Committee XII
Renal Transplantation
Prof. Dr. Hazem Rashad (Chair), Professor of Urology, Alexandria University
Ass. Prof. Ahmed Fahmy, Assistant Professor of Urology, Alexandria University
Dr. Ahmed Eissa, Lecturer of Urology, Tanta University
Dr. Ahmed Elsherbiny, Lecturer of Urology, Tanta University
Contents
- XII.1 List of Abbreviations
- XII.2 Abstract
- XII.3 Introduction:
- XII.4 Patients’ selection
- XII.5 Legal considerations in kidney transplantation
- XII.6 Pre-Transplant Assessment
- XII.7 Transplant procedure
- XII.8 Post-Transplant complications
- XII.9 REFERENCES
XII.1 List of Abbreviations
- ACR - Acute cellular rejection
- ADPCKD - Autosomal dominant polycystic kidney disease
- AMR - Antibody-mediated rejection
- ASB - Asymptomatic bacteriuria
- BK - Polyoma (BK) virus
- CDC - Chronic kidney disease
- CDC - Complement-dependent cytotoxicity
- CMV - Cytomegalovirus
- CT - Computerized Tomography
- DSA - donor-specific antibodies
- EBV - Epstein-Barr Virus
- ECG - Electrocardiogram
- FSGS - Focal segmental glomerulosclerosis
- GFR - Glomerular filtration rate
- GN - Glomerulonephritis
- HLA - Human leucocyte antigen
- HSV - Herpes Simplex Virus
- HTLV - Human T-cell lymphotropic virus
- LLDN - Laparoscopic living-donor nephrectomy
- MMR - Measles/Mumps/Rubella
- MRA - Magnetic resonance angiography
- PRA - Panel of reactive antibodies
- RAT - Renal artery thrombosis
- RCT - Randomized controlled trial
- TB - Tuberculosis
- UTI - Urinary tract infection
- VCUG - Voiding cystourethrogram
- VUR - Vesicoureteric reflux
- VZV - Varicella-Zoster Virus
XII.2 Abstract
XII.2.1 Objective:
XII.2.2 Methods:
XII.2.3 Results:
XII.2.4 Conclusion:
XII.3 Introduction:
XII.4 Patients’ selection
- We recommend that all patients with chronic kidney disease (CKD) G4-5 (glomerular filtration rate [GFR] < 30ml/min/1.73 m2 ) are to be considered for kidney transplantation regardless of sex, gender, race or socioeconomic status, except in CKD patients with metastatic untreatable malignancies, severe irreversible restrictive or obstructive lung disease, un-supported patients with serious mental retardation, non-compliance, unstable psychiatric disorder, active substance abuse, severe decompensated liver or cardiac failure (unless liver and cardiac transplantation are considered; respectively).
- We recommend pre-emptive kidney transplantation with kidneys from living donors as the treatment of choice in CKD patients.
- We encourage using living related donors as the main source of kidney donation followed by un-related donors.
- We recommend that the following conditions exclude any potential donor from kidney donation:
- Age < 21 yrs
- 50 yrs (living-unrelated) or >60 yrs (living-related)
- Hypertension
- Diabetes Mellitus or abnormal glucose tolerance test
- History of thrombosis or embolism
- Severe peripheral vascular disease
- Chronic lung disease with impaired oxygenation
- Recent malignancy with long time to possible recurrence
- Urological abnormalities, bilateral recurrent renal stones, or severe vascular anomalies
- Impaired renal function (GFR < 80 ml/min/1.73m²)
- Proteinuria> 300 mg in 24 hrs
- Active HIV, Hepatitis B or C infection
XII.5 Legal considerations in kidney transplantation
- Kidney transplantation in Egypt must be only done in licensed transplant centers, after obtaining an official approval from the higher supreme committee for organ transplantation, Ministry of Health.
- We recommend that an informed consent must be taken from both recipients and donors prior to kidney transplantation.
- We recommend that donor’s decision to withdraw at any stage prior to surgery should be respected and supported in a manner that protects confidentiality.
