The kidney is the most common solid organ transplant.
(See also Overview transplant.) The kidney is the most common solid organ transplant. The primary indication for kidney transplantation is end-stage are absolute contraindications kidney failure: comorbidities that could compromise the survival of the graft (eg severe heart disease, cancer.). They can be detected by a thorough screening. Relative contraindications: Weak controlled diabetes, which can lead to kidney failure. Certain viral infections (eg. As hepatitis C with end stage liver disease), which can be worsened by the required immunosuppression after transplantation as candidates for transplant patients are in their 70s, sometimes even to the 80 years considered. However, they must be healthy and functionally independent, with good support from the social environment and a relatively normal life expectancy. In such patients, a transplant may be the survival function and quality significantly improved only by eliminating the dialysis. In patients with type 1 diabetes mellitus can u. U. be performed simultaneously pancreatic transplants or kidney pancreas-to-kidney transplants. Kidney donors More than half of donor kidneys come from previously healthy people who have suffered brain death. Approximately one third of these kidneys have physiological and caused by the handling of the graft damages are due to the high demand but used anyway. It (called grafts from donation-after-cardiac-death [DCD]) uses more kidneys from donors with cardiac arrest. These kidneys may have been damaged by the ischemia before the death of the donor and their function is often impaired due to acute tubular necrosis, but in the long run, they seem just as kidneys from donors who (standard criteria so-called standard criteria donor [ BKT]) to work. The remaining kidneys (approximately 40%) are from living donors; because of the limited supply of donor kidney allografts are transplanted from carefully selected unrelated living donors increasingly. A living donor waived not only renal reserve capacity, but the risk can a procedural and long-term morbidity and expose advised regarding organ donation in a mental conflict. Therefore, potential living donors in terms of a normal bilateral renal function, the absence of other systemic diseases, histocompatibility, emotional stability and their ability to express the consent evaluated. Hypertension, diabetes and malignant diseases among potential donors (except for possible CNS tumors) mean the exclusion of the kidney donation. The living kidney donation from unrelated donors has increased; Kidney exchange programs often find suitable potential donors and recipients that do not fit other similar incompatible pairs. If many such pairs are identified, a chain exchange is possible, which increases the potential for a good match between donor and recipient. When an ABO matching is not possible, an ABO-incompatible transplantation can be performed under certain circumstances; with a careful selection of donors and recipients, and with a treatment before Tranplantation (plasma exchange and / or intravenous immunoglobulin [IVIG]), the results can be comparable to those of ABO-compatible transplantation. Procedure The donor kidney is laparoscopically (or more rarely during open surgery) were removed and then perfused with a cooling liquid containing relatively large concentrations of hard permeable substances (eg., Mannitol and starch) and the electrolyte concentrations similar intracellular values. Then, the thus-treated kidney is stored in ice-cooled solution. Kidneys, which are conserved in this way, usually work best when they are transplanted within 24 hours. By continuous hypothermic pulsatile perfusion with oxygenated perfusate to plasma, the viability of the transplant after removal of up to 48 hours can be obtained, even if it usually is not utilized. Prior to transplantation, dialysis may be needed at the receiver to ensure a relatively normal metabolic status. Allografts from living donors seem a transplant to survive something better for recipients who have started Duration dialysis before transplantation. Nephrectomy at the recipient is not normally required unless the native kidneys are infected. Whether transfusions in anemic patients who expect an allograft, are useful, is unclear. Transfusions may sensitize patients to alloantigens, but allografts survive better if indeed the recipients of transfusions, but are not sensitized. May induce transfusions a certain tolerance. The transplanted kidney is usually implanted in the iliac fossa. There are manufactured to Iliakalgefäßen renal vascular anastomoses, and the ureter of the donor is implanted into the bladder of the receiver or connected by anastomoses with the ureter of the receiver. VUR, usually without side effects, it occurs in about 