The Organ Trail (002) [Read-Only]...Stagesof Chronic Kidney Disease Stage Qualitative Description...

1

The Organ Trail: An Update on Transplant and the Patient Journey

Elizabeth Hall, PA-C, MSPASDivision of Transplant Surgery

Mayo Clinic Hospital, Phoenix, ArizonaMarch 1st, 2017

I have no financial disclosures

©2011 MFMER | slide-2

50 Y/O M WITH 28 YEARS ON DIALYSIS…


2

Chances are you’ve seen a patient with

• ESRD/Chronic Kidney Disease• Polycystic kidney disease• DM• FSGS• Glomerulonephritis• Hypertension• Systemic Lupus Erythematosus• IgA nephropathy• Nephrolithiasis

All indications for possible renal transplant AND nearly all on the Boards!

Polycystic Kidney Disease

• Multiple b/l cysts• Made in epithelial cells from renal

tubules and collecting system

• Reduction of renal mass reduces kidney function

• FMHx 75%, autosomal dominant most common

• Hematuria, infection, pain from rupture, nephrolithiasis, nocturia

• Weight loss, early satiety, N/V

• Associated with hepatic and pancreatic cysts

• US is choice method

• Tx: Pain management, ACE/ARBs, aggressive abx if symptomatic, transplantation


http://www.learningradiology.com/notes/gunotes/apkdpage.htm

https://www.google.com/search?q=polycystic+kidney+diseases

Diabetes Mellitus

Fasting Glucose HbA1C

Normal < 99 < 5.0

Pre DM 100-125 5.7-6.4

DM > 126 > 6.5


• Complications: DM retinopathy, neuropathy and nephropathy

• HALF the cases of ESRD!

• Increased risk of CV and stroke due to large vessel atherosclerosis

• Pre-DM are at risk for NODAT

3

Renal diseases

Glomerulonephritis

• E: IgA nephropathy/Berger dz, Postinfectious strep GN, endocarditis, MPGN, Goodpasture syndrome, Wegener’s granulomatosis

• 60% ages 2-12 yo

• Urine: RBC casts (cola colored urine)

Hypertension

• Primary (95%)• Genetic predisposition or

environmental (ie. obesity)

• Secondary (5%) • DM renal dz, endo, stress, meds,

pregnancy

• Sx: usually asymptomatic

• Dx: 2 episodes of SBP >140 or DBP >90

• Lifestyle modifications then medications

• Initial Tx: thiazide diuretic, ACE/ARB, Ca channel blockers


Systemic Lupus Erythematosus

• Multisystem, +ANA (96%)

• Young females 9x more likely than males

• Af. Americans > Caucasians

• Nephritis with proteinuria

Nephrolithiasis

1. Calcium: 75-85%, radiopaque

2. Uric acid: 5-8%, radiolucent

3. Cystine: <1% radiolucent

4. Struvite: 10-15%, radiopaque. Combo of Ca, Mg, ammonia. Pt with UTIs and recurrent caths.


To dialyze or not to dialyze

• Hemodialysis via fistula, graft, tunneled line

• Peritoneal dialysis

• Pre-emptive

• Weight • Physical exam• Lytes• UOP• GFR


4

Stages of Chronic Kidney Disease

Stage Qualitative Description Renal Function (mL/min/1.73 m^2)

1 Kidney damage-normal GFR > 90

2 Kidney damage-mild GFR 60-89

3a Moderate GFR 45-59

3b Moderate GFR 30-44

4 Severe GFR 15-29

5 ESRD <15 (or dialysis)



• Eligibility for Kidney Transplantation:• Informed consent• Estimated GFR ≤ 20 ml/min or dialysis, but if GFR 20-25 ml/min

considered if expected progression is rapid (>10 ml/min/year)• BMI ≤ 40, but 40-45 can be considered based age, body habitus and other

co-morbidities • Psycho-social clearance• Financial clearance

• Relative exclusion for > 2 of the following:• Age ≥ 70• Multi-vessel CAD with ischemia• LVEF ≤ 35• Trop T > 0.03 and EF < 45• BMI ≥ 35• Severe COPD (FEV1 < 50% predicted)• Cigarette smoking• Severe peripheral vascular disease• Poor functional capacity (wheelchair bound or 6 minute walk < 150 meters)

• Absolute contraindications• Inability to comply with transplant-related management and medical follow-

up• Active malignant neoplasm except non melanoma skin cancer• Active infectious disease • Severe immune deficiency state • Technical inability to perform kidney transplant surgery • Cannot safely undergo general anesthesia and post-operative recovery

due to severe cardiovascular, pulmonary or neurological condition• Life expectancy with successful transplantation is estimated to be <5 years

for any reason

Patient could wait years before a transplant.Varies from state to state.

