Deceased donor kidney transplant
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Transcript of Deceased donor kidney transplant
BRAIN DEATH AND DECEASED DONOR KIDNEY TRANSPLANTATION
Dr. Joel Arudchelvam Consultant Vascular and Transplant Surgeon
Teaching Hospital Anuradhapura
Chronic kidney disease
Renal Replacement Therapy Dialysis Renal transplantation
Live Donor Deceased Donor
Chronic kidney disease
Renal Replacement Therapy Dialysis Renal transplantation
Live Donor - 94% 5Yrs Deceased Donor - 76% 5yrs
Need for deceased donors
Why Number of patients awaiting transplants Number with potential live donors
Complications for live donors
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
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
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
Etiology of Brain Death
Severe head trauma Cerebrovascular injury Prolonged cardiac resuscitation or asphyxia Tumors brain surgery
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
Kidney donor criteria
Age less than 65 years S Creatinine normal No chronic kidney disease Serological test
Hep B,C, HIV No sepsis malignancy
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
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.
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
Effective Donor/ organ Management
Stabilize the donor Manage the donor – To optimize the function and
viability of all transplantable organs. Preserve organ
“
Organ retrieval (A) Sternotomy and midline laparotomy with or without bilateral extension. (B) Exposure of the thoracoabdominal organs
Principles of organ preservation
Hypothermia Prevention of oedema Prevention of acidosis Neutralise the formation of reactive O2 species
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
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
Preservation solutions Euro-Collins - EC University of Wisconsin - UW Histidine-tryptophan-ketoglutarate - HTK Celsior
Preservation solutions Euro-Collins - EC University of Wisconsin - UWHistidine-tryptophan-ketoglutarate - HTK Celsior
Comparison of select preservation solutions
Euro-Collins University of Wisconsin
Histidine-tryptophan-ketoglutarate
Celsior
Impermeant
Glucose Lactobionate
Mannitol
Lactobionate
Mannitol Raffinose Mannitol
Hydroxyethyl starch
BufferPhosphate
Phosphate Histidine HistidineBicarbonate
Antioxidant Mannitol
Allopurinol Tryptophan Glutathione
glutathione Mannitol Mannitol
Histidine Histidine
All units expressed in mmol/L.
Comparison of select preservation solutions
Euro-Collins University of Wisconsin
Histidine-tryptophan-ketoglutarate
Celsior
Impermeant
Glucose Lactobionate
Mannitol
Lactobionate
Mannitol Raffinose Mannitol
Hydroxyethyl starch
BufferPhosphate
Phosphate Histidine HistidineBicarbonate
Antioxidant Mannitol
Allopurinol Tryptophan Glutathione
glutathione Mannitol Mannitol
Histidine Histidine
All units expressed in mmol/L.
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
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