8/07/2014 cccn 2014 renal transplantation - bvn-sbn.be transplantation 28... · 2014. 7. 8. ·...

8/07/2014

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CCCN 2014

Renal transplantation

28/06/2014

Patrick Peeters, M.D.

Ghent University Hospital, Belgium

Plan of presentation

1. Indications.

2. Contra-indications.

3. Allocation and donor aspects.

4. Patient work-up.

Casus: ♀ ° 1965

- ATCD:

‣ 1991 Abruptio placentae

‧ Hypovolemic shok -> AKI

‧ Polytransfusion +++ : 50 units PC

‣ 2008 CKD stage 5 -> pretransplant evaluation

‧ antiHLA class 1 : strongly positive

‧ AntiHLA class 2 : strongly positive

‧ vPRA 99.8%

‧ -> Eurotransplant Acceptable Mismatch program

‣ 2009 CKD stage 5d -> start HD

Patrick Peeters, M.D. – Dept Nephrology Ghent University Hospital, Belgium

8/07/2014

2


1/ Kidney transplant indications.


Integrated ESRD Care

Residual

Renal

Function

Hemodialysis Cre

atinin

e C

leara

nce

(ml/m

in)

20

15

10

5

0

Time on

Dialysis Initiation of Dialysis

Transplantation

Peritoneal Dialysis

Transplantation

PD

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Why organ transplantation?

Organ transplantation is

Most effective

Life-saving

Cost-effective

Patient survival

Wolfe NEJM 1999; Meier-Kriesche Transplantation 2002

Patient survival

Wolfe NEJM 1999

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Graft outcome living versus deceased donor

transplantation

Terasaki P et al. N Engl J Med 1995;333: 333-336

Quality of life

-93% of the patients consider Tx as a new life and

a curative option

-90% have an increased quality of life

-> 75% can play an active role at home and carry

out housekeeping.

-45% go working again as before.

Total cost for all patients

.00 1.00 2.00

PERIOD

0

20000

40000

60000

80000

M ean TO TG LO B

8776

46036 43619

22150

78422

68592

24356

12810

4892

TYPE

PD HD Tx

Type:

0 = PD

1 = HD

2 = TX

Period:

0 = 1th hospital

1 = Year 1

2 = Year X

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Guideline 1.1 – Tx : Access to renal

transplantation UK 2011

We recommend that kidney transplantation should

be the renal replacement therapy of choice for

patients with chronic kidney disease stage 5 who

are considered fit for major surgery and for

chronic immunosuppression. All patients predicted

to have an increased life expectancy post-

transplantation should be assessed for

transplantation. Placement on the transplant

waiting list will be limited by individual co-

morbidity and prognosis. (1A)




We recommend that living donor transplantation

should be considered the treatment of choice for

all patients suitable for renal transplantation when

there is an appropriate donor. (1A)


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6–12 months 12–24 months >24 months

Pre-emptive

Living donor graft survival

Duration of

pretransplant

dialysis

<6 months

Ev

en

t-fr

ee s

urv

ival

(%)

Months post-transplant

100

80

60

40

20

0 0 12 24 36 48 60 72 84 96 108 120

Meier-Kriesche HU, et al. Transplantation 2002;74:1377– 81

Pre-emptive

<6

12

24

>24 0

20

40

60

80

100

0

20

40

60

80

100

Living

29 Cadaveric

94

Meier-Kriesche HU, et al. Transplantation 2002;74:1377– 81

Annual adjusted graft loss

rates per 1,000 patients

Annual adjusted graft loss

rates per 1,000 patients



We recommend that patients with progressive

deterioration in renal function suitable for

transplantation should be placed on the national

transplant list within six months of their anticipated

dialysis start date. Pre-emptive transplantation

should be the treatment of choice for all suitable

patients whenever a living donor is available. (1A)


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We recommend that there must be demonstrable

equity of access to deceased donor kidney

transplantation irrespective of gender, ethnicity or

district of residence. (1A)




We recommend that age is not a contra-indication

to transplantation but age related co-morbidity is

an important limiting factor. (1B)




