urology

forth stage

surgery
Lec-
د

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

recepient 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 mediated hypertension
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
*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
,preformed Ab 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 1st week- 1 month
occurs in 25 – 55% of patient
Diffrential diagnosis :
ATN , ureteral obst, drugs toxisity
Clinically : febrile , tenderness over the graft
impaired renal function,decrease urine output.
Diagnosis : renal biopsy
treatment.. by steroids & immunosuppressants

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
Delayed transplant renal artery stenosis
Anastamotic leak
Anastamotic or ureteral stricture
Ureteral obstruction
Ureterovesical disruption
Lymphocele
Non technical
Infections
Cancers:
lymphoma , Kaposi sarcoma