30% of recipients. The immunosuppressive regimens vary (see table: immunosuppressants for the treatment of transplant rejection). Usually be calcineurin (CNI) administered immediately after transplantation. Subsequently, the dose is titrated to toxicity and risk of rejection can be reduced to a minimum, said Talblutspiegel is kept high enough to prevent rejection. On the day of transplantation and corticosteroids are administered i.v. or p.o. administered; the dose is gradually tapered off. Complications rejection, despite the use of immunosuppressive drugs, about 20% of renal transplant recipients have one or more rejection in the first year after transplantation. Most episodes are easily treated with a corticosteroid bolus; yet they contribute in the long run to the insufficiency or lack of graft acceptance, or both. The signs of rejection are different depending on the type of rejection (see Table: Nierenransplantatabstoßung manifestations of their category). Manifestations of Nierenransplantatabstoßung by category rejection category manifestations hyper acute fever, anuria Accelerates fever, oliguria, swelling and tenderness of the graft acute therapy, fever, elevated serum creatinine, blood pressure, weight gain, swelling and tenderness of the graft proteins, lymphocytes, and renal tubular cells in the urine sediment Chronic proteinuria with or without hypertension, nephrotic syndrome, when the clinical diagnosis is not clear, a percutaneous needle biopsy is performed. By biopsy can also be antibody-mediated differ from T-cell mediated rejection, and other common causes of graft failure or failure to identify (z. B. calcineurin inhibitor toxicity, diabetic or hypertensive nephropathy, polyomavirus type 1 infection). With more sophisticated tests, the diagnosis accuracy can be improved for a rejection: In urine samples, the mRNA encoding mediators of rejection are determined, and from biopsy samples, a gene expression profile is created with the help of very small amounts of DNA. An accelerated or acute rejection reaction can usually by more intensive immunosuppression (z. B. with high-dose steroid pulses or antilymphocyte globulin) to be overcome. When the immunosuppressants are ineffective, allowed to phase out the therapy and the patient is on hemodialysis again, while waiting for a new transplant. Nephrectomy of the transplanted kidney is required if the discontinuation of immunosuppressive hematuria, graft pain and fever auftreten.Chronische allograft nephropathy urate nephropathy Chronic allograft has graft insufficiency or failure ? 3 months after transplantation back. In most cases, have one or more of the aforementioned causes. Some experts believe that the concept of chronic nephropathy only to apply to the description of graft failure or graft failure when the biopsy demonstrates a chronic interstitial fibrosis and tubular atrophy due to any other causes sind.Krebs develop Compared to the general population kidney transplant recipients probably about 10 to 15 times more likely to cancer because the reaction of the modulated immune system to cancer and is weakened infections. Cancer of the lymphatic system (lymphoma) is 30 times more common in kidney transplant recipients than in the general population, but a lymphoma is still unusual. Skin cancer is common in kidney transplant recipients after many years of immunosuppression. Prognosis Most rejection crises and other complications occur 3-4 months after transplantation; after which most patients return to a largely normal health and activity level, but they must take immunosuppressants in maintenance doses for an indefinite period. At 1 year after kidney transplantation, the survival rates living donor grafts are 98% (patients) and 94% (grafts) transplants from deceased donors: 95% (patients) and 88% (grafts) In the years following the transplant losses amount for living donors 3- 5% and body donations 5-8%. Of the patients whose transplants survive the first year, passes away one half despite normal functioning graft from other causes; the other half developed after 1-5 years a chronic nephropathy allograft and a malfunction of the graft. The rates for late malfunctions are higher than for white in dark-skinned patients. Measurements of the highest systolic and lowest diastolic blood flow in renal segmental arteries by Doppler sonography ? 3 months after transplantation can help in estimating the prognosis. The best clinical predictor remains Serial determination of serum creatinine when patients last measured creatinine levels should be compared with previous values; a sudden increase of creatinine indicates a rejection, or other problem (z. B. circulatory disorders, obstruction of the ureter). Ideally, the serum creatinine levels in all patients 4 to 6 weeks after the kidney transplant should be normal.