We recommend that all transplant units should

have written criteria for acceptance on to the

waiting list. The benefits and potential risks

associated with transplantation should be fully

explained both verbally and in writing. Potential

transplant recipients should be informed of all

donor options including living related and

unrelated donation. (1C)


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We recommend that all CKD 5 patients and CKD

4 patients with progressive disease should have

their suitability for transplantation assessed

annually and that appropriate patients should be

referred to a transplant centre. When

transplantation is considered inappropriate the

reason(s) should be documented. Patients should

be placed on, or removed from the waiting list only

after discussion and agreement with the

nephrologist, transplant surgeon and the patients

themselves according to local practice. (1C)




We recommend that the care of the renal

transplant recipient is best undertaken by a multi-

disciplinary team. (1C)




We recommend that simultaneous kidney-

pancreas transplantation or living donor renal

transplantation is the treatment of choice for

patients with Type 1 diabetes mellitus who are

suitable for renal transplantation. (1B)


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2/ Kidney transplant contra-indications.


Cancer – ERBP 2013


Cancer – ERBP 2013


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C2H5OH - ERBP 2013


HIV – ERBP 2013


aHUS – ERBP 2013


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The paradox of transplantation

UNDER-

IMMUNOSUPPRESSION

COMPLICATIONS REJECTION

OVER-

IMMUNOSUPPRESSION

The AXIS of EVIL - GW Bush

•Cardiovascular disease

•Infection

•Cancer

P Peeters, M.D. – Dept Nephrology - Ghent University Hospital, B

27 01 2011 Kuwait

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Mortality following kidney transplantion

Infection

Malignancy

Other

Cardiovascular

Cerebrovascular

20%

13%

7%

37%

23%


Factors affecting the net state of

immunosuppression in transplant recipients


Rubin

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Retrospective analysis of ANZDATA between 1980 and 2007

CVD is a leading cause of death with

a functioning graft

De

ath

ra

te

(pe

r 1

00

pa

tie

nt-

ye

ars

) 1,7

0,60,7 0,7

1,8

0,60,5

0,4

1,2

0,7

0,4 0,4

1,1

0,7

0,40,3

1

0,8

0,4 0,4

0,9

0,7

0,3 0,3

0,0

0,2

0,4

0,6

0,8

1,0

1,2

1,4

1,6

1,8

2,0

Cardiovascular Malignancy Infection Other

1980–1984

1985–1989

1990–1994

1995–1999

2000–2004

2005–2006

CVD, cardiovascular disease Pilmore HL et al. Transplantation 2010;89:851–7


Cardiovascular risk factors in transplant

recipients

Diabetes

Hypertension

Dyslipidaemia

Smoking

Vascular disease

Pre-transplant

– low GFR

– proteinuria

– phosphate,

calcium, PTH

– LVH, arterial

stiffness

– anaemia

● NODAT

● Hypertension

● Dyslipidaemia

● Smoking

● Increased age

Post-transplant

– low GFR

– proteinuria

– LVH

– Anaemia

– Inflammation

GFR, glomerular filtration rate; PTH, parathyroid hormone;

LVH, left ventricular hypertrophy; NODAT, new-onset diabetes after transplantation

Rigatto C et al. J Am Soc Nephrol 2003;14:462–8;

Ojo AO. Transplantation 2006;82:603–11

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Eve

nts

(%

)

Holdaas H et al. Nephrol Dial Transplant 2005;20:974–80

Impact of statin usage: ALERT trial

Cardiac death and non-fatal AMI to 5 years

p=0.002

0

1

2

3

4

5

6

7

8

9

10

Time after randomisation (years)

Placebo

Fluvastatin

1 2 3 4 5

56%

0

512

503

502

483

487

466

468

449

417

417

522

521

No. of patients at risk

Fluvastatin

Placebo AMI, acute myocardial infarction

Post-hoc analysis of 2102 renal transplant recipients with total cholesterol

levels of 4-9 mmol/L randomised to receive either fluvastatin or placebo

Presence of LVH is a strong determinant

of risk of cardiovascular disease

LVH is detected in 74% of patients at start of dialysis1

LVH in the 5th year post-transplant predicted death (RR 2.15)2

Pa

tie

nt

su

rviv

al

(%)