Update: average wait time for AZ:ABO O is 2-3 yearsABO A now down to 8 months


Annually in the US,Over 6,000 Liver Transplants

Over 16,000 Kidney TransplantsOver 1,000 Pancreas Transplants

Over 2,000 Heart TransplantsOver 1,500 Lung Transplants

Over 100 Intestine Transplants

5

• The need outweighs the availability

• Need to expand donor pool

• Types of Donors• Living donor• DBD• DCD

• CIT = time from cross clamp to reperfusion

• WIT = time from clamping vessels before cold flush


Update in Renal Transplant

Allocation Update

• KDRI – Kidney Donor Risk Index summarizes risk of graft failure

• KDPI is remapping into percentage scale • KDPI 80% has higher expected risk of graft

failure than 80% of kidney donors recovered previous year

• Age, Ht, Wt, Ethnicity/race, Hx of HTN, Hx of DM, COD, serum Cr, Anti-HCV, DCD

Blood Types

46%

34%

16%4%

Percent of Population

O

A

B

AB

O: Universal DonorAB: Universal Recipient A2/A2B Donors can give to B recipients

6

Difficulty finding a match

• Cross matching is done: Donor and Recipient blood is mixed

• Antibodies in recipient blood can cause reaction resulting in a positive crossmatch• Why? Previous Txp, Pregnancy, Blood

transfusions

• Want negative crossmatch

Kidney Allograft Function

• Regulates blood pressure

• Filters waste products from blood

• Controls water/chemical balance

Goal SBP 140 - 160

7

Types of Kidney Transplants

• DDKT

• LRRT, LURRT, PKE

• DCD

• AKI (expect DGF)

• High KDPI, previously extended criteria donor (expect DGF)

• PHS-IR

• Pediatric en bloc

What to expect when you’re expecting…your post transplant patient to return to you.

• New medications and the drug-drug interactions

• Hyper/hypoglycemia

• HTN/hypotension

• N/V/D

• Wound complications

• Anemia

• Changes in diet/nutrition

• Watch for hyper/hypovolemia (dehydration)


Volume

Hypervolemia

• Hyponatremia with hypervolemia usually CHF, nephrotic syndrome, ESRD or ESLD

• Hgb and Hct decreased

• Fluid restrict

• Consider diuretic therapy or potential dialysis for significant fluid overload

Hypovolemia

• Lost from extracellular compartment > intake

• GI tract, kidneys, “third spacing,” skin/injured tissues

• Hgb and Hct increased, Urine Na down, Urea increases

• Hyponatremia with hypovolemia usually renal or GI source

• Give Isotonic IVFs

• Rapid correction can lead to central pontine myelinolysis


8

Electrolyte abnormalities

• Hyperkalemia • Peaked T waves• Tx: HD, sodium bicarbonate, D50 + insulin, Kayexalate. Calcium gluconate for

cardiac protection.

• Hypocalcemia • Trousseau sign (carpal tunnel spasm) or Chevostek sign (spasm of facial

muscles)

• Hypercalcemia • Common in 1 hyperparathyroid

and malignancies• bones, stones and groans

• Hyperphosphatemia • Most commonly 2/2 CKD

• Hypophosphatemia • Associated with EtOH

• Hypomagnesemia • Widening of the QRS


“This diabetic patient doesn’t just have ESRD, they also have terrible glucose control.”

• DM is the 7th leading cause of death in the US

• 8.3% of the US population has DM, 90% is Type 2

• HbA1C 6.5% or greater = dx of DM


Type 1- Autoimmune- Early onset- Risk of DKA- HLA DR3-DQ2 & DR4

Type 2- Later onset- +FH- Obesity/overweight- hyperinsulinemia

Type 1 Diabetes Mellitus

• Polydipsia, polyuria, nocturia, weight loss, blurred vision, pruritus, weakness, postural hypotension

• Untreated = DKA: N/V, dehydration, stupor, can lead to coma• Ketoacidosis

• Treatment: Insulin, dietary (no longer specific ADA diet), ASA (prevention as increased 10 yrCV risk >10%), preventative medicine (ophthalmology, podiatrist, exercise and hygiene), or transplant!


