5. Recipient issues in Surgery
DDKT are generally conducted at a short
notice.
Immediate pretransplant dialysis should be
avoided to minimize DGF.
If HD is necessary, UF should be minimal.
Some differences in surgical techniques
(Carrel aortic patch, IVC extensions, dual
kidney transplantation).
7. Induction Immunosuppression.
ATG is traditionally used in patients at high risk
for acute rejection.
ATG also theoretically benefits recovery from
DGF due to delayed start of CNIs.
8. Induction Immunosuppression.
Anti CD52 antibody (Alemtuzumab):
Off label use.
“prope” (almost) tolerance enabling lowering
the CNI dose or early steroid withdrawal.
The INTAC study showed lesser AR
compared to IL2Ra in low risk(n=335) and
similar results to ATG in high-risk (n=139)
patients at the end of 3 yrs in an early steroid
withdrawal protocol (but ECD, DCD, prolonged
CIT and cross match positive were excluded).
Hanaway et al. N Engl J Med 2011;364:1909-19.
9. High Risk factors for acute rejection (KDIGO):
Number of HLA mismatches.
Younger recipient age.
Older donor age.
Blacks.
PRA>0%
Presence of DSA.
ABO incompatibility.
Cold ischemia time >24 hours
In these settings the KDIGO guidelines favor the
use of lymphocyte depleting agents rather
than an IL2Ra
10. Other immunosuppresive
protocols in DDKT
Steroid withdrawal protocols has been found
to be successful in DDKT even in those with
ECD.
Data from Cornell Medical center, NY
Transplantation 2012;94
12. Data from the OPTN/UNOS showed that rATG
based induction perform better than IL2Ra and
Alemtuzumab induction in a Tac/MMF/Early
CSWD regimen.
This could be due to the favorable effects of
rATG induction in high-immune risk patients.
Sureshkumar et al. Transplantation2012;93: 799–805
14. Delayed Graft Function
Defined as: “failure of the kidney allograft to
function immediately post transplant with
the need of more than dialysis session
within one week.”
Incidence of DGF is variable:
Living Donors Tx--------------3%
Standard Criteria DDKT-----21%
Expanded criteria DDKT----29%
USRDS Data
15. It can be compounded by acute rejection and
CAN. DGF translates to a 40% reduction in
long term graft survival.
Patients with both DGF and acute rejection
had a 5-year survival rate of 34%.
Transplantation 1997; 63: 968–974.
Patients with DGF had a 49% pooled
incidence of acute rejection compared to 35%
incidence in non-DGF patients.
Nephrol Dial Transplant 2009; 24: 1039–1047.
16. Causes of ischemia in the
deceased donor kidneys.
1. Preharvest donor state 4. Transplantation of
recipient
Prolonged second warm
2. Organ procurement
ischemia time
surgery
Trauma to renal vessels
Hypovolemia/hypotension
3. Organ transport and
storage 5. Postoperative period
Cyclosporine/tacrolimus
Acute heart failure (MI)
Hemodialysis
19. Post-transplant dialytic therapy
Best is to avoid dialysis.
Minimal anticoagulation.
Avoidance of hemodynamic instability.
Peritoneal dialysis is best avoided in the 1st
week due to risks of peritonitis and spillage
over the wound site.
PD can be safely started in extraperitoneal
transplants with small volumes and gradually
increased.
Indian data from South India and Gujarat show a lower patient and graft survival as compared to the Western literature (limited experience could be a factor).
ATG has additional effects of preventing the L flooding of the donor kidney if given Intraop, endothelial protection and effects on rolling and adhesion of lymphocytes. Cochrane review also showed similar results, in which there was a reduction in AR only. A RCT (2006)on 278 (high imm. risk) DDKT had a lower incidence of acute rejection but similar incidences of graft loss, DGF and death with ATG induction compared to basiliximab. ATG group also had higher risk of infection.
OPTN data published in 2007 showed that Campath had higher incidence of AR at 6 months and 1 yr postTx but similar graft loss. Rapid and profound depletion of Lymphocyte counts and slow repopulation results in near tolerance specially marked with Campath. Significant proportion of patients in INTAC were DDKT in all the three groups.
USRDS Data
NDT study is a metanalysis of 34 studies from1988 through2007.
Even though there are conditions like acute arterial thrombosis, acute CNI toxicity, accelerated or AR, post renal cause etc, the mc cause of DGF is ischemic ATN.
CCB (DHPs)-RCT multicentric on isradipinefialed to show results.
When a diagnosis of DGF is made, it is taken for granted that all the other issues are investigated and resolved like hypovolemia, acute pyelonephritis, vascular causes etc. Recovery usually starts at 7-10 days post Tx but can be delayed by weeks.