1. Parfrey PS et al. Nephrol Dial Transplant 1996;11:1277–85;

2. Rigatto C et al. J Am Soc Nephrol 2003;14:462–8

p=0.02

0

20

40

60

80

100

0 10 20 30

No LVH in 5th year (n=236)

LVH in 5th year (n=38)

Time post-transplant (years)

LVH, left ventricular hypertrophy; RR, relative risk

Retrospective cohort study of LVH in renal transplant recipients


26 01 2011 Kuwait

Relative tumor risk after renal

transplantation

Cancer risk Cancer site RR

Small

(RR > 2)

Lung

Bladder, urothel.

Sarcoma

Liver

CNS

Melanoma

Cervix, vulva,vagina

2.67

2.81

3.38

3.96

3.99

4.13

4.42

Intermediate

(RR > 5)

Thyroid

Multiple myeloma

PTLD (vs. NHL)

Farynx, larynx

5.09

7.33

8.50

12.85

High

(RR > 15)

Kidney

Skin (non-melanotic)

Kaposi sarcoma

17.60

52.70

142.32

All malignancy

RR = 4.3

Adapted from Wimmer CD et al, Kidney Int 2007; 71: 1271

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26 01 2011 Kuwait

Risk factors associated with post-transplant

malignancy

Increasing age1,2

Exposure to UV light1

Previous exposure to carcinogens1

Genetic predisposition1,2

History of malignancy1

Cigarette smoking2

Analgesic abuse2

Immunosuppressive regimen,

eg CsA3 or tacrolimus6

Chronic viral infection2

Previous treatment with cytotoxic

agents, e.g. cyclophosphamide2

Transmission of malignancy

from donor2

Levels of immune system

components, eg high regulatory T-cells4

MMP-26 and MMP-9 levels5

Time after transplant6

Duration of haemodialysis6

Race6

Age at time of transplant6

1. Valantine H. J Heart Lung Transplant 2007;26:557–64;

2. Morath C et al. J Am Soc Nephrol 2004;15:1582–8; 3. Hojo M et al. Nature 1999;397:530–4;

4. Carroll RP et al. J Am Soc Nephrol 2010;21:713–22;

5. Kuivanen T et al. J Cutan Pathol 2009;36:929–36; 6. Imao T et al. Cancer 2007;109:2109–15

UV, ultraviolet; CsA, cyclosporin;

MMP, matrix metalloproteinase

43

Conventional Transplant specific

3/ Kidney transplantation

- allocation.

- donor aspects.


Transplant Newsletter 2008 – Council of Europe

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Transplant Newsletter 2008 – Council of Europe


Eurotransplant: donation,

waiting lists and transplants

Bron: ET Jaarverslag 2012

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Number of deceased donors in

Eurotransplant, used for a transplant


Number of deceased donors used for

transplant, per million population


Median age of deceased donors in

Eurotransplant, used for a transplant


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Median age of patients on active waiting

list at year end


Median waiting time for patients on

active waiting list at year end


Median age of transplant recipients

(deceased donor transplants)


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Median waiting time to transplant

(deceased donor transplants)


Kidney waiting list, percentage of

patients at year end, by urgency


Number of deceased donor kidney transplants, by

recipient urgency at transplant


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Dynamics of the Eurotransplant kidney transplant

waiting list and transplants


Dynamics of the Eurotransplant pancreas+kidney and islet+kidney

waiting list, pancreas+kidney, islet+kidney, pancreas and islet-only

transplants


Eurotransplant Statistics 2013

Registrations on the kidney waiting list

Per country, 2012/2013 (compared to 2009-2011)

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Reason for kidney exchange with other ET countries

Eurotransplant, Jan 2008 – Sept 2013


Impact of kidney organ exchange on

selected patient groups

Belgium, 01.01.2001 - 31.12.2005

Evolution of the donor offers

Convertieratio UZG : 64,1 %

0

10

20

30

40

50

60

70

80

90

100

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Donor Potentiëel Donor Effectief

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Donor refusal

Overlijdensoorzaak donoren

0%

20%

40%

60%

80%

100%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

SHT na VKO Ander SHT CVA Anoxie / ander

Reason of donor death

Vascular Pancreas donor: 49 y

Heart donor: 63 y

Lung donor: 73 y

Kidney donor: 75 y

Liver donor: 90 y

Belgium: Oldest Organ donors 2013

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DCD - NON HEART BEATING DONOREN

donoren DCD ; België 2013 : 21,2 % .