9

Types of Pancreas Transplants

• SPK, PAK, PAT


Combined Kidney PancreasEligibility for combined Kidney Pancreas Transplantation

Insulin requiring diabetes mellitusBMI≤35, or if C peptide is > 2, the BMI < 28. Age≤65Informed consentEstimated GFR ≤ 20 ml/min or dialysis, but GFR 20-25 ml/min considered if expected progression is rapid (>10 ml/min/year)Psycho-social clearanceFinancial clearance

Relative exclusion for >2 of the following:Age ≥ 55Insulin requirement > 1 U/kg/dayMulti-vessel CAD with ischemiaLVEF ≤ 35Trop T > 0.03 and EF < 45BMI ≥ 30Severe COPD (FEV1 < 50% predicted)Cigarette smokingSevere peripheral vascular disease Poor functional capacity (wheelchair bound or 6 minute walk < 150 meters)

Solitary PancreasEligibility for Pancreas After Kidney

Insulin requiring diabetes mellitusBMI≤33, or if C peptide is > 2, the BMI < 28. Age≤65Informed consentPsycho-social clearanceFinancial clearance GFR ≥ 50, or if GFR 35-50 and proteinuria < 1 gm/24 hours or biopsy shows only mild chronic change

Pancreas Transplant Anatomy• Originally located behind

stomach and connected to small intestine

• Produces insulin and glucagon

• Produces digestive juices

“I can’t stop checking my sugars.”Life after new pancreas

• If considering giving insulin, likely non-functioning allograft.

• SPK less likely to have DGF than kidney alone. Why?

• Gastroparesis: DM is RF, along with systemic sclerosis and Parkinson’s dz. Tx with metoclopramide, domperidone, erythromycin


10

Liver and ESLD

• Regulates glucose, protein, fat in blood

• Removes bilirubin, ammonia, and other toxins from blood

• Processes nutrients absorbed by intestines

• Produces cholesterol, albumin, and proteins,

• Produces clotting factors• Metabolizes drugs and

EtOH

Liver disease presents in varying stages.

“I just got insurance and my liver tests are off. Apparently, I have HCV.”

Some symptoms

“My husband’s eyes are yellow.”

Acute symptoms

“I just threw up blood.”


ESLD

• Viral Hepatitis

• NASH

• EtOH

• PBC

• PSC/UC

• HCC

• Autoimmune hepatitis

• Cholangiocarcinoma


11

Acute hepatitis

Hepatitis A

• Fecal-oral route, mild hepatitis

• S/Sx: malaise, fever, jaundice

• 30/30: incubation 30 days & US incidence + antibody 30%

• Tx: supportive, post exposure prophylaxis

• Prevention: vaccination

Hepatitis B

• IV drug users, MSM

• S/Sx: variable

• 6/6: Incubation 6 wks – 6 months

• Tx: Interferon + lamivudine

• Prevention: Vaccine, Hep B immune globulin (HBIG)


Hepatitis C

• Post-transfusion, IVDU

• S/Sx: asymptomatic – mild

• risk of HCC, plus cirrhosis 20%, chronic hepatitis 80%

• Tx: Interferon + ribavirin

• 6 genotypes• No vaccine

Cirrhosis

• Irreversible fibrosis and nodule formation

• Labs: Anemia, thrombocytopenia, elevated LFTs and Tbili, increased INR

• US for assessing ascites/nodules, EGD for varices, biopsy


Five Findings of late cirrhosis

1. Ascites

2. Varices

3. Hepatic encephalopathy

4. HCC

5. Jaundice


Spontaneous bacterial peritonitis & hepatorenal syndrome. Tx directics & paracentesis.

Esophageal varices: usually distal end, caused from portal HTN. NSAIDS exacerbate bleeds. E: Cirrhosis or thrombosis. Tx: BB, banding, TIPS placement

Tx: Lactulose & Rifaximin

TACE or microwave ablation & exception points for OLT

Relating to hyperbilirubinemia. Tb 3.0 mg/dL associated with scleral icterus and jaundice

12

Liver Allocation

• Bilirubin: measures how effectively liver excretes bile

• INR (PT), measures liver’s ability to make clotting factors

• Creatinine: measures kidney function

• Update: Now including Na

Hepatocellular carcinoma

• HBC, HCV, chronic hepatitis, EtOH, hemochromatosis

• AFP serum tumor marker elevated

• Dx on CT or MRI (lesion with washout) +/-biopsy• Blood supply from HA branches• Early arterial enhancement


http://www.scielo.mec.pt/img/revistas/ges/v22n4/22n4a05f3.jpg

Update on Liver Transplant

• Types of Donors• DBD• DCD• Living Donor

• Increased micro/macrosteatosis in allograft

• Increased CIT

• Simultaneous Liver/Kidney

• Liver allograft pump©2011 MFMER | slide-36

13

Hospital Course

• OR to ICU• Extubation 4-24hrs after surgery• Drains – 2 to 3, q4h +/- surgeon preference• NGT – caution with Roux

• M/S for 4-7 days

• US POD#1 and #7, plus labs and US POD#21

• Activity – ambulate, PT/OT right away• PMR, malnutrition, muscle wasting

Hernia

• Protrusion of organ or structure through the wall in which it is normally contained.

• Umbilical, hiatal, incisional, inguinal, ventral.

