Guidelines onRenal Transplant

Guidelines on Renal Transplantation T. Kälble, A. Alcaraz, K. Budde, U. Humke, G. Karam, M. Lucan, G. Nicita, C. Süsal © European Association of Urology 2009 TABLE OF CONTENTS PAGE 1. INTRODUCTION 6 1.1 Reference 6 2. KIDNEY DONATION 7 2.1 Ethical issues in transplantation 7 2.1.1 Primary ethical principles 7 2.1.1.1 Beneficence: doing good, avoiding harm, autonomy, fairness 7 2.1.2 Deceased donor organ donation 7 2.1.2.1 2.1.2.2 Deceased organ donor 7 Allocation of deceased donor organs 7 2.1.3 Living-organ donors 7 2.1.4 References 8 2.2 Policies to increase the supply and use of deceased donors 8 2.2.1 Donor cards 9 2.2.2 Improved organisation and resources 10 2.2.3 ‘Opting-out’ legislation 10 2.2.4 Non-heart-beating donor (NHBD) 10 2.2.5 Elderly donors 11 2.2.6 References 11 2.3 Policies to enhance living donation 11 2.3.1 Medical methods to increase the number of living donations 12 2.3.1.1 2.3.1.2 2.3.1.3 2.3.1.4 2.3.1.5 2.3.1.6 2.3.1.7 2.3.1.8 2.3.1.9 Acceptance of grafts with anatomical anomalies 12 Laparoscopic living-donor nephrectomy (LLDN) 13 References 13 ABO-incompatible donors 14 Cross-match-positive living-donor kidney transplants 15 Living unrelated kidney donation 15 ‘Non-directed‘ living-donor transplantation 15 Payment to living donors from a central organisation 15 References 15 2.3.2 Ethical ways of showing appreciation for organ donation 17 2.3.2.1 Donor ‘medal of honour’ 17 2.3.3 Organisational ways to encourage organ donation 17 2.3.3.1 2.3.3.2 Cross-over transplantation or paired kidney exchange 17 Medical leave for organ donation 17 2.3.4 References 18 2.4 Kidney donor selection and refusal criteria 18 2.4.1 Introduction 18 2.4.2 Infections 18 2.4.3 Special exceptions for infections 19 2.4.4 Malignant tumours 19 2.4.5 Special exceptions for malignant tumours 19 2.4.6 Vascular conditions and renal function 19 2.4.7 Marginal donors 20 2.4.8 One graft or two grafts per recipient 20 2.4.9 References 20 2.5 Explantation technique 22 2.5.1 Technique of deceased donor organ recovery 22 2.5.2 The living donor 23 2.5.2.1 2.5.2.2 2.5.2.3 2.5.2.4 2.5.2.5 Evaluation 23 Choice of kidney 24 Pre-operative management 24 Surgical alternatives in live-donor nephrectomy 24 Post-operative care 25 2.5.3 References 26 2.6 Organ preservation 28 2.6.1 Kidney storage solutions 28 2.6.2 Methods of kidney preservation 28 2 UPDATE MARCH 2009 2.6.3 Duration of organ preservation 28 2.6.4 References 29 3. KIDNEY RECIPIENT 29 3.1 Pre-transplant therapy 30 3.1.1 Abnormal urogenital tract 30 3.1.2 Urinary diversion 30 3.1.3 Indications for pre-transplant nephrectomy 30 3.1.4 References 31 3.2 Selection and refusal criteria 31 3.2.1 Contraindications 31 3.2.1.1 3.2.1.2 3.2.1.3 Malignancy 31 Infection 32 Other contraindications for transplantation 32 3.2.2 Co-morbidity 33 3.2.2.1 3.2.2.2 3.2.2.3 3.2.2.4 3.2.2.5 3.2.2.6 3.2.3 Age Cardiac disease 33 Peripheral artery disease, cerebral occlusive vascular disease 33 Diabetes mellitus 34 Obesity 34 Coagulopathies 34 Other diseases with potential influence on post-transplant outcome 35 35 3.2.4 Recurrence risk (original renal disease) 35 3.2.5 Patients with a previous