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

% NHBD 0 3,6 19,1 16,3 4,8 15,8 12,5 12,3 11,4 14

% HBD 100 96,4 80,9 83,7 95,2 84,2 87,5 87,7 88,6 86

0,0

5,0

10,0

15,0

20,0

25,0

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

%

% DCD België % DCD UZ Gent

ECD score

Age O I

Screat O I

Hypertension O I

CVA O I

YES /NO

Improved Scoring System to

Assess Adult Donors For

Cadaver Renal Transplantation

Scott L. Nyberg

American Journal of Transplantation 2003: 715–72

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Table 2. Association between donor variables and recipient

creatinine clearance at 6 months

Donor variable

p-value by

univariate

analysis

p-value by

multivariate

analysis

Delta R21

1.1 Improvement in R2 by adding donor variable to linear regression

model.

Age < 0.001 < 0.001 0.0950

Creatinine

clearance < 0.001 < 0.001 0.0044

History of

hypertension < 0.001 < 0.001 0.0027

HLA mismatch < 0.001 < 0.001 0.0019

Cause of death < 0.001 < 0.001 0.0013

Duration of cold

ischemia < 0.001 < 0.001 0.0009

Ethnicity < 0.001 < 0.001 0.0003

CMV antibody

status < 0.001 0.019 0.0002

History of

diabetes

mellitus

< 0.001 0.022 0.0001

Improved Scoring System to Assess Adult Donors For Cadaver Renal Transplantation

American Journal of Transplantation

Volume 3, Issue 6, pages 715-721, 28 MAY 2003 DOI: 10.1034/j.1600-6143.2003.00111.x

http://onlinelibrary.wiley.com/doi/10.1034/j.1600-6143.2003.00111.x/full#f3





http://onlinelibrary.wiley.com/doi/10.1111/ajt.2003.3.issue-6/issuetoc

http://onlinelibrary.wiley.com/doi/10.1034/j.1600-6143.2003.00111.x/full









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Table 3. System for scoring adult donors in cadaver renal

transplantation

Variable Score

•CVA = cerebrovascular accident, including ischemic and

hemorrhagic types.

•1 To convert values to mL/s, multiply by 0.01667.

Age, y

< 30 0

30–39 5

40–49 10

50–59 15

60–69 20

≥ 70 25

History of hypertension

None 0

Yes; duration unknown 2

≤ 5 y 2

6–10 y 3

> 10 y 4

Creatinine clearance, mL/min1

≥ 100 0

75–99 2

50–74 3

< 50 4

HLA mismatch, no. of antigens

0 0

1–2 1

3–4 2

5–6 3

Cause of death

Non-CVA 0

CVA 3

Total points, range 0–39

Table 4. Renal function in 32 901 patients 12 months after cadaver

renal transplantation

Kidney Patient

s,

Mean

CrCl,

Patients with renal function2, no.

(%)

grade Points no. mL/mi

n1

Excell

ent Good Fair Poor

•2 Based on CrCl, mL/min; excellent, > 60; good, 40–60; fair, 20–

40; poor, < 20.

A 0–9 12 683 61.0 6 575 3 734 1 258 1 116

(52) (29) (10) (9)

B 10–19 11 005 51.8 3 931 3 950 1 691 1 433

(36) (36) (15) (13)

C 20–29 8 065 42.6 1 605 2 925 2 041 1 494

(20) (36) (25) (19)

D 30–39 1 148 33.7 95 337 404 312

(8) (29) (35) (27)

Table 4. Renal function in 32 901 patients 12 months after cadaver renal transplantation






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Rao (Kidney Donor Risk Index)

Transplantation 2009: 231-6

KDRI includes 14 donor and transplant factors, each found to be independently associated with graft failure or death:

donor age,

race,

history of hypertension,

history of diabetes,

serum creatinine,

cerebrovascular cause of death,

height,

weight,

donation after cardiac death,

hepatitis C virus status,

human leukocyte antigen-B + DR mismatch,

cold ischemia time

double or en bloc transplant

highest KDRI quintile (>1.45) had an

adjusted 5-year graft survival of 63%,

compared with 82% and 79% in the two

lowest KDRI quintiles (<0.79 and 0.79-

<0.96)






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Donor risk grade

Schold et al.

