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    renal transplantation


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    1 : Welcome Kidney Transplantation Abja Sapkota And Tulza K.C. MN 2nd Year
    2 : Background First kidney transplant from an allograft by U Voronoy -1936 First successful kidney transplant between identical twins by Joseph.E. Murray & Team – 1954 Total body irradiation -1956 Immunosupp drugs by Calne, Peart & Porter, azathioprine & corticost.- 1961
    3 : Introduction Transplantation of a kidney from a living donor or deceased donor to recipient who no longer has renal function. More cost-effective & better quality of life. Longer life expectancy
    4 : Contd… More energy, less restricted diet, & fewer complications. Less co-morbidity Higher risk of rejection during first year
    5 : Contd… Higher risk of all sorts of infection & cancer. Very time-consuming post-transplant follow-up. Financial burden Many facts need to be taken into consideration while planning
    6 : First transplant aparatus Dr. Merrill explaining the workings  to twins brother
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    10 : Donor Living related donor Living unrelated donor Deceased (cadaver) donor
    11 : In Nepal Organ transplant act – 2000 A.D. (2055/10/21) Implementation -2058/10/22 Total kidney transplantation (2008 to 2011 ) -195 (121 TUTH, 73 Bir). HLA lab available at Arogya diagnostic centre, Lalitpur, Nepal.
    12 : Epidemiology transplantation rates differ based on race, sex, & income mortality declined to around 10%/year >400,000 renal transplantations up to now –USA number of transplants grew over last decade, with 62% of countries reporting at least a 50% increase
    13 : Contd… Saudi Arabia had the highest reported transplant rate at 32 per million population followed by; Jordan (29), Iceland (26), Iran (23), USA (21), & in Nepal, (<2) approximately
    14 : Prognosis Pt. will live 10 to 15 years longer Increased longevity for younger pts. Pre-emptive transplant has good outcome
    15 : Perfusion & bench dissection R/L (iced) 3lit in a big bowl One tetra emerged in bowel R/L (1000ml) in stand Kidney placed in tetra R/L infused via renal artery Perfusion until clean fluid comes out All sutures removed Total time 15 to 20 min
    16 : Warm ischemic time (1st) period after clamp of artery & vein until perfusion Cold ischemic time Time of cold storage with or without perfusion with a storage solution Warm ischemic time (2nd) Period of transplantation, anastomosis of artery & vein
    17 : Procedure extensive medical evaluation native kidneys are not usually removed Kidney is usually placed in iliac fossa renal artery connected to external iliac artery  renal vein  connected to the external iliac vein.
    18 : Contd… The ureter is transplanted into bladder or anastomosed to the ureter.
    19 : Inclusion Criteria Pts. must have ch. irreversible kidney disease, & who are on dialysis or may require dialysis in near future. Not responded to other medical or surgical treatments Must be able to tolerate major surgery.
    20 : Contd… Pts. & family must be able to understand risks & benefits, including long-term need for close medical follow-up & life-long need for drugs. Pts/families must be able to accept the responsibility of long-term financial care
    21 : Contraindications 1. Presence of other life-threatening disease; recent malignancy active or chronic infections DM, extreme obesity severe, uncorrectable heart disease, chronic lung disease active autoimmune disease, Pregnancy incompatible blood types
    22 : Contd… 2. History of chronic non-compliance to medical treatments, medications 3. History of chronic and ongoing drug and/or alcohol abuse.
    23 : Benefits Dialysis no longer required Increase in energy & overall well-being Return to an almost normal lifestyle Increased independence Less or no restrictions of diet or fluid intake
    24 : Risks No guarantees High risk of infections Communicable diseases High risk of malignancies Transplant rejection Lympho-proliferative disorder G/I inflammation & ulceration Hirsutism, hair loss, acne Obesity DM, hypercholesterolemia osteoporosis
    25 : Investigation Contd… Lipid profile - Cholesterol, HDL, LDL, Triglyceride Parathyroid Hormone Urine-RE/ME (WBC, RBC, Albumin, Sugar) Urine culture 24 hr, creatinine clearance PAP/ Mamogram, liver-a-feto protein, PSA for age above 35 years ECG and Echo/ CxR/ X-ray KUB/renal CT angiography and DTPA scan USG/ Endoscopy
    26 : Investigation:- Blood-Hb, TLC, DLC, Blood gr, ESR, Platelet, BT, CT, PT, Serology - HIV, HCV, HBsAg, EBV, CMV,HSV biochemistry-Urea, creatinine, calcium, phosphate, Potassium Sodium, Protein, Albumin, Uric acid Blood (LFT) - Bilirubin (Total / Direct), SGPT, SGOT, ALP
    27 : Investigation Contd… Lipid profile - Cholesterol, HDL, LDL, Triglyceride Parathyroid Hormone Urine-RE/ME (WBC, RBC, Albumin, Sugar) Urine culture 24 hr, creatinine clearance PAP/ Mamogram, liver-a-feto protein, PSA for age above 35 years ECG and Echo/ CxR/ X-ray KUB/renal CT angiography and DTPA scan USG/ Endoscopy
    28 : Histocompatibility test A. HLA -T and B cells lymphocytes (Donar Specific Cross-match):- 1 Serum from intended recipient mixed with T & B lymphocytes of donor. 2 positive result indicate likely incompatibility
    29 : Histocompatibility test contd… B. Tissue Cross Match (donar cells and recipient serum) Done to detect antibodies in recipient’s blood Negative cross-match suggests compatible results. performed with white blood cells from the potential donor & serum
    30 : Histocompatibility test contd… C. Panel Reactive antibodies- IgG type show a pt’s level of sensitization to donor antigens. high PRA levels tend to have more rejection episodes. more difficult to identify a compatible kidney for patients with a high PRA level. helps the transplant team choose the appropriate anti rejection medications
    31 : contd… D. Tissue Typing:- looks for 6 histocompatibility antigens that define the amount of “matching” between a recipient and donor. Although this test is necessary for placement waiting list, its importance has diminished. even transplants with minimal matching can have excellent outcomes
    32 : Investigation Contd… Auto cross match (recipient cells and recipients serum) Angiogram of renal artery (donar) Note : Ideally final crossmatch -performed not more than three days prior to transplant
    33 : Donar related test ABO match HLA match HIV, HCV, HBV, EBV, CMV Renal function:-GFR>120ml/min Should have two kidneys
    34 : Evaluations of client before transplant Clearance from the hospital legal committee obtain before surgery, to ensure a close biological or legal rela­tionship existed between donor and recipient. Nepali law permits transplantation among close relatives:- the father, mother, sister, brother, husband, wife, son, daughter, uncle, aunt, mother-in-law, fathe­in-law, step father/mother or adopted children.

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