When to go for Kidney Transplantation
Dr. Sant Kumar Pandey
Myself, Dr. San Pandit. I am a chairman and director department of technology in the Chandan hospital lockdown and today I am discussing one of the important topics that is when to go for kidney transplantation. This discussion is meant for physician to discuss updates on when to go for kidney transplantation and it is meant for the educational and purpose only. It is possible that some information on this specific drug is not of the approved level. Sanofi is not responsible for off-level uses for of their products. Traditions are requested to refer to the full prescribing information before prescribing any product. Let's start with the basic function of the kidney. As we know, kidney removed the base product of the body but apart from this function kidney has a lot of other functions also like fluid balance, acid base and electrolyte balance, blood pressure control, kidney produces erythropartins hormone which are responsible for RBC production and for increase in the global level. Also, kidney have important function for activation of vitamin D so the deficiency of when the kidney function deteriorated in kidney diseases here is a chance of vitamin D deficiency. This slide shows the increasing incidence and prevalence of end stage kidney disease. This is the US data and it clearly shows that both incidence and prevalence of the disease increase day by day in whole world. In India also, the CKD prevalence increases very fastly and now every one individual of 10 person. If we if we gather 10 individuals, one person is suffering from any type of kidney diseases. It is so common and the incidence is also increasing day by day. So then what is the possible symptoms of kidney disease? Light reduce the amount of urine formation swelling of feed, homelessness, drowsiness, fatigueness, nausea vomiting and later stage, seizure and coma. Attributed to other conditions but in the general OPD practices many patients come with asymptomatic forms. Without any symptoms and when we check with her kidney function it shows there is some form of kidney disease. Many patients are aware until reached up to the advanced stage. Then it means that this kidney disease may present in India. The data from the CKD statistics in India shows that nearly approximately 4 lakh individual reached up to the Indian stage renal disease every year and only 9 to 10,000 patient length go for the renal transplantation. So large amount of patient reached up to that going for continuous dialysis and many patients died without going to the transplantation. So it is very not realistic that most of the CKD patients in India who needs renal transplant, they died before going to the even dialysis or transplant. Though the what are the basic treatment options for Indian stage kidney disease? Indian stage kidney disease is defined as when GFR for less than 15% and patient needs either renal replacement therapy or supportive care. In renal replacement therapy bested the treatment options includes transplant, peritoneal dialysis or ecmodialysis. When we go for the pre-eandy stage kidney disease planning when the patients GFR fall below 20 then we start the pre-eandy stage kidney disease planning should be started and this includes discussion the available options. Plan in advance transplant versus dialysis recommended not to delay these therapies and avoid life-threatening complications or emergencies. This slide is very important compared the patient survival incident dialysis patient shows that the survival on the patient who are on dialysis survival improved nowadays as compared to earlier but one interesting thing is that the long-term survival of dialysis patient at even at the present days not very good as compared to the transplant patient. This slide shows the dialysis survival compared to the patient with common cancers and the long-term survival in dialysis patient not much improved in patient who are on dialysis whether the various malignancies is now improving day by day due to the availability of better options and immunological treatment but that long-term dialysis patient survival little bit improved but not very much improved. Adjust it all cause mortality by treatment modality overall dialysis and transplant clearly shows that transplant is better than the patient who are on dialysis for long-term survival part point of view and the overall survival is better in case of transplant patient as compared to the dialysis patient. This is the previous slide and we now discussing about the ratty option basically the transplant part. What is a kidney transplant? There is a donor kidney which is surgically placed into the recipient this is the disease kidney contracted small kidney of the patients or the recipients this is the native kidney and one transplanted kidney from the donor after nephraptomy we ligated with the ileia vessels and this is the transplanted kidney this whole process is known as the kidney transplant surgery. The surgical procedures transplanted kidneys placed in the right or left lower part of the abdomen in and it struck at atonal positions and this is transplanted kidneys very much superficially then it is easily too palpable on examination. Why kidney transplant? It is the most effective therapy for any stage kidney disease patient, better long-term survival and improved the quality of life as compared to dialysis. Benefit includes significantly reduced risk of mortality, life expectancy and triple reduced risk of heart attack stroke, heart failure which is more common in dialysis patient, improved quality of life and more likely to stay employed or patient remain active in transplant patient. What are the risk related with the renal transplant? The risk includes acute rejection this is the immunological graft dysfunction which may occur early stage or late stage lead to the graft failure, anti-rejection medication effect. This medication are immunosuppressant which reduces the immunity of the body