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KIDNEY TRANSPLANT

Q.674.What is the risk of donor nephrectomy?

KIDNEY TRANSPLANT



Q.674.What is the risk of donor nephrectomy?

A. I. Immediate risk: The most important peri-operative risks include.:

(1) Atelectasis.

(2) Pneumothorax.

(3) Pneumonia.

(4) Urinary tract infection.

(5) Wound complication.

(6) DVT with or without P.E.

(7) Death.

To 🠋 risk for perioperative T.E., women are required to discontinue hormonal contraception or hormone R.T. 6 w.s prior to donor nephrectomy. Estrogen containing intra-uterine devices & vaginal rings should be removed 6 w.s prior to surgery, since they carry risk of T.E. Low-dose progesterone only (<30 mcg of levonorgestrel) or intra-uterine devices may be continued, as there’s very little data to support an increase. risk for T.E. Most operations on living donor are performed laparoscopically vs open approach.

II. Long-term risk: Overall long-term survival after donor nephrectomy is the same as similar matched individuals who did not undergo surgery. Alth. 50 % of functioning R. mass is removed after unilateral nephrectomy, compensatory hypertrophy é remaining normal kid. returns GFR to 70 % baseline at 10-14 d. & 75-85 % of baseline é long-term follow-up . In addition, long-term follow-up have not shown a progressive loss of GFR over time. Despite good long-term R. outcomes in almost ptn.s who have undergone unilateral nephrectomy, there have been occasional rep. of ESRD, possibly due in some to hereditary f.. So, some have suggested: annual assessment of R. function, include: screening for Prot. Most Tx. programs recommend: donors periodic follow-up é their primary care doctors. Specific risk of 🠉B.P. over time after donation still needs further studies. Racial differences in medical outcomes post-nephrectomy was observed. Comp. to white donors, black donors had é risk of H.T., D.M. tht needed medical thpy, & CKD. Hispanic donors had similar outcomes as black donors. However, comparisons to NHANES data sugg.: incr. risk of these morbidities is not greater thn tht ass. é blacks in general population. There’re no definitive studies shown🠞donor nephrectomy🠉 risk of D.M., H.T., CKD. in black race . Multicenter donor registry is essential for long-term foll. up of all donors to fully understand the risk of nephrectomy across race, age & sex. African/American & Hispanic donors should be counseled by the “living donor advocate. In potential donors of African-American or Hispanic ethnicity, the most conservative assessment for GFR, 24-h. ambulatory B.P. monitor-ing & gluc. tolerance testing, are recommended. However, studies evaluating long-term risks of nephrectomyPtn. & R. outcomes are generally excellent😃😀

Q.675.What is the recommended issues as regard renal transplantation in diabetic nephropathy?

A. Dc Np🠞the most common cause ESRD in Western societies. It’s the etiology of ESRD in 20 % of R.Tx. recip. in U.S.. R.Tx. offers🠞best survival advantage. among diabetics é ESRD. Pre-DX. Dc.s é CKD eligible for Tx., preemptive R.Tx. is recommended rather initiation of DX. & then Tx.. Diabetics é ESRD already on DX., we recommend: R.Tx. rather than continued DX. & living donor kid. is preferred to a deceased one. We suggest: wait-listed Dc.s should accept extended criteria donor kid. rather thn wait for standard donors. Referral to Tx. center shd be é  GFR <40 mL/min,👈for preemptive Tx.  🔔 To detect CAD & perhaps lower risk of S.E. é Tx. (esp. surgery), Dc.s é ESRD evaluation for CAD. Optimal approach to Dc kidney Tx. recipient is unclear. Screening dobutamine  stress echo. is recomm. as initial noninvasive test é initial screening coronary angio., given superiority of this test & potential S.E. of catheterization. Cardiac cth. is performed é Sm and/or Sn consistent é CAD., P.H. of M.I., and/or unstable angina, unless recent revascul-arization ws done. Post Tx. hents incl.: 🠋UTI., allog. Rj., malignancies, & recur. dis. in allograft, & glycemic control. Dc. R. Tx., it’s recomm.:🠞 A.B. for prox. agnst UTIs. TMP/SMX indefinitely, unless there’s C.I. or they’re unable to tolerate it.

Q.676.What is the effect of pulsatile perfusion on allograft survival?