Am J Transplant 2005:757-65.

Adjusted parameter estimates for calculation

of risk score

Donor/Recipient CMV match D+/R−

Donor race African American

Donor age

Cause of death

HLA-A mismatches

Cold ischemia time1

Donor history of hypertension

Donor history of diabetes

Table 2. Donor grade statistics

Donor grade

Relative

frequency n

(%)

Risk score

range

AHRs1 0–1

years

AHRs1 1–5

years

1.195% CI for AHRs in parentheses.

I 5084 (11.1%) [0–0.234] Reference Reference

II 14881

(32.5%)

(0.234–

0.524]

1.34 (1.18,

1.53)

1.05 (0.94–

1.18)

III 15782

(34.4%)

(0.524–

0.853]

1.85 (1.63,

2.10)

1.36 (1.27–

1.51)

IV 7782

(17.0%) (0.853–1.17]

2.55 (2.24,

2.90)

2.00 (1.79–

2.24)

V 2321 (5.1%) >1.17 3.72 (3.22,

4.31)

2.22 (1.92–

2.57)

Table 2. Donor grade statistics

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The Broad Spectrum of Quality in Deceased Donor Kidneys


Volume 5, Issue 4, pages 757-765, 27 JAN 2005 DOI: 10.1111/j.1600-6143.2005.00770.x


DGF scores

delayed graft function (DGF) Nomogram

Irish et al.

J Am Soc Nephrol 2003: 2967

Neural networking

Walsh et al.

Histopathology scores

Anglicheau AJT 2008 :2325-34

Remuzzi NEJM

CADI

….






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Interpretatie van de “gap”


Levende donor organen

Wachtlijst

Nieuw

Overlijden

NT

Allocatie

Match Transplantatie

Infrastructuur

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8 9 10

jaren na transplantatie

%

overleving

Lever

Hart

Nier

??

Levende donor organen

“rechtvaardige orgaan allocatie”

THEORIE

- principes of biomedische ethiek : Beauchamp & Childress

* positieve bijdrage (beneficence)

* geen schade berokkenen (nonmaleficence)

* eerlijk (justice)

* autonomie patiënt (respect for autonomy)

=> in concreto : medical utility

equality of opportunity justice


Organ allocation within Eurotransplant

1. Immunologic compatibility : AB0, cross-/HLA-match

2. Medical urgency

3. Organ viability

4. Medical ethics [ Fairness - Efficiency - Equality ]

=> Waiting time, age, “non-resident”, donor accrual.

expertise

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Allocatie Procedure (1)


Match Programma (computer)

ET Wachtlijst Selectie Hiërarchie

Sorteren

Donor

Orgaan

Matchlijst



Aanbied Procedure

Aanbod / Geen aanbod

Aannemen / Weigeren

Matchlijst

Donor

Orgaan Transplantatie / Geen transplantatie



HLA-report

Donor Non-Renal Kidney Match Kidney

Report Allocation Cross-match Allocation

20-30 min 2 - 3 hrs 15 min 1.5 - 2.5 hrs

Procurement

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Kidney Allocation factors

HLA-A,B,DR mismatch

Probability

Nier 0&1 HLA-MM

Waiting time punten 0.09 punten per dag wachttijd [ 33 / jaar ]

Ischemia time

Country balance


punten 400 333 267 200 133 67 0

MM 0 1 2 3 4 5 6

punten 0 100

Kans Klein Groot

punten lokaal nationaal

4/ Kidney transplant patient work-up.