and lead to increased chance of infections, post transplant malignancies, increased risk of diabetes especially by the CNI and steroid drugs, high blood pressure, dyslipidemia and the final nerve graft loss over the time. Then now compare the dialysis versus transplant. How dialysis is how transplant is better than dialysis in dialysis can only do the 10 to 15% of what a normal kidney does. People on dialysis have to follow a rigid diet plan because we generally do twice or twice per week dialysis. Normal kidney functions 24 is to 7 so 10 8 to 12 hour dialysis in a week is only contribute to 10 to 15% of normal kidney functions. We adhere must be adhered or rigid to that particular diet plan and people who are in dialysis typically have a low energy level where the transplant can do 55% of the normal kidney functions and GFR after transplantation in a recipient increases up to 50% after surgery. People who get a transplant can eat and eat more freely because the hemostasis of the body get normalized after transplant lived near normal life and the person who get a transplant often have a more energy than patient on dialysis and go back to the work normally. So the survival this graph also clearly shows that the patient survival who when we compare with the dialysis and transplant transplant have a better survival and better quality of life as compared to the dialysis patient. Cost of the dialysis versus transplant this is also very important. Some person's thing thought that the transplant is a very costlier thing but data clearly shows that transplant there is a one time of its investment where the dialysis continuous there is a cost is continuously it's a potential is continuously going on. So the overall cost is in transplant is less as compared to the dialysis and this study clearly shows that the even after two years the transplant cost is lesser as compared to dialysis patient. Similarly this is also shows that overall transplant cost is less as compared to the dialysis cost. So the overall transplant for the cost point of view also better as compared to dialysis. Then who can undergo the kidney transplant? There is a no absolute is limit absolute contributed contraindication includes active infection malignancies, severe respiratory condition, stomach heart disease, peripheral vascular disease, non-compliance but earlier hepatitis in HIV was considered as a contraindication but nowadays it is not considered contraindication any HIV positive patient can donate kidney to the HIV positive recipients and nowadays hepatitis can be like hepatitis C can be completely curable and patient go for the normal transplantation. Pre-transplant issue must be considered before transplant cardiovascular status of the patient infection is malignancies, psychosocial immune function, physical co-ignitions and the patient expectation and the quality of life all issues must be considered. Types of donor there are two type of donor one is the living donor and second is the disease donor or category donor group. Living donor will lead a living related transplant or we go further, kidney-paired exchange transplant or swab transplant. In case of disease donor after brain death that is the bleeding hurt and after the cardiac death who can donate? Close the relative of the recipients like parents sibling children is pals, grandparents and grandchildren the human organ transplant I clearly mentioned that the close blood relative can donate the kidney. In case of special situations after the clearance from the authorization committee, other donor like cousins uncle and aunt also can be considered if family members have medical issues and they're not able to donate the kidney. Patient donor age should be a junior or more. Pre-transplant donor evaluation must be done proper history, physical examination, blood group, routine blood investigations, urine culture, renal scan for the correct GFR estimation of both the kidneys, six hours, great intolerance, x-ray, eco-ultra sound, CT renal angiography to assess the number of renal vessels, at cellate typing, tissue cross-match, donor specific antibody and the psychiatric evaluation must be done before transplant. Dinal donors the commonest causes of discolification includes hypertension if not well-controlled diabetes, is to make her disease, donors GFR is if low associated with some systemic disease, genetic disease and there's the positive tissue cross-match. Positive tissue cross-match is the absolute contradiction for the transplant if CDC is positive. Post-naprectomy donor is a normal as anybody at any incident's hospital disease that he may suffer from subsequently. Authorization is required. There's a two type of authorization committee. One hospital authorization committee, they review and section the transplant and manage the state authorization committee. If in case of unrelated transplant, they could send for a patient to the state authorization committee. After the clearance from the state authorization committee, then file comes to the hospital authorization committee and finally patient go for the transplant. For foreign nationals, there is a passport and clearance from the embassy is mandatory and documents supporting the relationships are required including effort evidence. Then to go in for a renter transplant, either pre-emptive transplant means patients go for the direct transplant without going for dialysis, leaving donor non-pre-emptive transplant and disease donor transplant. The determining factor includes donor availability, blood group, antibody compatibility, pre-emptive transplant benefits. This is transplant and before dialysis started, there is a less chance of rejection, improved graft survival, long-term improved patient survival, less DGF, decreased overall hospitalization and avoid need for dialysis access. Blood group compatibility includes ABO compatible transplant and ABO incompatible transplant, ABO incompatible kidney transplant patient may be enrolled for the paired exchange or the