urology

RENAL FAILURE & TRANSPLANTATION

Renal Failure
Reduced clearance of certain solutes principally excreted by the kidney The most common indicators are urea & creatinine RF could be acute or chronic

Causes of end stage renal failure

- DM 36% - Hypertensive nephrosclerosis 30% - chronic glomerulonephritis 24% - Autosomal dominant polycystic kidney disease 12% -chronic pyelonephritis In pediatric age group ( <18 year ) congenital causes predominate like cong. hypoplasia.

Treatmentof end stage CRF

Treatment is by hemodialysis, peritoneal dialysis, or renal transplantation

Renal transplantation

Renal Transplantation is the treatment of choice & the most cost effective treatment for end stage renal failure.

The upper age limit for renal transplantation is 70 year of age in average

DONER RECEPIENT

recepient evaluation:

Cardiac statusMalignant diseases: waiting time : 1 – 2 year for low metastatic potential 5 – 6 year for high risk tumorsInfectionsGIT diseases like peptic ulcer GU abnormalities : MCUG , URODYNAMIC STUDY

Pretransplant bilateral native kidney nephrectomy

Seldom required Indications: Pyelonephritis Medically uncontrolled renin mediated hypertension Malignant disease Nephrotic syndrome Extremely large polycystic kidney

Types of donors for renal transplantation

Living related donors : Allograft half life is 10 year longer than cadaveric renal donation Living unrelated donors Cadaveric donors :

Contraindications for renal transplantation

Active infections including AIDS Active malignant diseases

the donor is always left with the better kidney Left kidney is prefered due to longer renal vein

Investigations & HLA tissue matching

Tissue matching is performed for HLA –A,B,&DR antigen that are found on the 6th chromosome ABO blood grouping & cross matchin

Types of rejections

Hyperacute rejection Acute rejection Chronic rejection

Hyperacute rejection

incidence 1/1000 analogous to blood transfusion reaction , occurs immediately ,preformed Ab against HLA expressed on donor renal vascular endothlium occurs as soon as blood flow to the donor kidney is established treatment : immediate transplant removal

Acute rejection

occurs between 1st week- 1 month occurs in 25 – 55% of patientDiffrential diagnosis : ATN , ureteral obst, drugs toxisity Clinically : febrile , tenderness over the graft impaired renal function,decrease urine output. Diagnosis : renal biopsy treatment.. by steroids & immunosuppressants

Chronic rejection

Defined as a gradual progressive loss of renal function that cannot be attributed to another cu. there is no definitive treatment for this type of rejection retransplantation to be consedered

Immunosupression

: Focused on preventing & reversing acute rejection Agents used in 3 ways induction : immediately after Tx like Azathioprine & steroids maintenance : initiated once creatinine in normalised like Azathioprine & steroids, cyclosporin A treatment of acute rejection like steroids

Complications of renal transplantation

Technical Delayed transplant renal artery stenosis Anastamotic leak Anastamotic or ureteral stricture Ureteral obstruction Ureterovesical disruption Lymphocele

Complications of renal transplantation,cont

Non technical Infections Cancers: lymphoma , Kaposi sarcoma