• Umbilical common with large ascites

• Tx: surgical


Common Radiology Findings

• Hematoma

• Seromas

• Lymphoceles

• Abscess

• HAS/HAT

• RAS/RAT

• Page Kidney

• Hydronephrosis

• Pancreas leak


Chamorro HA, Forbes TW, Padkowsky GO et-al. Multiimaging approach in the diagnosis of Page kidney. AJR Am J Roentgenol. 1981;136 (3): 620-1. AJR Am J Roentgenol

14

Immunosuppression

• Depleting lymphocytes, diverting lymphocyte traffic by blocking response pathways

• Decrease in donor-specific responsiveness to decrease risk of rejection

Immunosuppressive Medications• Induction, Maintenance, Reversal of Rejection

• Common Inductions• Alemtuzumab (Campath) – anti-lymphocyte induction• Basiliximab (Simulect) – non-depleting antibody and

fusion proteins• Thymoglobulin – Depleting antibodies – rabbit

antithymocyte globulin

• Maintenance• Tacrolimus (Prograf) FK• Mycophenolate mofetil (Cellcept) MMF • Prednisone• Sirolimus (rapamyacin) – not as nephrotoxic• Cyclosporine – unpredictable bioavailability

Tacrolimus

• HA, HTN, tremors, hyperglycemia, hyperK, CA, infxn, decreased renal function

• Increases with Diflucan, CCB, antifungals, macrolide abx, Prilosec, BCPs, Z-packs, amiodarone

• Decreases with Bactrim, Dilantin, phenobarbital, anti-epileptics agents, rifampin

• BID dosing, usually BID8&20

15

Mycophenolate mofetil

• GI upset, decreased WBC

• Blocks lymphocyte proliferation by inhibiting inosine monophosphate dehydrogenate

• Decreases incidence of bx-proven rejection during the first year• 50% decrease in loss of renal allografts• IV dose half of oral dose

Common Medication List

• Prograf 3mg in am and 2mg in pm

• CellCept 1000mg bid

• Prednisone 5mg

• Bactrim daily

• Fluconazole daily

• Valcyte daily

• PPI to prevent GERD


Infections

• Most commonly bacterial in early post transplant phase (<1 month)

• Primarily nosocomial• Enterococci, staphylococcus, G- aerobes,

anaerobes, or candidal species (75% of fungal infections)

16

Cytomegalovirus

• CMV most common viral infection found in immunocompromised pts

• Most prominent first three months

• Given in Valcyte or acyclovir (3-12 months)

• Fevers, malaise, arthralgias, lymphocytes, thrombocytopenia

• Gastroenteritis, myocarditis, pneumonitis, fatality

• Treatment with IV Ganciclovir, IVIG, CMV hyperimmune globulin, foscarnet

EBV and BK Virus

• “kissing disease”: mononucleosis

• Tx: symptomatic, steroids if enlarged LNs or thrombocytopenia, possible splenectomy

• Virus persists in kidneys, ureters, brain, and spleen

• 45-50% reactivation after kidney transplant

• As high as 80% associated graft loss

• Risk Factors: High HLA MM, recurrent rejection, high IS levels

Malignancy

• 2nd leading cause of late death in liver transplant recipients

• Lymphomas, squamous cell carcinoma, and PTLD (post transplant lymphoproliferative disorder)

• Squamous more common, especially given our area

17

PANCE/PANRE Blueprint• GU 6%

• Renal Diseases• Acute renal failure• Chronic kidney disease• Glomerulonephritis• Hydronephrosis• Polycystic kidney disease

• Fluid and Electrolyte Disorders

• Hypervolemia• Hypovolemia

• GU Tract Conditions• Nephrolithiasis

• ID 3%• Viral diseases

• CMV• EBV

• GI 10%• Esophagus

• Varices• Stomach

• GERD• Liver

• Acute/Chronic Hepatitis• Cirrhosis• Neoplasms

• Gallbladder• Cholangitis

• Hernias

• Endocrine 6%• DM Type I & II

• M/S 10%• SLE


Resources• Abbas Rana, MD, et al. Survival Benefit of Solid-Organ Transplant in the

United States. JAMA Surg. 2015;150(3):252-259. doi:10.1001/jamasurg.2014.2038. Published online January 28, 2015.

• Danovitch, Gabriel MD. Handbook of Kidney Transplantation. Wolters Kluwer Lippincott Williams & Wilkins. Philadelphia 2010.

• WANT MORE? http://www.ASTS.org


The Organ Trail (002) [Read-Only]...Stagesof Chronic Kidney Disease Stage Qualitative Description...

Documents

Transcript of The Organ Trail (002) [Read-Only]...Stagesof Chronic Kidney Disease Stage Qualitative Description...