Deceased donor kidney transplant

cadaveric transplant renal transplant, cold preservation

1. Brain death and Deceased donor kidney transplantation Dr. Joel Arudchelvam Consultant Vascular and Transplant S urgeon Teaching Hospital Anuradhapura

2. Chronic kidney disease Renal Replacement Therapy Dialysis Renal transplantation Live Donor Deceased Donor

3. SURVIVAL AND MODES OF RRT Charlotte Medin et al. Nephrol. Dial. Transplant. 2000;15:701-704

4. Chronic kidney disease Renal Replacement Therapy Dialysis Renal transplantation Live Donor - 94% 5Yrs Deceased Donor - 76% 5yrs

5. Need for deceased donors Why Number of patients awaiting transplants Number with potential live donors Complications for live donors

6. Deceased donors Types Donation after brain death - DBD Donation after cardiac death - DCD

7. The basic principles for excellent cadaveric organ retrieval Identification of potential donors Early confirmation of the brain death consent Prompt notification of the retrieval team Careful and intensive management of the donor Rapid retrieval of the organs

8. Uniform Determination of Death Act Who is a deceased donor : An individual is considered dead if: 1.irreversible cessation of circulatory and respiratory function or 2.irreversible cessation of all functions of the entire brain , including the brain stem . JAMA Nov 13, 1981 – Vol 246, No. 19

9. Uniform Determination of Death Act Who is a deceased donor : An individual is considered dead if: 1.irreversible cessation of circulatory and respiratory function or 2.irreversible cessation of all functions of the entire brain , including the brain stem . JAMA Nov 13, 1981 – Vol 246, No. 19

10. Etiology of Brain Death Severe head trauma Cerebrovascular injury Prolonged cardiac resuscitation or asphyxia Tumors brain surgery

11. Brain Death

12. Determination of Brain Death

13. The Neurologic Examination Coma No evidence of responsiveness. No motor response to noxious stimuli

14. The Neurologic Examination (cont.) Absence of Brainstem Reflexes No pupillary reflex Absent corneal reflex. Absent - gag oculocephalic testing (doll’s eyes test) Oculovestibular testing – ice water irrigation of each ear canal

15. The Apnea Test

16. Brain death declaration ****Detailed documentation

17. Kidney donor criteria Age less than 65 years S Creatinine normal No chronic kidney disease Serological test Hep B,C, HIV No sepsis malignancy

18. The basic principles for excellent cadaveric organ retrieval Identification of potential donors Early confirmation of the brain death consent Prompt notification of the retrieval team Careful and intensive management of the donor Rapid retrieval of the organs

19. For successful deceased donor organ transplant program Members Anaesthetist Coordinators Tissue cross match facilities Retrieval team Transplant team Theatre/ ward/dialysis unit/ ICU staff Etc.

20. The basic principles for excellent cadaveric organ retrieval Identification of potential donors Early confirmation of the brain death consent Prompt notification of the retrieval team Careful and intensive management of the donor Rapid retrieval of the organs

21. CHANGES FOLLOWING BRAIN DEATH

22. Effective Donor/ organ Management Stabilize the donor Manage the donor – To optimize the function and viability of all transplantable organs . Preserve organ “

23. Donor management guidelines Cardiac Respiratory Renal Endocrine General care

24. Potential brain dead donor management

25. Organ retrieval (A) Sternotomy and midline laparotomy with or without bilateral extension . ( B) Exposure of the thoracoabdominal organs

26. Exposure of aorta and cold perfusion

27. Cellular changes during ischaemia

28. Principles of organ preservation Hypothermia Prevention of oedema Prevention of acidosis Neutralise the formation of reactive O2 species

29. Principles of organ preservation Hypothermia Metablism at 4 C – 10% Ideal temperature - 4 C Prevention of oedema Prevention of acidosis Neutralise the formation of reactive O2 species

30. BASIC COMPONENTS OF PRESERVATION SOLUTIONS Prevention of oedema Impermeants – saccharides e.g – Mannitol Anions – citrate, gluconate , lactobionate Colloids – dextran,polyethylene glycol Prevention of acidosis Buffers – phosphate and histidine Neutralise the formation of reactive O2 species Antioxidants – glutathione, tryptophan, allopurinol

31. Preservation solutions Euro-Collins - EC University of Wisconsin - UW Histidine -tryptophan- ketoglutarate - HTK Celsior

32. Preservation solutions Euro-Collins - EC University of Wisconsin - UW Histidine -tryptophan- ketoglutarate - HTK Celsior

33. Comparison of select preservation solutions Euro-Collins University of Wisconsin Histidine -tryptophan- ketoglutarate Celsior Impermeant Glucose Lactobionate Mannitol Lactobionate Mannitol Raffinose Mannitol Hydroxyethyl starch Buffer Phosphate Phosphate Histidine Histidine Bicarbonate Antioxidant Mannitol Allopurinol Tryptophan Glutathione glutathione Mannitol Mannitol Histidine Histidine All units expressed in mmol /L.

34. Comparison of select preservation solutions Euro-Collins University of Wisconsin Histidine -tryptophan- ketoglutarate Celsior Impermeant Glucose Lactobionate Mannitol Lactobionate Mannitol Raffinose Mannitol Hydroxyethyl starch Buffer Phosphate Phosphate Histidine Histidine Bicarbonate Antioxidant Mannitol Allopurinol Tryptophan Glutathione glutathione Mannitol Mannitol Histidine Histidine All units expressed in mmol /L.

35. In situ hypothermic perfusion and packing of abdominal cavity with ice Lower aorta mobilised Heparin 300 IU/Kg Aorta cannulated Suprarenal aorta clamped Perfused with Cold preservation solution

36. Kidney removal

37. Back bench dissection

38. Make sure all areas are perfused well Back table perfusion

39. Organ packaging and transport

40. Transplantation

41. Future recommendations National protocol development Maintenance of common list for recepient Establishment of donor coordination programme – countrywide Education on recognition of potential donor, donor management, consent Education of public Establish clear legal pathways Train more personnel - ? Surgeons (8 vs 4) Transplantation and post op facilities Operating theatres and ICU facilities Follow up plans

42. Thank You