XII.6 Pre-Transplant Assessment
XII.6.1 Patients’ Education and counselling
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XII.6.2 Transplant Workup
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1- Age, smoking, alcohol, or drug dependence 2- Medical conditions (such as history of peripheral edema, gout, nephrolithiasis, diabetes mellitus, cardiovascular disease, and current or previous malignancy) 3- Transmissible infection (such as TB, HIV, and hepatitis) |
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1- Cardiovascular examination (blood pressure, ECG, chest X-ray) 2- Calculation of BMI 3- Examination for abnormal masses or swelling 4- Surgical scars 5- Mental health |
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1- Urinalysis for detection of hematuria, proteinuria, and glucose and urine culture (at least two times are recommended). 2- General laboratory examination (complete blood count, liver function test, coagulation profile, lipid profile, thyroid function, blood electrolyte, fasting blood sugar…. etc) 3- Assessment of renal function (urea, creatinine, eGFR) 4- Evaluation of infection (HBV, HCV, HIV, CMV, EBV) 5. Blood group/HLA typing |
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1- Age, smoking, alcohol, or drug dependence 2- Medical conditions (such as history of peripheral edema, gout, nephrolithiasis, diabetes mellitus, cardiovascular disease, and current or previous malignancy) 3- Transmissible infection (such as TB, HIV, and hepatitis) 4- Renal disease assessment (etiology, assessment of the native renal biopsy if possible, history of previous transplant, and previous graft loss) |
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1- Cardiovascular examination (blood pressure, ECG, chest X-ray, echocardiogram) 2- Calculation of BMI 3- Examination for abnormal masses or swelling 4- Surgical scars 5- Psychological and mental assessment 6- Conditions that may require pre-transplant surgical treatment (inguinal hernia, and peripheral vascular disease) |
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1. Urinalysis and culture (at least two times are recommended). 2. General laboratory examination (complete blood count, liver function test, coagulation profile, lipid profile, thyroid function, blood electrolyte, fasting blood sugar, and renal function tests) 3. Evaluation of infection (HBV, HCV, HIV, CMV, EBV) |
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XII.6.2.1 General Assessment
XII.6.2.2 Informed consent
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Strength Rating |
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XII.6.2.3 Laboratory Assessment
XII.6.2.4 Radiological Assessment
XII.6.2.5 Vascular Assessment
XII.6.2.6 Cardiac Assessment
- We recommend that all transplant donors and recipients undergo cardiac assessment prior to kidney transplantation. Cardiovascular disease is the leading cause of death in recipients after kidney transplantation. Cardiac assessment is essential to optimize the cardiac condition prior to surgery, as well as to exclude recipients with decompensated cardiac failure.
- We recommend electrocardiogram (ECG) and echocardiography to be done to all transplant donors and recipients prior to surgery. Additional tests are to be done, accordingly, for specific or symptomatic cases.
XII.6.2.7 Vaccination
- We recommend that all potential transplant recipients should be fully immunized before transplantation.
- We recommend live vaccines to be administered at least 6 weeks before kidney transplantation.
- We recommend that transplant recipients should receive the following vaccinations prior to transplant: Diphtheria, Pertussis, Hepatitis B, Haemophilus Influenza-B, Meningococcal (conjugate), Pneumococcal (conjugate and/or polysaccharide), Influenza and Measles/Mumps/Rubella (MMR).
- We recommend post-transplant vaccination to be resumed one year after kidney transplantation, except for seasonal flu vaccine which can be given 4 weeks after transplantation.
- We recommend no live vaccines to be given after kidney transplantation.
- We recommend yearly influenza immunization to all transplant recipients post transplantation.
XII.6.2.8 Specific Assessment
- We recommend performing cystoscopy to assess the lower urinary tract, upper and lower GI endoscopy to selected kidney transplant recipients. (strong)
- We recommend urodynamic evaluation only in suspected cases of bladder filling or emptying dysfunction. (weak)
XII.6.2.9 Immunological considerations
- We recommend a negative crossmatch preferably using flowcytometry before kidney transplantation.
- We suggest performing crossmatch using complement-dependent cytotoxicity (CDC) as a less favorable alternative.
- We recommend assessing anti-HLA and donor-specific antibodies (DSA) in all transplant recipients prior to transplantation. According to which immunological risk can be assessed. We recommend highly sensitized recipients to be desensitized prior to transplantation.
