PREPARATION FOR KIDNEY TRANSPLANTATION

Ahmed I. Kamal, MD, FISN

Mansoura Urology and Nephrology Center

Mansoura University

Rational for living donation

• Better out come

• Shorter waiting time

• Elective planning and optimization of the recipient health status

• Realistic chance for pre-emptive kidney transplantation

Preparation

Donor evaluation process

• Education, counseling and consenting

• Psychological evaluation

• Medical screening process

• Identification of transmissible infections

• Evaluation of renal anatomy

Education, counseling and consenting

• Complications

• Blood grouping and HLA

• Medical evaluation steps

• Stress of the right to withdraw at any time

• Follow up

• Informed consent

Erratum in: Am J Transplant. 2015 May;15(5):1447

Psychological evaluation

• Psychiatrist, psychologist or social worker

• For :

– Psychological evaluation and identification of active mental health problems

– Social assessment including high risk behavior

– Assessment of consenting ability

Medical screening process

• History of physical examination

• Laboratory testing

• Identification of transmissible infection

• Evaluating renal anatomy and function

2014

COUPLE EVALUATION

• Education, counseling and consenting• Detailed history • Medical evaluation• Identification of active infections• Evaluation of urinary tract• Hematological and full chemistry • Virology screening • Microbiology

– Urine culture – TB ZN and PCR

2014

Immunological work up

• Cross Match

• HLA genotyping

• (PRA) panel reactive antibodies

Role of the NIH Standard Crossmatch in Kidney Transplant Outcomes

Graft SurvivalRecipients with Anti-HLA Antibodies Recipients

without Anti-HLA

AntibodiesPositive

CrossmatchNo

CrossmatchNegative

Crossmatch

ImmediateFailure

24 (80%) 6 (26%) 4 (15%) 4 (2.4%)

Failure < 3months

0 6 4 32

Failure > 3months

1 3 7 22

Survival < 3months

2 2 1 6

Survival > 3months

3 (10%) 6 (26%) 11 (41%) 104 (62%)

Total Patients 30 23 27 168

80

Patel and Terasaki, NEJM 280:735, 1969

Donor

HanksMononuclear

cell layer

Ficoll

Recipient

Serum

23o

C

30

23o

C

60

Standard NIH Crossmatch

Rabbit

complement

Antiglobulin-Enhanced Technique

• More sensitive

• Can detect non-complement binding antibodies

• Can detect antibodies present in small amounts

Donor

Hanks

Mononuclear

cell layer

Ficoll

Recipient

Serum

Anti-human

globulin

antibodies

23o

C30

23o

C

60

Anti-human Globulin Enhanced Crossmatch

Wash x 3Rabbit

complementC

Laser

Cells

Flow chamber

Laser activated fluorochromes

emit light in red or green spectrum

Flow Crossmatch

Donor cells are incubated with

recipient serum and then fluorochrome-coated antihuman

antibodies

Flow cytometry cross match

HLA TYPING

•MHC class I molecules•HLA A, B, C•found on all nucleated cells

•MHC class II molecules•HLA DP, DQ, DR•Expressed on antigen presenting cells (and inducible)

•Nomenclature • according to the techniques “ serological or DNA sequencing “

Immunological work up

Structure and Function of HLA Molecules

StructureRegion

Peptide

Binding

Region

Immunoglobulin

-like Region

Transmembrane

Region

Intracytoplasmic

Region

Function

Antigen

Presentation

CD4 / CD8

Binding site

Membrane

Anchoring

Signal

Transduction?

C

C

Class I

a2 a1

NN

a3 b2ms

.

..s

s

.

..s

C C

Class II

NN

a1 b1

a2 b2s

.

..s

s

.

..s

Match v. Mismatch

A2A7

B7

B8

DR15

DR3

Samy

A1

A2

B27

B8DR3

DR4 Mai

A1

A2

B27

B8DR11

DR4

Seif

PRA

• Panel Reactive Antibodies

• Donor non specific

• Donor specific

• Different limit across centers

Why Do Patients Make Anti-HLA Antibodies?

Antibodies occur due to exposure to:

-- blood product

-- pregnancies

-- transplants

-- idiopathic

Identification of transmissible infection

• Identification of transmissible infection

– HCV, HBV, HIV and CMV

– TB

– Rapid plasma reagin

– Strongleloids, Trypanosoma cruzi and West Nile virus

DONOR RADIOLOGICAL ASSESSMENT

US Chest x ray

Spiral CT CTA

Renogram

RECIPIENT RADIOLOGICAL ASSESSMENT

MCUG FOGD

ENDOSCOPY

• Cystoscopy

– Exclude any bladder lesion

–Any uretheral narrowing

–Assessment of bladder capacity

–Biopsy any suspicious lesions

SURPRISES

SURPRISES

• FINAL CROSS MATCH

• INEVITABLE BLOOD TRANSFUSIONS

• CATCHING INFECTIONS

• DONOR HESITATION

• RECURRENT DISEASES “MODIFIED PROTOCOL”

• MISSED DATA “HISTORY”

Contraindication for donation

• Absolute – <18 year-old – Active substance abuse– Impaired ability ta make a decision– Hypertension – DM– Morbid obesity– Renal disease– Renal stones – Inherited renal disease– Infections – Cancer – Cardiovascular disease – Significant size discrepancy

Contraindication for donation

• Relative

– Age > 65

– Controlled Hypertension

– Impaired glucose tolerance

– Obesity

– Borderline line renal function

– Microscopic hematuria

– Single renal stone

SPECIFIC SITUATIONS

• Re-transplant patient

– Cause of the first graft loss

– Duration of the first transplant

– Nephrectomy

– Malignancy, cardiovascular risk

SPECIFIC SITUATIONS

• pre-sensitized patient

Thank you

drkamal@mans.edu.eg

How we detect it

• Serology

• DNA sequencing

– SSOP (sequence specific oligonucleotide probe)

– SSP (sequence specific primer)

– SBT (sequencing based typing)

Cells vs. Beads for PRA and antibody specificity determination

• Cells have multiple HLA antigens

• Use of donor cells determines if a patient has antibodies to donor antigens (OK for the crossmatch)

• But cells do not allow identification of specific antigens to which a patient has antibodies

• Beads have only HLA and their use can determine PRA and identify antibodies to specific antigens

FLOW PRA value

• Percentage of HLAantigen coatedbeads in a pool thatreact withantibodies in apatient’s serum

Negative control

Patient Serum

Background fluorescenceof a negative control

Increased fluorescenceindicatespresence of antibodies

40

50

60

70

80

90

100

0 1 2 3 4

NDSA (152)

DSA (66)

no antibodies (550)

89%

Years after testing

% G

raft

su

rviv

al

p < 0.0001

p < 0.0001 70%

51%

Lachmann, Terasaki, et al. Clinical Transplants 2006, p. 189

Impact of DSA on Graft Survival

Patients were tested once, post transplantation in 2002,

and followed for 4 years

HLA Antibody Identification

•Using Luminex Single Antigen Beads

•Beads have HLA molecules of a single specificity

•Can identify unacceptable donor antigens

•Can identify acceptable donor antigens