4 a/ The renal patient


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Equitable Organ Allocation UNOS = United Network for Organ Sharing - USA

maximize patient and graft survival

- minimize deaths while waiting for a transplant

- maximize opportunity for patients with biological or

medical disadvantages to receive a transplant

- minimize disparities in chance of organ offer

among patients with comparable medical and

demographic characteristics

- minimize effects related to geography

- minimize overall transplantation-related costs

=> provide for accountability and public trust


Guideline 2.1 – Tx : Pre-transplant

assessment UK 2011

We recommend that the object of pre-transplant

assessment is:

a) to ensure transplantation is technically possible;

b) to ensure the recipient’s chances of survival are not

compromised by transplantation;

c) to ensure that graft survival is not limited by premature

death (maximum benefit obtained from a limited

resource);

d) to ensure pre-existing conditions are not exacerbated

by transplantation;

e) to identify measures to be taken to minimise peri- and

post-operative complications; f) to inform patients of

likely risks and benefits of transplantation. (1C)


Guideline 2.2 – Tx : Pre-transplant

cardiac assessment UK 2011

We suggest that there is no compelling evidence

that in ESRD patients pre-transplantation

screening tests for coronary artery disease in

asymptomatic patients is effective in preventing

future cardiac events or reducing mortality after

transplantation. Until better evidence emerges,

screening tests may be best used to identify high-

risk patients for exclusion from the transplant

waiting list. (2C)


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Guideline 2.3 – Tx : Preparation of the

renal transplant recipient UK 2011

We suggest that the use of pre-operative beta-

blockers may be considered in patients at high

cardiovascular risk undergoing renal

transplantation but must be introduced at least 1

month before transplantation. Beta-blockers

should not be discontinued abruptly peri-

operatively. Low dose aspirin therapy is not a

contraindication to transplantation and can be

continued peri-operatively. (2C)




We recommend that patients should be strongly

encouraged to stop smoking before and after

transplantation. Formal smoking cessation

programmes should be offered and accessed in

primary care. (1A)




We recommend that obese patients (BMI >30

kg/m2) present technical difficulties and are at

increased risk of peri-operative complications.

They should be screened rigorously for

cardiovascular disease and each case considered

individually. Although obesity is not an absolute

contra-indication to transplantation, individuals

with a BMI >40 kg/m2 are less likely to benefit.

(1B)


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We recommend that all potential transplant

recipients should be tested for prior exposure to

viral infections including: CMV, EBV, VZV, HBV,

HCV and (HIV). Immunization should be offered to

all hepatitis B (if not already immunised) and VZ

virus antibody negative patients before

transplantation. Patients otherwise suitable for

renal transplantation with evidence of chronic

hepatitis B and/or C or HIV infection should be

managed according to British TS and Eur BP

Guidelines prior to transplantation. (1A)


Guideline 2.7 – Tx : Evaluation and

selection of the renal transplant recipient

We recommend that in potential recipients with

previous malignancy (excluding non-melanoma

skin cancer), renal transplantation should only be

considered if there is no evidence of persistent

cancer. It is recommended that the waiting time

between successful tumour treatment/remission

and transplantation be at least 2 years. For certain

malignancies the waiting time may need to be

extended to more than 5 years. The Israel Penn

Transplant Tumour Registry should be consulted

for tumour specific advice (1A)


(www.ipittr.uc.edu/Home.cfm).

Guideline 2.8 – Tx : Evaluation and

selection of the renal transplant recipient

We recommend that patients who are at risk of

developing recurrence of original renal disease

should be managed according to the European

Best Practice Guidelines (EBPG) and the UK

Guidelines for Living Donor Kidney

Transplantation. (not graded)

Chadban S. Glomerulonephritis recurrence in the renal graft. J Am Soc Nephrol. 2001;

12(2):394-402

European Best Practice Guidelines (EBPG). Nephrol Dial Transplant 2000; 15(7):11-20

http://www.bts.org.uk/transplantation/standards-and-guidelines/


http://www.ipittr.uc.edu/Home.cfm






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Guideline 2.9 – Tx : Screening investigations

in the renal transplant recipient UK 2011

We suggest that there is no evidence that

asymptomatic potential transplant recipients

require screening for diverticular disease, peptic

ulceration or gall bladder stones. (2C)


