Kidney Tran nsplantation Historical per rspective and current practice Piyanut Poo otracool, M.D. Departmen nt of Surgery, Ramathibo odi Hospital, Mahidol University
Kidney Transplantation DDKT Adult deceased donor Pediatric deceased donor LRKT Open nephrect tomy Laparoscopic nephrectomy Multiorgan transplantation SPK(Pancreas - Kidney) Liver - Kidney
DDKTDKT
Pediatric decease ed donor
LRKT
SPK
Patients with type I DM and ESRD Choice of four transplant procedures 1. Kidney transplant alone 2. Simultaneous Pancreas Kidney transplantation 3. Pancreas transplant alone 4. Islet cells transplant
INFORMATION Types of Transplantation in type I DM & ESRD Effect of Pancreas transplant on pt. survival, metabolic CPX. Pancreas Tx. vs. Islet Selection criteria for Donor and Recipient Surgical procedures Rejection surveillancee cells transplant
Pancreas transplant alone The least common pancreas transplant procedure performed (5%) Indication - Absence kidney failure - Frequent, acute and severe metabolic CPX. - hypoglycemia - hyperglycemia - ketoacidosis - Failure with exogenous insulin therapy Ref ; Endocrine Reviews, De ecember 2004, 25(6) : 919-946946
Is Islet cells transplantation takeover care of Pancreas transplantation? PTX. - Counterregulatory hormone response glucagon response to hypoglycemia Ref ; Endocrine Reviews, Dece ember 2004, 25(6) : 919-946946 PTX. - Currently more available Px. for euglycemia and normal glycosylated hemoglobin levels Ref ; Annu Rev Me ed 46 : 281, 1995
Islet cells VS Pancreas transplantation Pancreas Tx. - Aggressive and more invasive surgery - Prolong operation time (4-5 hrs.) -Islet transplantation could be option for seriouss CVS Ref ; Transplantation Reviews, Vol 18, No 3 (July) 2004 : pp129-138138
Advantages of SPK transplant in IDDM - To restore normoglycemia - Prevent secondary complication of DM - Retinopathy Angiopathy stabilize or reversed Neuropathy Ref ; Transplantation : March 15, 1999, 67 : 5
Advantages of SPK (Cont.) - Substantial reduction in mortality in IDDM pt. 10 yrs. after successful SPK - Improvement in cardiac function 12 months after successful SPK Ref ; Transplantationn 1995; 59 : 1105 - SPK does not negative impact on success of kidney graft Ref ; Cecka JM 2000 The UNO OS Scientific Renal Transplant Registry - 2000. Clin Tra anspl 1-1818
Advantages of SPK (Cont.) - 12 months after SPK significant decreased in triglycerides, Hb A1 C, SBP, DBP - Protection of kidney graft and improve survival of kidney graft - Prognosis improves after SPK as compared with KTA or dialysis Pt. due to - Reduce cardiovascular risk - Improved renal / metabolic Fn. Ref ; Transplantation Procee edings, 37, 3570-7171 (2005)
Contraindication for Cadaveric Pancreas Donation - Persistent severe parenchymal pancreas edema - Severe hypernatremia ( > 160 mg / dl ) - Hemodynamic instability - Positive hepatitis serology - Active acute or chronic pancreatitis - Hx. of DM
Contraindication for Cadaveric Pancreas Donation (Cont.) - Previous pancreatic Sx. - Significant intra-abdominal contamination - Mod. to severe atheros sclerosis - Lack of experienced pancreas retrieval team Ref ; Transplantation. 2003; 75 : 1271-12761276 Surgery 1995 ; 118 : 73-81 Transplantation. 1996; 61 : 1323-13301330
Clinical criteria for potential SPK and PTA recipients Age < 55 yr Low C - peptide levels Minimal cardiovascular risk (negative thallium stress test and / or absent or mild CAD) Absence of amputations 2 DM - related PAD Hx. of adherence to medical recommendations and Px.
Criteria for SPK and PTA recipients (Cont.) Ability to understand the BMI < 32 kg/m 2 Presence of two or more CPX. related to type I DM procedure potential and organ Apparent willingness to subscribe to post transplantation guidelines and management. Ref ; J Am Soc Nephrol 12 : 2517-2527, 2001
Conclusion The present state of success in kidney transplantation, including benefits to patients with ESRD was achieved from transplantation team m, nurses, coordinators, nephrologists, experience transplant surgeons, as well as surveillance outcomes and complications after surgery.