SOLID ORGAN TRANSPLANTATION

III.  Kidney (Renal) Transplantation

Introduction
Indication for Transplantation
Causes of ESRD
Wait on Transplant List

Types of Transplant
Absolute Contraindications to transplant
Relative Contraindications
Evaluation
Complications

Introduction

Kidney transplants are performed for treatment of End Stage Renal Disease (ESRD).  The primary contributor to ESRD is diabetes mellitus; although there are certainly other causes such as malignancies, chronic reflux and injuries.  End Stage Renal Disease can be treated with two basic methodologies, dialysis or transplant.  There are varying types of dialysis options, depending on the particular needs of the patient.  Hemodialysis is typically provided within a dialysis center, although there are some instances when it can be provided in the home setting.  Continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) are performed in the home setting.  Paul Eggers (1992) notes that dialysis is a costly therapy, but the cost tends to be stable over time.  The alternative treatment option for ESRD is kidney transplant, which has a high initial cost followed by a much lower costs of maintaining a functioning graft (Eggers, 1992).

Shires et al. (1994) writes that the advent of successful hemodialysis in the early 1960s was a major stimulus to the development of kidney transplantation, both living-related and cadaveric, as an alternative to dialysis, with dialysis remaining a back-up treatment should graft failure occur.  Additionally the development of new and better immunosuppressant drugs contributed to the success of transplantation.  More kidney transplants are performed than any other type of solid organ transplant.  The fact that living donors are capable of supplying the organs certainly contributes to this fact.  Additionally, in November 1972 President Richard Nixon signed into law an amendment to the Social Security Act which provided Medicare coverage for virtually all eligible ESRD patients (Shires et al., 1994).

Potential living donors, usually living-related donors, must be evaluated with numerous tests to determine if they are suitable candidates for donation of an organ.  This is an important fact in that consideration must be given to the time commitment needed from a potential living-related donor.  Although the OPO will cover the cost of all reasonable pre-transplant procedures, hospital charges, and post operative care; they do not cover lost time from work. 

The Lahey Clinic outlined the following information for prekidney transplant evaluation for the living donor.  The living donor evaluation includes:

  • A complete history and physical (including routine cancer screening).

  • Blood work for blood chemistries, kidney and liver function, blood counts, blood work for infection exposure (syphilis, hepatitis B & C, AIDS, and other viruses), blood clotting studies, and urine examination.

  • 24-hour urine collection will be needed on two separate occasions to screen for kidney disease.

  • A preoperative chest x-ray.

  • EKG.

  • Ultrasound of the kidneys.

  • If there were a family history of diabetes, a 2-hour glucose tolerance test would be needed.

Other appointments scheduled for the potential donor:

  • A transplant coordinator consult.

  • Transplant surgeon appointment.

  • Financial advisor appointment.

  • Social services and/or behavioral medicine evaluation.

If all of the above testing is acceptable, then the potential donor will be scheduled for an abdominal CAT scan, which evaluates the kidney arteries.  (Lahey Clinic.)  If all parameters were met for donor suitability, the surgery would then be scheduled.  Living donor surgery as of the early 1990s has become less invasive.  They can now do this laproscopically, allowing for 24-hour hospital stay, quicker recovery, out of work for one week, less pain and less expense (Demayo, E., RN 2003).

There were 57,910 kidney transplant candidates on the UNOS waiting list in 2004 (OPTN/SRTR 2005 Annual Report).  This number has surely increased since that time, and in spite of the fact that donor kidneys can in some cases be obtained from living-related donors, organs remain in short supply.  The wait for a suitable organ varies, depending on the availability of a living-related donor and the severity of the potential recipients ESRD.  ESRD, in most cases, can continue to be treated and the patient’s life maintained with one of the forms of dialysis until a suitable organ becomes available. 

Eileen M. Demayo, RN, lead inpatient transplant coordinator at Northwestern Memorial Hospital in Chicago, IL presented the following information at United Resource Network’s, A Course In Transplantation For Case managers in Newport, RI October 2003.

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Indications for Transplantation

  • Patients with end stage renal disease (ESRD).

  • Patients with Type I diabetes.

  • 18-65 years of age (Demayo, E., RN 2003).

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Causes of ESRD:

  • Glomerular diseases; Diabetes mellitus (30% of ESRD.  Third leading cause of death.); Hypertension, Congenital disorders (Polycystic kidney disease, Obstructive uropathy, Alport’s syndrome).

  • Retransplant.

  • Vascular diseases.

  • Tubular and interstitial diseases (Analgesic nephropathy, chemotherapy induced nephritis, radiation nephritis).

  • Neoplasms (Demayo, E., RN 2003).

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Wait on Transplant list
5 – 6 year waiting for cadaveric donor
            Must be ABO compatible, HLA compatible, need tissue typing
Living donor only has to be ABO compatible (Demayo, E., RN 2003).

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Types of transplants:

  • Kidney – Cadaveric (Data for 2000, shows that 60.6% of all kidney transplant recipients received kidneys from cadaveric donors.  (2002 Milliman USA).

  • Kidney - Living donor (Demayo, E., RN 2003).

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Absolute Contraindications to transplant:

  • AIDS or HIV.

  • Acute (not-treatable) or chronic infection.

  • Severe coronary artery disease.

  • Severe carotid artery disease.

  • Chronic active hepatitis.

  • Morbid obesity.

  • Active substance abuse.

  • Significant history of noncompliance (number one reason for graft failure). (Demayo, E., RN 2003).

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Relative Contraindications:

  • Patients age > 65 for kidney.

