RT PPT 3

RENAL TRANSPLANTATION:Current Practice. : 

RENAL TRANSPLANTATION:Current Practice.

HISTORY ORGAN TRANSPLANTATION : 

HISTORY ORGAN TRANSPLANTATION J. Murray , 1954 – nobel prize. KEM Hospital, Mumbai- 1965 1971- CMC(Vellore), AIIMS, PGI (Chandigarh) H O T A- 1994

GRAFTS : 

GRAFTS SYNGRAFT- b/w Identical twins (No immunosuppression required) ISOGRAFT- from one part to other in same person ALLOGRAFT- b/w two different persons of same species ( commonest) HETEROGRAFT- b/w two different species.

Advantages R T : 

Advantages R T Better long term patient survival Better quality of life Complete Rehabilitation Economically cheaper to patient & society

CONTRAINDICATIONS : 

CONTRAINDICATIONS ABSOLUTE 1. Reversible Renal Failure 2. Active on – going infections 3. Advanced Malignancy 4. Severe C A D / C V D RELATIVE 1. Major psychiatric illness 2. Advanced iliofemoral disease 3.Irrepairable lower urinary tract

Donor R .T : 

Donor R .T Living Donor Transplant 1. Related 2. Unrelated Cadaveric 1.Heart beating 2. Non-heart beating

Criteria L R D : 

Criteria L R D Should be an adult Preferably Below 65 but not absolute Donation should be without any pressure No monetary transaction

Marginal Donors : 

Marginal Donors Sibling of diabetic recipient Mild hypertension without any end organ damage Single stone in kidney with negative metabolic workup for stone Borderline GFR in an elderly donor Simple Cysts Correctible Obstructive uropathy

Investigations : 

Investigations A. Blood group matching (transfusion principles) Complete Haemogram Complete Urine examination Detailed Biochemistry E C G Chest X-ray Cardiac , Psychiatric evaluation, Gynaecological Clearance in a female donor

Inv Contd. : 

Inv Contd. Viral status Hbs Ag Anti-HCV HIV CMV EBV Tuberculosis X-Ray KUB Ultra sound Abodomen Micturating Cystourethrogram Intravenous Pyelogram

Special Investigations : 

Special Investigations HLA matching for A,B, DR , DQ , antigens Panel reactive antibodies Cross match test Glomerular Filtration rate by Nuclear method test Renal angiography for donor

Structure of the HLA class I and class II antigens : 

Structure of the HLA class I and class II antigens

Organization of the human HLA genes on chromosome 6. : 

Organization of the human HLA genes on chromosome 6.

SURGICAL PROCEDURE : 

SURGICAL PROCEDURE In LRD , recipients kidneys are not removed. Indications –Native Kidney Nephrectomy 1.Very large polycystic kidney (transplant side) 2.Peristant infection 3.Suspicion of malignancy in native kidney. 4.Severe malignant hypertension not controlled on medical treatment

IMMUNOSUPPRESSION : 

IMMUNOSUPPRESSION

Immunologically high Risk Patients : 

Immunologically high Risk Patients Second renal Transplant High Panel Reactive Antibody Children Diabetic Recipient Black Race 4-6 Antigens Mismatch RT with delayed graft function

Induction Antibodies : 

Induction Antibodies Anti-Thymocyte Globulin(ATG) Interleukin-2 recepetor Antibodies(IL-2 rab) Anti-CD25 antibodies(Daclizumab,Basiliximab) Anti-CD52 antibodies(Alemtuzumab) OKT3 – against CD3 complex

Characteristics IMS : 

Characteristics IMS

COMPARATIVE POINTS OF IMS DRUGS : 

COMPARATIVE POINTS OF IMS DRUGS

Complications RT : 

Complications RT

Renal Allograft Rejection : 

Renal Allograft Rejection 1- Hyperacute. 2- Acute. 3- Chronic.

Hyperacute Rejection : 

Hyperacute Rejection Is mediated by preformed antibodies that recognize HLA antigens in donor organ. Usually these are formed as a consequence of blood transfusion, pregnancy, prior organ transplantation, autoimmune diseases. Fibrinoid necrosis lead to immediate graft loss. Delayed form may occur several days following transplantation. Plasmapheresis and pulse steroid may be used

Hyperacute rejection : 

Hyperacute rejection

Acute Renal Allograft Rejection : 

Acute Renal Allograft Rejection Is mediated by activated T-lymphocytes. Activations of T-cells occur after recognition of graft antigen This usually occur during the first 6 mon. It manifests as increase in s. creatinine with or without oliguria.

Histology of acute cellular rejection : 

Histology of acute cellular rejection

Treatment Of Acute Rejection : 

Treatment Of Acute Rejection Pulse steroids ATG, OKT3. MMF, Tacrolimus. IVIG. More than 90% of acute rejection episodes occuring in the first 6 mon can be reversed.

Chronic allograft Rejection : 

Chronic allograft Rejection Manifest clinically by a slow and gradual decline in renal function, usually more than 6 mon after transplant and typically accompanied by moderate to heavy proteinuria. Histologically, characterized by glomerulo-sclerosis, interstitial fibrosis, and obliteration of arteriolar lumina. Treatment is unsatisfactory.

Chronic rejection with tubulointerstitial lesions : 

Chronic rejection with tubulointerstitial lesions

Banff criteria for diagnosis of allograft rejection : 

Banff criteria for diagnosis of allograft rejection

Acute tubular necrosis : 

Acute tubular necrosis Due to Ischaemia- warm / cold Presents as 1.Delayed Graft function 2.Early Graft dysfunction

Chronic Complications : 

Chronic Complications Chronic Graft dysfunction Hypertension Post Transplant Diabetes Infections Bone disease Cataract Acclerated Atherosclerosis Malignancy(Kaposi,Lymphoma)

Factors Important For Good RT Outcome : 

Factors Important For Good RT Outcome

Slide 36: 

Thank You