Challenges in Renal

Transplantation

By
Salwa Mahmoud Elwasif, MD
Assistant Professor of Internal Medicine and Nephrology
Urology and Nephrology Center, Mansoura University
 Challenges before renal transplantation

• donor availability ( living Vs cadaveric, paired donation)

• Recipient age (pediatric Vs geriatric)
• Patient comorbidities
• Surgical challenges
• Availability of induction therapy
• Availability of laboratory investigation (immunological workup)
• Anesthesia challenges
 Challenges after renal transplantation

• Patient compliance
• Drug/drug interactions with immunosuppression
• Complications (diagnosis & management)
• Special circumstances (pregnancy, need of surgery)
• comorbidities
Challenges Before Renal Transplantation
 Donors …
• Ethics and legal issues
• Living :
• Hereditary disease
• Incompatible blood group

Related • Unavailable related

Unrelated
Commercialism
• Compared with grafts from unrelated donors,
grafts from immediate relatives were
associated with reduced graft failure
 Donors … (continue…)

Cadaveric:
• DCD Vs DBD
• Law
• Social acceptance.
• Religious acceptance.
• Hospital infrastructures
• Organ Transportation
Immunological Risk of The Recipient
Egyptian clinical practice guideline
for kidney transplantation 2021
 Pediatric renal transplantation
• Patient compliance with medications
• Post-transplant Follow-up.
• Exercise rehabilitation

Awareness of neurocognitive deficits may allow the pediatric nephrologist (as

well as families, educators, and general pediatricians) to educate better and
inform the pediatric KT recipient of the need for optimal medication adherence
in a way that leverages the individual's cognitive skills and minimizes cognitive
reliance on areas of weakness.
 Geriatric renal transplantation

Immune
senescence

Elderly KT recipients (>70 years) have worse overall survival at all time points and long-
term GS compared with younger recipients
The DGF, AR, death with functioning graft, and graft loss in the elderly population were
not inferior to those in the younger population.
Renal Transplantation in Ischemic Heart Disease
Renal Transplantation in Ischemic Heart Disease
Renal Transplantation in Ischemic Heart Disease
• Value of screening….
 False
positive
stress test?
 Surgical challenges
• Multiple vessels
• Short ureter ( ex. laparoscopic donor nephrectomy )
• Expanded donor criteria (angiomyolipoma, cyst, gravels….)
• Retransplant
• Atherosclerotic recipient
• Previous surgeries / PD and adhesions
• Obese recipient
• Intraoperative Surprise
 Recurrence of Original Kidney Disease
• the recurrence rate of FSGS after kidney trans-plantation
remained high. Our results indicated that young age at
transplantation and age at onset, a short time from diagnosis to
kidney failure, high level of proteinuria before KT, related donor,
and nephrectomy of native kidneys were associated with recurrent
FSGS in kidney transplant recipients.

(Renal FailuRe2023, VOl. 45, nO. 1, 2201341)

• Nephrolithiasis is one of the most common conditions affecting the
kidney and is characterized by a high risk of recurrence. Thiazide
diuretic agents are widely used for the prevention of the recurrence of
kidney stones

(N Engl J Med 2023; 388:781-791)

(Clinical Kidney Journal, 2023, vol. 16, no. 10, 1644–1655)
 Anesthesia challenges

• Assessment of volume status

• Choice of IV fluid.

• Management of hypo/hypertension

• Delayed recovery from anesthesia

Challenges After Renal Transplantation
Patient compliance
 Patient compliance

• In renal transplant recipients, compliance with medical therapy is vital.

Non-adherence is considered a risk factor for the worst outcomes in
kidney recipients, with attributed outcomes of 64% for graft loss and
80% for late acute rejection.

• non-adherence was diagnosed in one-third of renal transplant

recipients. Its definition included more than just medication.
 Drug/drug interactions with
immunosuppressive drugs

phenytoin,
Antifungals carbamazepine,
Antihypertensives and phenobarbital

Antidiabetic drugs

Grapefruit Juice
Herbals Antibiotics
Antidepressants
 Drug/drug interactions with
immunosuppressive drugs
• Omeprazole is the most prescribed PPI for the prophylaxis of gastric
and duodenal ulceration and can be the cause of unexpected
pharmacological DDIs by pharmacogenetic pathways

• switching to rabeprazole allowed the improvement of gastrointestinal

function and muscle pain as well as the decrease in creatinine levels.

(Life 2023, 13, 1627. )

 Drug/drug interactions with
immunosuppressive drugs
• Drug treatment in renal transplant patients poses a significant burden in terms of
nephrotoxicity potential and drug–drug interactions. A dedicated ambulatory clinical
pharmacy service monitoring drug use coupled with drug deprescribing strategies is
the need of the hour in this population.

(Drug Deprescribing’. 1 Jan. 2023 : 135 – 143.)

 Complications (diagnosis & management)

• Complications related to the graft (early)

• Related to immunosuppressive state (rejection Vs infection)

• Drug side effects.

• Associated morbidities
Special circumstances (pregnancy, need of surgery)

• When to allow pregnancy

• Immunosuppressive drugs monitoring

• Prenatal and postnatal follow-up

• Delivery and lactation

• Contraception
 Challenges and future prospective
• Tolerance

• Increase donor pool

• Robotic surgery

• Population culture change for deceased donor

 Take home messages
• Despite being challenging, renal transplantation is a step toward
perfection in the management of ESKD patients.

• Patient compliance and frequent follow-up are crucial for better

outcome.
 Take home messages
• Increase awareness about the beneficial effect of renal
transplantation among ESKD children

• Choice of proper immunosuppressive protocol

• Ensure compliance and patient adherence to treatment

• Frequant follow-up and registry

Thank you