  • Active peptic ulcer disease.

  • Malignancy within the past 5 years.

  • Psychological dysfunction.

  • Lack of family or support system (Demayo, E., RN 2003).

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Evaluation:

  • Diagnostic Studies – ABO, HLA typing, CBC, Chemistry, LFT’s, lipids, amylase, lipase, Serologies (CMV, HIV, Epstein bar); C-peptide, Glycosylates hemoglobin; Chest x-ray; Cardiac evaluation (EKG, Adenosine stress test, Angiogram (with angioplasty/CABG if indicated); Mammogram, ultrasound of Gallbladder.

  • Psychosocial assessment.

  • Financial assessment (Insurance coverage, pharmaceutical coverage, home health coverage.)

Many patients go home with home health needs such as wound care and IV infusion.
Medicare only covers immunosuppression medications for 3 years at 80%.  (Demayo, E., RN 2003).

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Complications:

  • Infection which increase after requiring treatment of rejection episode.

  • Cardiovascular – Increase risk for post operative MI.

  • Vascular Thrombosis (#1 problem for kidney transplant.)

Preventive measures – heparin, aspirin, bedrest, restrict hip flexion.
            Diagnosis – HMPAO scan, renal scan.
            Treatment – Surgical removal of organ.

  • Bladder Anastomotic Leak

            Bladder anastomosis.
Diagnosis – Ultrasound and analysis of fluids.
Treatment – Percutaneous nephrostogram with stent placement and surgical repair.

  • Dehydration/Electrolyte Imbalance (This is a big problem for patients who have been on dialysis, because they are use to being restricted on fluid intake and it is hard to change habits.)

Treatment – IV hydration, bicarbonate replacement, diuretics, hemodialysis.

  • Delayed Graft Function – Early use of nephrotoxic immunosuppressants such as Cyclosporin and Prograf.

  • Hematuria – from erosion of bladder mucosa and ulceration of the duodenal segment. 

Treatment – Cystoscopy and cauterization of bleeding site.  Conversion to enteric drainage.

  • Graft Pancreatitis – Reflux of urine into pancreas.

            Treatment – Insertion of Foley catheter.  Anticoagulation.

  • Intra-Abdominal Abscess – Anastomotic leak of enteric drained pancreas.

Treatment – Broad spectrum antibiotics and surgical intervention.

  • Gastro-Intestinal Bleeding – Anticoagulation, bleeding from the anastomosis

Treatment – blood transfusions, IV hydration, Surgical intervention (Demayo, E., RN 2003).

The OPTN/SRTR Annual Report 2005 noted that the use of induction immunosuppression for kidney transplantation continued to increase steadily through the decade.  In 2005, 72% of kidney transplant recipients were receiving induction immunosuppression, compared to 46% in 1995.  The administration of antithymocyte globulin (rabbit), the most commonly used induction agent, has increased: it is currently used for 37% of patients.  In 2003, the first year that usage for alemtuzumab was reported, it was used for 4% of patients; this practice nearly doubled in 2004 to 7%.  (2005 OPTN/SRTR Annual Report).

In order to ensure the survival of the allograft, kidney transplant recipients must be maintained on immunosuppression therapy for life.  According to data published in the 2005 OPTN/SRTR Annual Report, tacrolimus-mycophenolate mofetil is the most frequently used maintenance immunosuppression combination at one and two years following transplantation, and its prevalence for maintenance use has increased in recent year.  At one year after transplantation in 2003, 51% of patients were receiving tacrolimus-mycophenolate mofetil, 17% were receiving cyclosporine-mycophenolate mofetil, 8% tacrolimus-sirolimus, and 1% sirolimus-mycophenolate mofetil.  Both the tacrolimus-sirolimus and the sirolimus-mycophenolate mofetil regimens were more prevalent at one and two years after transplant than at discharge, indicating a significant switch toward these combinations after transplant.  Surprisingly, at one year about 7% and at two years about 2% of patients were receiving tacrolimus alone, compared to about 4% at discharge. All of these percentages refer to medication regimens regardless of steroids, meaning that most of the patients were on steroids in addition to the indicated regimens.  However, data from OPTN/SRTR outlines a trend toward steroid avoidance with 23% of all first transplants in 2004 discharged without steroids.  The report notes the first significant numbers of steroid avoidance protocols were seen in 2000, when 5% of patients were discharged without steroids; there has since been a steady increase in the prevalence of steroid-free regimens.  Steroid avoidance protocols are used more frequently for living donor transplant recipients (28% in 2004) than for recipients of deceased donor. (2005 OPTN/SRTR Annual Report).

The OPTN/SRTR Annual Report 2005 noted that graft survival rate for Living Donor kidney to be 95.1% at one year and 80.2% at 5 years.  For cadaveric donor kidneys the one year survival rate was 89.0% at one year and 66.7% at 5 years.  Graft survival rate does depend significantly upon the recipient’s compliance with treatment regimens.  With each subsequent transplant the survival rate of the allograft reduces.  Typically no more than three kidney transplants will occur over the course of a patients life.  When estimating the cost of kidney transplantation one must consider the cost of a return to dialysis in the event of graft failure, along with the cost of re-transplantation.  A return to dialysis must be factored into the plan for a period before each transplant procedure.  This should likely be a period equal to the average time for donor procurement.

The Milliman Research Report 2005, outlines estimated average 2005 first-year charges associated with kidney transplant to be as follows:  Evaluation - $12,300; Procurement - $50,800; Hospital $62,900; Physician - $17,700; Follow-up - $40,200; Immunosuppressants - $26,100.  (Milliman 2005).

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