Pre and post operative in renal tranplant

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1. “PRE AND POST OPERATIVE IN RENAL TRANPLANT” S. Grace let Melita 2 nd yr. M.Sc.(N)

2. INTRODUCTION: Kidney transplantation is the preferred means of renal transplant therapy in the pediatric age group Transplantation offers the opportunity for a relatively normal life

3. RENAL TRANSPLANT: Renal/ kidney transplant is the organ transplant of a kidney into a patient with end stage renal disease

4. STATISTICS:

5. CLASSIFICATION: Diseased donor: Cadaveric 2. Living donor: Genetically related living related Non related( living non related)

6. COMPATABILITY: The patient has to be ABO compatible The recipient should share as many as HLA antigens and minor antigens as possible Immuno-suppressant drugs are given to prevent antibody reaction Perform antibody test on potential recipient

7. LIVING DONOR: Evaluate donors on physical, medical and psychological grounds Assure the patient that there will be no long terms harm to donor In some cases male living donor may develop a hydrocele on the scrotum on the side of the nephrectomy

8. Live donor procedure are mostly laparoscopic, hence less painful , less scaring and faster recovery

9. DISEASED DONOR: Brain dead donors Donation after cardiac death

10. INDICATION: ERSD( GFR< 15ML/L) Malignancy Hypertension Diabetes mellitus Genetic disease( polycystic kidney disease) Metabolic disorders

11. Auto immune condition( lupus, good pastures syndrome) Chronic renal failure

12. CONTRA INDICATION: Cardiac and pulmonary insufficiency Hepatic disease Substance abuse HIV Concurrent tobacco use Morbid obesity

13. PRE OPERATIVE PERIOD: TEAM comprises; Urologist, nephrologist, nurses, transplant co Ordinator, renal transplant educator, clinical dietician and physiotherapist

14. MANAGEMENT: OVERALL GOAL: To promote maximum renal function To maintain fluids and electrolyte balance within safe biochemical limits To treat systemic complication To promote active and normal life as long as possible

15. DIET: Protein: 0.8- 1g/kg/day Sodium: since renal regulation of Na reabsorption is impaired, its dietary intake needs to be individualized Potassium: should be avoided

16. DIET SCHEDULE: 1 st day: neural & sips 2 nd day: clear fluids 3 rd day: soft solids 4h day: normal diet

17. Calcium and phosphorus: given in the form of calcium carbonate or acetate, diary products should be avoided Water: restriction in case of fluid overload, excessive use of diuretics, restriction of salt and gastroenteritis may lead to dehydration that should be corrected

18. CONTROLLING HYPERTENSION: Decreased fluid intake Sodium restriction Administration of hydralazine. Beta blockers( atenolol, propanalol), ca channel antagonist( nifedipine, amlodipine) If not treated , angiotensin converting enzymes inhibitors( enalapril), clonidine or prazosin

19. MANAGING ANEMIA: Parental administration of recombinant human erythropoietin is the treatment of choice for anemia of CRF Iron & folic acid supplementation Red cell packed transfusion( Hb< 6g/dl) slowly since it can aggravate hypertension and lead to heart failure

20. MANAGING INFECTIONS: UTI should be treated promptly with effective and least toxic drugs

21. MAINTAIN GROWTH: Treatment of osteodystrophy is important Administration of recombinant human growth hormone improves growth velocity in children with CRF

22. DENTAL CARE: Dental defects are common in children( hypoplasia, hypo mineralization, tooth discoloration and alteration in size and shape of teeth Therefore regular care of teeth is vital

23. POST OPERATIVE PERIOD: The main focus is on achieving graft function and early mobilization without the difficulties of rejection, infection, fluid overload and technical mishap Fluid replacement Hemodynamic monitoring Urine output Care of Vascular and ureteric drain

24. Vital signs Central venous pressure( to ensure appropriate renal function) Antibiotic and immunosuppressive therapy Ventilatory support( increase in intra abdominal pressure causes respiratory difficulties in case of transplant of adult kidney to the child)

25. DRUGS: Tab. Mycofenolate mofelate ( 40mg/kg/day in 2 divided dose) or tab. Mycophenolate sodium(30mg/kg/day in 2 divided dose) Tab. Tacrolimus( 0.15mg/kg/day in 2 divided dose) Azathioprine( 1.5- 2mg/kg/day 3 days prior to transplantation) Inj. Dexamethasone( 0.3mg/kg) In. Emeset Tab. Prednisolone(start 0.4 mg/kg/day & continue 10mg once daily)

26. Cyclosporin:

27. INVESTIGATIONS: On receiving the Patient: TC, Hb, PCV, urea, creatine, electrolytes, RBS 2 nd day: Same as 1 st day, PT, APTT, platelet count if patient is on heparin 3 rd day: urea, creatine, TC, electrolyte if indicated 5 th day: LFT, Tacrolimus assay( on empty stomach)

28. COMPLICATIONS: Allograft dysfunction Delayed graft function Anastomotic hemorrhage Renal arterial thrombosis Renal vein thrombosis Transplant renal artery stenosis lymphocele

29. Rejection Vascular thrombosis Obstruction Infection Dehydration Nephrotoxicity Elevated creatinine

30. PROGNOSIS: Early stage- good prognosis End stage- bad prognosis