Contra/indications
What are three absolute contraindications to kidney transplant?
active malignancy
active infection
unreconstructable PVD
severe cardiac or pulmonary disease
active IV drug use
significant psychosocial barriers
Immunosuppressant with side effects of nephrotoxicity, neurotoxicity, HTN, gingival hyperplasia, and hirsutism
Cyclosporine
Why is the Left kidney most commonly used for transplant?
The longer length of L renal vein makes connecting to iliac vein easier
What is the most common vascular complication in Kidney transplantation?
Renal artery stenosis. Sx include HTN refractory mm or concomitant w/ graft dysfunction
What drives the hyperacute rejection phase?
ABO incompatibility
CI to pancreas transplant
>65
Significant uncorrectable CAD
MI within 6 months
LVEF <30%, PAP> 50mmHg
Incurable malignancy
Active sepsis
PUD
Immunosuppressed
Psych hx
Pancreatic transplant patient presents with diarrhea, blurry vision, fever, chills, myalgia
Histology shows owl eyes
CMV
tx: ganciclovir
A 35-year-old man is undergoing laparoscopic right donor nephrectomy. His preoperative CT scan demonstrated a single renal vein, single renal artery, and single ureter. What is the first structure to be transected to remove the kidney?
Adrenal vein
Ureteral stents are routinely placed at the ureteral-bladder anastomosis in kidney transplant. What complication are these stents targeted towards?
urinary leaks
3 weeks after uncomplicated kidney transplantation 53 y/o patient begins experiencing a T-cell mediated immune response against his allograft. What microscopic findings do we expect to see when examining graft vasculature?
leukocyte infiltration of graft vessels
Selection criteria for pancreas transplant
-T1DM with EOD, frequent life threatening complications, or issues with insulin tx
-T2DM with BMI<30 and insulin requirement and no evidence of insulin resistance
-Post prophylactic pancreatectomy
Immunosuppressant that inhibits purine synthesis
Mycophenolate
Incision for Simulataneous pancreas-kidney transplant
Lower midline incision w/ a medial visceral rotation
A 54-year-old woman is postoperative day 1 from routine laparoscopic left donor nephrectomy. Vital signs are HR 120 beats/min, respiratory rate 16 breaths/min, BP 105/60 mm Hg, and O2 saturation 98% on room air. On abdominal examination, the patient has diffuse tenderness and abdominal bloating. What is the next step?
Blood work, invluding CBC.
The concern in this clinical scenario is whether the patient is suffering from postoperative bleeding. The patient is tachycardic but not overtly hypotensive. The first step is to obtain blood work to rule out postoperative bleeding versus other causes of tachycardia, including infection, arrhythmia, and postoperative pain.
Obtaining serial abdominal examinations is incorrect. In this scenario, the patient is postoperative day 1 and has some abnormal vital signs. There is a strong suspicion of postoperative bleeding. If the patient does indeed have postoperative bleeding, balanced resuscitation with blood products is ideal. If the patient continues to have vital sign abnormalities with a drop in hemoglobin, imaging is not required. Given the stable BP at this point, operative exploration would be premature.
What drives transplant rejection years after operation and what results might you see in the graft?
antibody formation, graft fibrosis
CI to be pancreas donor
-Age >60
-T1 DM or other pancreatic disease
-EtOH intake
-Fhx of DM
-Elevated serum amylase
- Fibrotic pancreas are assoc w/ severe reperfusion pancreatitis
-BMI >30
-Injury during retrieval
-Sx of AP, glandular edema, hematoma, or fatty infiltration
-PSHX of duodenal/pancreas surgery or splenectomy,
-Malignant tumor
-ID ie AIDS, Hep B and C
-Chronic liver disease
Immunosuppresant that target and reduce the number of T-lymphocytes to prevent attack on the new kidney
Thymoglobulin
Pancreas can be drained by
The pancreas can be drained by systemic or portal venous blood. Drainage of exocrine secretion of the graft can be enteric in the form of side-to-side duodenojejunal anastomosis or involving the bladder in the form of side-to-side duodenovesicular anastomosis
Most common complication of enteric draniage
Most common complication of vesicular drainage
Enteric drainage: SBO 2/2 adhesions, anastomotic leak, CMV colitis or Cdiff
Vesicular drainage: anastomotic leak, UTI, metabolic acidosis, dehydration
What is the treatment for chronic transplant rejection?
increased immunosuppresion and possible retransplant
A 19-year-old man desires to be a living kidney donor for his uncle. He denies any urinary symptoms and has a history of anxiety that is well controlled on escitalopram. Both of his parents require medication for HTN. On imaging, the patient appears to have a small 2-mm stone in the left kidney. The young man reports that his uncle has told his nephew that if he donates his kidney to his uncle, the uncle will buy his nephew a new motor vehicle. What is a contraindication for kidney donation in this case?
potential financial gain from donation
Immunosuppressants for solid organ transplant (4)
Calcineurin inhibitors
Mycophenolate Mofetil (MMF) promotes T cell apoptosis
mTOR inhibitors- inhibits activation of T cells
Steroids- suppress immune response and inflammation
Y graft is created by
The vascular Y graft reconstruction is done, which involves using iliac arteries from the donor with the pancreatic graft superior mesenteric artery and splenic artery.
A 55-year-old man, blood type AB, with end-stage renal disease secondary to HTN, undergoes uncomplicated renal transplantation from a living-related donor. On postoperative day 2, the patient has a significant drop in urine output from 3000 mL to 400 mL. He is complaining of increased incisional pain. He is hemodynamically stable, but has fullness and tenderness at the incision site and hematuria. Creatinine has increased to 3.8 mg/dL from 1.7 mg/dL the previous day. A renal ultrasound shows a large, hypoechoic kidney. What is the most likely diagnosis?
Renal vein thrombosis. Transplant renal artery and vein thrombosis occurs early in the postoperative period. Patients have increased pain and swelling over the graft site with decreased urine output, hematuria, and an enlarged graft. The best imaging is Doppler ultrasound. In renal artery thrombosis, there will be an absence of flow, and in renal vein thrombosis, there is a large, hypoechoic kidney with reduced or absent flow in the renal vein or hilum. Treatment involves thrombectomy to salvage the graft or graft nephrectomy if the graft is unsalvageable
In graft versus host disease what is driving the immune response?
donor T cells proliferate and attack host tissues