- We recommend classifying transplant recipients according to history of previous transplantation, multiple pregnancies, repeated blood transfusion, high panel of reactive antibodies (PRA), HLA mismatching, and the presence of HLA antibodies to; low, intermediate or high immunological risk groups.
- We recommend using induction immunosuppression in all high-risk recipients, preferably using a T-cell depleting antibodies (anti-thymocyte globulin) induction therapy. We recommend using any induction therapy in intermediate-risk group whether with monoclonal or polyclonal antibodies, while the use of induction in low-risk group is preferred.
- We recommend the use of multi-drug regimen immunosuppressive therapy to all recipients post transplantation.
- We recommend to routinely assess the blood levels of measurable immunosuppressive drugs in all recipients after transplantation.
XII.7 Transplant procedure
XII.7.1 Donor Nephrectomy:
XII.7.1.1 Choice of kidney
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XII.7.1.2 Surgical approach
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XII.7.2 Surgery on the Renal Transplant Recipient:
XII.7.2.1 Immediate preoperative preparation
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XII.7.2.2 Native kidney
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XII.7.2.3 Surgical approach:
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XII.7.2.4 Vascular anastomosis:
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XII.7.2.5 Ureteral anastomosis:
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XII.8 Post-Transplant complications
XII.8.1 Medical Complications
XII.8.1.1 Infection
Recommendations |
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1- Removal or replacement of urinary tract device such as (urethral catheter or stent). 2- Urine culture and sensitivity. 3- Start empirical treatment with fluoroquinolones, amoxicillin-clavulanate or third generation cephalosporin. 4- If persistent, shift to antimicrobial shown by the urine culture and sensitivity. |
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1- CMV positive donor and negative recipient 2- CMV positive donor and recipient 3- CMV negative donor and positive recipient |
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XII.8.1.2 Rejection
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XII.8.1.3 Malignancy
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1- Renal cell carcinoma. 2- Hepatocellular and colon cancers. 3- Bladder cancer. 4- Prostate cancer. 5- Lung cancer. 6-Breast and cervical cancers. |
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XII.8.1.4 Post-transplantation Diabetes Mellitus
Recommendation |
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1- Weekly for first month after transplantation. 2- Every three months for the first year. 3- Then annually. |
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1.1.1 De novo or recurrent glomerulonephritis
Recommendation |
Strength Rating |
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1-Plasma exchange for patients showing focal segmental glomerulonephritis. 2-High doses corticosteroids and cyclophosphamide for patients presenting with recurrent antineutrophil cytoplasmic autoantibody-associated vasculitis or anti-glomerular basement membrane disease. 3-Angiotensin converting enzyme-inhibitors or angiotensin II receptor blockers are recommended for patients with proteinuria and recurrent glomerulonephritis |
XII.8.2 Surgical Complications
XII.8.2.1 Urological complications
Recommendation |
Strength Rating |
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1- Relief of obstruction by the placement of percutaneous nephrostomy. 2- Antegrade pyelography for the localization and characterization of the stricture. |
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1- Stricture <3 cm can be treated endoscopically using balloon dilatation or laser incision. 2- Strictures ≥3cm in length or failed endoscopic treatment in patients with <3 cm strictures should be treated by surgical reconstruction. |
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1- Double J stenting and indwelling urethral catheter or percutaneous nephrostomy. 2- If endoscopic management failed consider surgical treatment. |
XII.8.2.1.3 Hematuria
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1.1.1.1 Lymphocele
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XII.8.2.2 Wound complications
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1- Superficial wound dehiscence is managed by washout and debridement 2- Complete fascial wound dehiscence is managed by primary repair with (in the absence of infection) or without synesthetic mesh reinforcement |
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XII.8.2.3 Vascular complications
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1- Failed minimally invasive endovascular options 2- Recent transplant 3- Complex stenosis (long, narrow, and/or multiple) |
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XII.8.3 Other Complications
XII.8.3.1 Cardiovascular complications
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1- Within 2-3 months of the transplantation surgery 2- Within 3 months after the change of treatment or development of any condition that might cause dyslipidemia 3- Annually |
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XII.8.3.2 Bone disease
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XII.8.3.3 Fertility and sexual function
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XII.9 REFERENCES
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