transplant 36 3.2.6 References 36 3.3 Transplantation in pregnancy 40 3.3.1 Planning pregnancy 40 3.3.2 Graft survival 41 3.3.3 Care during pregnancy 41 3.3.4 Immunosuppressive treatment 41 3.3.5 Follow-up 42 3.3.6 References 42 4. TRANSPLANTATION TECHNIQUES 43 4.1 Transplant preparation and transplant techniques in adults 43 4.2 Early complications 45 4.2.1 General complications 45 4.2.1.1 4.2.1.2 4.2.1.3 4.2.1.4 Wall abscesses 45 Haemorrhage 45 Haematuria 45 Incisional hernia 45 4.2.2 Urinary fistulae 45 4.2.2.1 Management 45 4.2.3 Arterial thrombosis 45 4.2.3.1 Treatment 46 4.2.4 Venous thrombosis 46 4.3 Late complications 46 4.3.1 Ureteral stenosis 46 4.3.2 Reflux and acute pyelonephritis 47 4.3.3 Kidney stones 47 4.3.4 Renal artery stenosis 47 4.3.5 Arteriovenous fistulae and pseudo aneurysms after renal biopsy 48 4.3.6 Lymphocele 48 4.4 References 48 4.5 Kidney transplantation in abnormal urinary tract 52 4.5.1 References 52 5. MATCHING OF DONORS AND RECIPIENTS 52 5.1 Histocompatibility (human leukocyte antigen [HLA]) matching 52 5.1.1 Practical aspects of HLA-testing 53 UPDATE MARCH 2009 3 5.2 Cross-matching 53 5.3 Pre-existing HLA-specific antibodies 53 5.3.1 Eurotransplant Acceptable Mismatch (AM) programme 54 5.4 ABO compatibility 54 5.5 References 54 6. IMMUNOSUPPRESSION AFTER KIDNEY TRANSPLANTATION 55 6.1 Introduction 55 6.2 Primary immunosuppressive prophylaxis 55 6.2.1 Calcineurin inhibitors (CNIs) 55 6.2.1.1 6.2.1.2 6.2.1.3 Cyclosporine A 55 Tacrolimus 56 Summary 56 6.2.2 Mycophenolates 57 6.2.3 Azathioprine 58 6.2.4 Steroids 58 6.2.5 Inhibitors of the mammalian target of rapamycin (m-TOR) 58 6.2.5.1 6.2.5.2 6.2.5.3 Side-effects 58 Comparison of pharmokinetics and licensed use 59 Conversion from CNIs to m-TOR inhibitors 59 6.2.6 T-cell depleting induction therapy 59 6.2.7 Interleukin-2 receptor antibodies 60 6.2.8 References 60 7. IMMUNOLOGICAL COMPLICATIONS 65 7.1 Introduction 65 7.2 Hyper-acute rejection (HAR) 66 7.2.1 Prevention 66 7.3 Acute allograft rejection 66 7.3.1 Treatment of T-cell mediated acute rejection 67 7.3.2 Treatment of acute humoral rejection (AHR) 68 7.4 Chronic allograft dysfunction/interstitial fibrosis and tubular atrophy (IF/TA) 68 7.4.1 Diagnosis and treatment 68 7.5 References 69 8. MALIGNANCY 71 8.1 Transmission of a donor neoplasia to the recipient 71 8.2 Prior malignancy in the recipient 72 8.3 ‘De-novo’ tumour in the recipient 73 8.3.1 Skin cancer and Kaposi’s sarcoma 73 8.3.2 Lymphatic disease 74 8.3.3 Gynaecological cancers 74 8.3.4 Prostate cancer 74 8.3.5 Bowel cancer 74 8.3.6 Urothelial tumours 74 8.3.7 Renal tumours 75 8.3.8 Chest X-ray 75 8.4 References 75 9. ANNUAL SCREENING 77 9.1 Recommendations for annual screening 77 9.2 References 77 10. GRAFT AND PATIENT SURVIVAL 77 10.1 Deceased and living donors 78 10.1.1 Graft survival 78 10.1.2 Patient survival 80 10.2 Age of donor and recipient 81 10.2.1 Donor’s age 81 10.2.2 Recipient’s age 81 4 UPDATE MARCH 2009 10.3 HLA-matching 81 10.4 Immunosupression 83 10.5 Number of transplantations 84 10.6 Cold ischaemia time 84 10.7 Time on dialysis 85 10.8 References 86 11. ABBREVIATIONS USED IN THE TEXT 87 UPDATE MARCH 2009 5 ... - tailieumienphi.vn