)

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Pediatric Kidney Transplantation

■ Many children requiring renal transplantation will receive an adult organ.

■ This has of course an implications with regards to the size match of kidney to recipient
that is why it is necessary to place the kidney within the peritoneal cavity.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 DONATION AFTER CARDIAC DEATH
CADAVERIC DONORS

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Complications

■ Bleeding and Thrombosis

■ Hemorrhage
■ Hematoma
■ Arterial Thrombosis and Renal Vein Thrombosis
■ Uteric Complications

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Perioperative care and Early
Complications
■ Examination
– A full physical examination of patient should be performed including the
observation of fluid status, peripheral pulses and abdominal scars/hernias.
Examine also signs of infection.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Perioperative Management

■ Dialysis
– Hemodialysis is indicated before transplantation if serum potassium is greater than
5.5 mmol/l or significantly having a fluid overload
■ Drug Therapy
– Antihypertensive Medications
■ This should all be reviewed during perioperative evaluation.
– Antiplatelt and Anticoagulation therapy
■ Aspirin therapy can be continued peri-operatively, as it has not been shown to increase
the risk of postoperative hemorrhage.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Long Term Management and Outcomes

■ Advanced donor age is the strongest predictor of poor long –term graft survival.
■ Transplant glomerulopathy is an alloimmune-mediated lesion that is strongly linked to
an anti-human leukocyte antigen class II antibodies.
■ Proteinuria is common after renal transplantation and is an important marker of graft
injury.
■ Renal Transplant recipients are at 3 to 5 fold higher risk of cancer than the general
population.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 Long Term Management and Outcomes

■ Urinary Tract Infection is the most common infection in kidney transplant recipients
and usually occurs in the first year following transplantation.
■ Chronic allograft nephropathy remains the most common cause of chronic graft
dysfunction, where the mainstay if treatment is calcineurin inhibitor reduction or
withdrawal.

Klein, A. (2011). Organ Transplantation: A Clinical Guide.

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 **End of Kidney Transplantation**

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