A. In a previously published study, machine or pulsatile perfusion of the kidney to be transplanted, vs cold storage, appeared to dcrease the incidence of delayed allograft function & improve allograft survival at one year. In a follow-up report of this study, the three-y. graft survival remained superior for machine perfused kidneys compared é cold storage.

 Q.677. What are the recommended issues for dialysis prior to and after R.Tx.?

A. Preemptive Tx. & outcomes: There’s compelling evidence for avoidance of DX é early preemptive Tx.. This strategy shd be aggressively pursued, espicially for young ptn. é [preserved functional status, low levels of Ssz & low comorbid burden dis.]. However, only 20 % of living donor & 5 % of deceased donor Tx. are performed preemptively in U.S.. This’s due to rapid expansion in No. of Tx. candidates with No parallel expansion of donor pool. However, it also stems fr. failure to recognize DX. as a modifiable risk f. for relatively poor post-Tx outcomes. Pre-Tx. DX. modality & Tx. outcomes: HDX best avoided immediately prior to Tx. unless signif. volume overload/hyperk+ coexist. If unavoidable 🠞 biocompatible membrane Dzer é minimal or no fluid removal should be considered.

DX. immediately post-Tx. & outcomes: Need for DX. é 1st postoperative w. after Tx. [DGF] has been independently ass. é nearly 2-3 fold incr. in M.R.., graft failure & death-censored graft failure . Although usually due to post-ischemic ATN., DGF may also be the result of Rj. episodes, urinery obstruction, or allograft thrombosis. The nonsp. inflmm. é ATN might 🠞upregulation of “adhesion molecules  & enhanced MHC class I & II Ag expression, eventually 🠞Ac. Rj.. In this context, a signif. association has bn noted between DGF & early Ac. Rj.. In cadaveric R.Tx., 25 % Ac. Rj. rate was reported é presence of DGF vs only 8 % without DGF.

It’s speculated: early R. injury ass. é DGF may 🠞 fewer functioning nephrons 🠞 hyperfiltration injury & fibrosis ; this may eventually have an adverse effect on graft survival. Occurrence of DGF alone ws noted to decr. allograft ½-life fr. 14. 2 y. to 9.4 y. If superimposed é Ac. Rj. é 1st 6 post Tx. ms., this ws further 🠟to 6.2 y., synergistic adverse effects of Ac. Rj. & DGF on graft survival. Comp. é H.DX., incid. of DGF is signif. lower for P.D.. Evolution of graft func. (determined by T1/2 s. cr.) is also much faster for P.D. Despite these significant beneficial effects, preTx. P.D. has been ass. é higher rate of early graft losses🕭

Q.678. What are the general considerations on renal transplantation in elderly patient?

A. The most important outcomes é any form of RRT are ptn. survival & quality of life. In younger ptn., Tx. hs 3 potential adv., compared with DX.:

1)    Longer survival.

2)    Better quality of life.

3)    Release from tedium of DX.

Additional aspects of R.Tx. tht may differ in elderly patient incl.:

1)    Ethics of Tx.

2)    PreTx. evaluation

3)    Mechanisms of graft loss & death

4)    Degree & type of im/m. therapy.

Tx. vs DX : A paucity of data exists concerning relative M.R. é DX vs Tx for elderly ESRD ptn. There’s a similar lack of data concerning quality of life. Survival: Older studies comparing survival after R.Tx. to continued DX. were tainted by methodologic flaws, such as selection bias. However, subsequent recipient that have limited these methodologic problems show a survival adv. é Tx. among the elderly, incl. recipients of extended criteria donor kidneys.                    

Quality of life: Successful R.Tx. improves overall quality of life and relieves the burden & tedium of DX among all ptn.s é ESRD. However, insufficient information exists as to the impact of Tx. on energy level of the elderly ptn. One study, e.g. found: average recip. 60 y. of age & older did not gain strength (quadriceps & grip strength & stepping up on a chair) é 1st y. after Tx. Findings of improved well-being after Tx may also be due in part to amelioration of anemia. This ass. has been noted in DX ptn.s in whom successful ttt of anemia é Epo is strongly ass. é significant improvement in general well-being.                       

Summary: Due to many adv., some clinicians sugg.: in abs. of C.I., Tx. should be offered as RRT to all patients independent of age.