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Forth stage
Surgery (Urology)
Lec-6
د.محمد فوزي
29/11/2015
RENAL FAILURE & TRANSPLANTATION
Renal Failure
• Reduced clearance of certain solutes principally excreted by the kidney
• The most common indicators are urea&creatinine
• RF could be acute or chronic
Causes of end stage renal failure:
-DM 36%
- Hypertensive nephrosclerosis 30%
- chronic glomerulonephritis 24%
- Autosomal dominant polycystic kidney disease 12%
-chronic pyelonephritis
• In pediatric age group ( <18 year ) congenital causes predominate like cong.
hypoplasia.
Treatment of end stage CRF:
Treatment is by
• hemodialysis,
• peritoneal dialysis,
• or renal transplantation
Renal transplantation
Renal Transplantation is the treatment of choice & the most cost effective treatment for
end stage renal failure.
The upper age limit for renal transplantation is
70 year of age in average
DONER
RECEPIENT
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recipient evaluation:
• Cardiac status
• Malignant diseases:waiting time :
1 – 2 year for low metastatic potential
5 – 6 year for high risk tumors
• Infections
• GIT diseases like peptic ulcer
GU abnormalities : MCUG , URODYNAMIC study
Pretransplant bilateral native kidney nephrectomy:
Seldom required
Indications:
• Pyelonephritis
• Medically uncontrolled renin mediatedhypertension
• Malignant disease
• Nephrotic syndrome
• Extremely large polycystic kidney
Types of donors for renal transplantation
• Living related donors :
• Allograft half life is 10 year longer than cadaveric renal donation
• Living unrelated donors
• Cadaveric donors.
Contraindications for renal transplantation
• Active infections including AIDS
• Active malignant diseases
*the donor is always left with the better kidney
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*Left kidney is prefered due to longer renal vein
Investigations & HLA tissue matching
• Tissue matching is performed for HLA –A,B,&DR antigen that are found on the 6th
chromosome
• ABO blood grouping & cross matchin
Types of rejections
• Hyperacute rejection
• Acute rejection
• Chronic rejection
Hyperacute rejection
-
incidence 1/1000
-analogous to blood transfusion reaction ,
occurs immediately
,preformedAb against HLA expressed on donor renal vascular endothlium
-occurs as soon as blood flow to the donor kidney is established
-treatment :immediate transplant removal
Acute rejection
occurs between 1
st
week- 1 month
occurs in 25 – 55% of patient
Diffrentialdiagnosis :
ATN ,ureteral obst, drugs toxisity
Clinically: febrile , tenderness over the graft
impaired renal function,decrease urine output.
Diagnosis: renal biopsy
treatment..by steroids &immunosuppressants
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Chronic rejection
Defined as a gradual progressive loss of renal function that cannot be attributed to another
cu.
there is no definitive treatment for this type of rejection
retransplantation to be considered
Immunosupression
Focused on preventing & reversing acute rejection
Agents used in 3 ways
• induction :
immediately after Tx like Azathioprine &steroids
• maintenance :
initiated once creatinine in normalised like Azathioprine & steroids, cyclosporin A
• treatment of acute rejection like steroids
Complications of renal transplantation:
Technical
1. Delayed transplant renal artery stenosis
2. Anastamotic leak
3. Anastamotic or ureteral stricture
4. Ureteral obstruction
5. Ureterovesical disruption
6. Lymphocele
Non technical
• Infections
• Cancers:
lymphoma , Kaposi sarcoma