disease donor program also. This is the medicine if you have blood type O, this blood group only received O blood group of donor kidneys. If A, then you can normally receive kidney from a donor of A or O. If blood group recipient is B, receive kidney for B or O, if AB can receive kidney from any blood type of blood group. So, O is the universal donor and AB is the universal receiver. Now, the ABO compatible kidney transplant is readily included. Three important functions there. One is the B cell depletion. Earlier it was done by the synchomy but now it is retoxymab is used for the B cell depletion. Earlier dose was 500 mg but now most of the center uses 200 mg and the antibody removal mainly done by the plasma pharases, double filtration plasma pharases immunoabsorption or using the IBIG. IBIG have a extra benefit that it is the immuno modulator and reduces the unwanted antibodies and press version plasma. This is the important thing is that kidney paired donation or swap transplant it is a very good of modality in which we can transplant a different blood group of patients by exchanging the kidney one to another. It may be done by two or more pair, incompatible pairs or compatible matches. Simultaneous donation is done by this kidney pair donation. This is the very good example of two pair type of kidney pair transplant. One is donor A recipient is donor one recipient is one but donor blood group one is blood group is A recipient blood group recipient one blood group is B and another donor come donor two and recipient two both blood group is B and A. Then direct transplant is compatible transplant is not possible between this but we can give the kidney donor A one can give kidney to the recipient two and donor two blood group B can give the donate the kidney to the recipient one. This type of known as kidney pair transplant both type of all the patient surgery done in the same day so that both recipient can receive the kidney from them both different type of donors. This kidney pair donation transplant may be three pair four pair this and long series of chain may be developed and this can incompatible pair can be transferred into the compatible type of transplant blood group. So the kidney pair transplant needs for incompatible pairs for difficult to transplant patient increase the donor pole, a few incompatible and desensitization process very costly and we can change to the kidney pair donate transplant program then possibly reduced. Disease donor transplant rate is low nowadays so this is a very good option for a abu incompatible group of patients. Indication is blood group incompatibility and presence of DSA's. Advantages this low cost outcome is better than disease donor transplant, mutually beneficial exchange disadvantage disadvantage includes more HLA mismatch. Come on the disease donor or catabary transplant after brain death or it can be done cardiac death most of the patient comes after the head injuries then that is beating that means harvesting the organs. Kidney is a very beauty only the kidney has the organ remain the function after 24 to 34 hour but it is the outside of the body. So the kid is the only organ where catabary transplant program is very good functional. Brain death there is a brain death there is a hospital there is a committee includes a neurosurgeon and physician they've declared the patient is the brain death. Brain death includes irreversible loss of consciousness loss of brain stem reflex absence of risk parations. This is done by the apnea test flat e g no other condition which is responsible for the comatose stage main cause are trauma or brain hemorrhage. What about the rejection after the kidney transplant? The body sees the kidney transplant as a foreign attack it to get rid of it this process known as rejection. This is the basically immunological process of the body which is which leads to the rejection the graph kidney considered as the foreign body and they try to reject them and lead to the thrombosis and necrosis of the kidney tissues and finally graft loss. Rejection is prevented by the use of immunosuppressant medication. The immunosuppressant includes the induction agent which includes ATG or Becileximab and the maintenance used triple drug regime includes steroid, CNI's and the anti-motivolite like MMF or other thiambary. How long one has to take a transplant medicine? It is a lifelong rejection connector. Anytime when particularly if the medication is stopped tolerance induction techniques are still in this future part for the so that the immunosuppressant medication can be reduced. However doses of the medicine is can be reduced. So the medication is reduced as the rejection lesson with the science. Follow and the precautions how frequent A-visit means CBC, ureocortine drug level, special tax, unice level should be monitored when required. Weight, blood pressure, side effect, dose adjustment, blood sugar level, infection especially CMV, parbo virus, BK virus, ABN and osteo dystrophy all should be considered in follow-up visits. Avoid crowded places, wear in masks, food, water, salat, non-vegetarian foods and the marriage children. All parts should be considered in follow-up visits and doses and immunosuppressant medication can be changed before patient planning for marriage or children. Logistic of the transplant drug supply, no interruption at any cost. He is just not another patient in your queue as his life depends on you virtually. Bovulability of teclolimus, cyclosporine and microferent varies with the brand formulation as they have a narrow throughput of So summarizing the whole when patient go for transplantation summarizing the thing that the best treatment for end stage kidney disease is renal transplant. Kidney transplant saves lives, improves the quality of life and saves the cost. Living kidney donation is a safe and provides better outcome and the pre-transplant plantation is the best option as compared to patient who opted transplant after the starting dialysis. Thank you.