Smoking – Obesity ERBP 2013


CV disease testing – ERBP 2013


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Native nephrectomy – ERBP 2013


HLA and anti-HLA ERBP 2013


HLA- matching - ERBP 2013


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HLA-matching - ERBP 2013


Cross-matching ERBP 2013


Previous transplant explantation? ERBP 2013


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HD before Tx - Fluid during Tx - ERBP 2013


4 a/ The living donor


The LRD donor – acceptance criteria

Age – variable acceptance

Proteinuria < 100 mg/24h and albuminuria < 30 mg/24h Kasiske AJKD 1995 Klausen Circulation 2004

GFR > 80 ml/min/1.73m³

OGTT normal

No haematuria

Normal blood pressure

BMI < 30

No infectious or cancer risk

Correct social / psychological evaluation

Willingness to donate and follow-up

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ERBP guideline 09/2013

Exercise on a regular basis, lose weight and stop

smoking. (1C)

individual risk of donation carefully discussed with

donor using check list. (US)

donor be evaluated by an independent physician +

psychologist. (US)

process of donation should be stopped if any doubt

on donor safety arise, especially in younger donors,

or when benefit for the recipient is limited. (US)

US ungraded statement

ERBP guideline 09/2013 hypertension

simultaneous presence > 1 risk factor

(hypertension, obesity, proteinuria, impaired

glucose tolerance, haematuria) precludes

donation.(US)

blood pressure <140/90 mmHg on at least 3

occasions without antihypertensive medication, is

normotension. (1C)

measuring ambulatory blood pressure in potential

donors who have office hypertension (BP≥140/90

mmHg) or who are taking pharmacological

treatment for hypertension. (2C) US ungraded statement

ERBP guideline 09/2013 hypertension

well-controlled primary hypertension, <130/85

mmHg, under treatment with maximum 2 anti-

hypertensive drugs (diuretics included) is not

considered a contraindication to living kidney

donation. (2C)

discourage hypertensive donors with evidence of

target organ damage such as left ventricular

hypertrophy, hypertensive retinopathy and micro-

albuminuria.(1C)

suggest that these potential donors could be re-

evaluated for disappearance of this target organ

damage after appropriate treatment. (2D)

8/07/2014

40


obesity

BMI >35 kg/m2 is a contraindication to donation.

(2C)

We recommend counseling obese and overweight

donors for weight loss before and after donation.

(US)



impaired glucose tolerance

diabetes mellitus is a contraindication to

donation, other than in exceptional circumstances.

(1D)

impaired glucose tolerance is not an absolute

contraindication to donation. (2C)


proteinuria

quantify urinary protein excretion in all potential

living donors. (1C)

overt proteinuria is a contraindication for living

donation [24-h total protein >300 mg or spot urinary

albumin to creatinine (mg/g) ratio >300 (>30

mg/mmol)].(1C)

evaluate potential living donors with persistent (> 3

measurements with 3 months interval) proteinuria

<300 mg/24 h by the quantification of micro-

albuminuria to assess their risk of living donation.

(US)


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41


proteinuria

considering persistent (>3 measurements with 3

months interval) micro-albuminuria (30–300

mg/24 h) a high risk for donation. (US)



haematuria

consider persistent haematuria of glomerular

origin as a contraindication to living donation,

because it may indicate kidney disease in the

donor. (1B)

however, thin basement membrane disease might

be an exception. (US)



old age

old age in itself is not a contraindication to

donation. (1B)

8/07/2014

42

Expected decline in kidney function due to

ageing

British Transplant Society 2011

Kidney Transplantation - CONCLUSION

PRO:

‣ QOL

‣ prognosis

CON ‣ Risk

‧ Operative risk

‧ Infections

‧ Cancer

‧ CV morbidity/mortality

Long term transplant follow-up

Control BP

Use CCB + ACEi liberally

Control hyperlipidemia

Control weight

Control anaemia

Smoking prevention

Use Aspirin

Worry about the bone

Worry about compliance

8/07/2014

43


Q & A

http://nl.metrotime.be/2014/06/26/must-read/belgie-heeft-de-tiende-beste-invloed-op-de-wereld/

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