Guidelines For Kidney Transplantation – Living Donor Criteria

 Living Kidney donation is accepted by law, religion and bioethics, provided that the donor is aware of the consequences of his/her act & makes the decision without outside pressure or commercialism. Living donor evaluation includes a medical history, physical examination, laboratory tests, serologic screening & imaging studies in order to reach the following conclusions:-

1. Donor has compatible blood and cross-match with the recipient.

2. Donor is healthy, with no unacceptable medical or surgical risk after donor nephrectomy.

3. Donors will have a stable renal function after donation.

4. Donor does not have transmissible infection or malignancy.

5. Donor has acceptable renal anatomy.

6. Donor does not have nor will have a psychosocial problems.

In order to fulfill the above conclusion, the following is the algorithm we follow:-

ABSOLUTE EXCLUSION CRITERIA Ø Age <18 years

Hypertension in someone younger than 50 years old,

Evidence of end-organ damage, or on three or more anti-hypertensive medications

A.   Diabetes (diagnosis of diabetes) or abnormal glucose tolerance test History of thrombosis or embolism  

B.   Psychiatric contraindications

C.  Obesity: BMI>35kg/m2

D.  Coronary Artery Disease

E.   Symptomatic Valvular Disease

F.   Peripheral Vascular Disease

G.  Symptomatic Valvular Disease

H.  Chronic lung disease with impairment of oxygenation or ventilation  Recent malignancy, or cancer with long times to recurrence eg.,

I.     breast cancer  

J.    Significant Urologic abnormalities of donor kidney Ø

K.   Proteinuria>300 mg/24hours

L.   HIV infection RELATIVE CONTRAINDICATIONS:-

M.  Hepatitis C Virus Infection

N.  Hepatitis B Virus Infection

O.  Age 18-21 years old; elderly donors especially those without significant comorbid disease

P.   Obesity (BMI 30-35)

Q.  Kidney stones

R.  Distant history of cancer  

S.   Past history of psychiatric disorder

T.   Renovascular Disease

U.  Thin basement membrane disease

V.   Prior valve surgery

W. Moderate Cardiac Valvular Disease with otherwise normal echocardiographic findings 

kidney transplantation

SURGICAL ANATOMIC EVALUATION 

This includes the assessment of the anatomic features of the donor's kidney to determine if nephrectomy can safely be performed, to determine which kidney should be removed & to determine what nephrectomy technique is to be employed. For many years, Intra Venous Pyelography & renal angiography was used to evaluate renal anatomy, but now Spiral CT has replaced both IVP & MR. The Left Kidney is preferentially selected for donation because of long left renal vein. The Right Kidney is selected for donation if:  Left Kidney has more a complex vascular anatomy as compared to Right e.g. multiple vessels.  Right kidney has only minor renal abnormalities like cyst, UPJ obstruction & left kidney is normal, especially in younger donors.  In women who may become pregnant. The kidney removal from a prospective kidney donor is either by an open approach or by a laparoscopic approach. Whatever approach is used, following principles merit emphasis-:  Donor safety at all times.  Adequate exposure.  Careful handling of the kidney, especially during periureteral dissection.  Preservation of adequate perihilar & periureteral fat to ensure vascularity to ureter.  Maintenance of active diuresis, which make prompt post transplantation function more likely. 

Arteriovenous fistula

 

Illustration of an arteriovenous fistula

An arteriovenous fistula is an abnormal connection or passageway between an artery and a vein.It may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial aneurysm

Presentation

Associated conditions

•             Hereditary hemorrhagic telangiectasia

Complications

Just like berry aneurysm, an intracerebral arteriovenous fistula can rupture causing subarachnoid hemorrhage.

Causes

The cause of this condition include

•             Congenital (developmental defect)

•             Rupture of arterial aneurysm into an adjacent vein

•             Penetrating injuries

•             Inflammatory necrosis of adjacent vessels

      Intentionally created (for example, Cimino fistula as vascular access for hemodialysis). Blood must be aspirated from the body of the patient, and since arteries are not easy to reach compared to the veins, blood may be aspirated from veins. The problem is that the walls of the veins are thin compared to those of the arteries. The AV fistula is the solution for this problem because, after 4-6 weeks, the walls of the veins become thicker due to the high arterial pressure. Thus, this vein can now tolerate needles during hemodialysis sessions.

Mechanism

When an arteriovenous fistula is formed involving a major artery like the abdominal aorta, it can lead to a large decrease in peripheral resistance. This lowered peripheral resistance causes the heart to increase cardiac output to maintain proper blood flow to all tissues. The physical manifestations of this typically consist of a relatively normal systolic blood pressure accompanied by decreased diastolic blood pressure, resulting in a wider pulse pressure.

Normal blood flow in the brachial artery is 85 to 110 milliliters per minute (mL/min). After the creation of a fistula, the blood flow increases to 400–500 mL/min immediately, and 700–1,000 mL/min within 1 month. A brachiocephalic fistula above the elbow has a greater flow rate than a radiocephalic fistula at the wrist. Both the artery and the vein dilate and elongate in response to the greater blood flow and shear stress, but the vein dilates more and becomes "arterialized". In one study, the cephalic vein increased from 2.3 mm to 6.3 mm diameter after 2 months. When the vein is large enough to allow cannulation, the fistula is defined as "mature".

An arteriovenous fistula can increase preload.AV shunts also decrease the afterload of the heart. This is because the blood bypasses the arterioles which results in a decrease in the total peripheral resistance (TPR). AV shunts increase both the rate and volume of blood returning to the hear

MECHANISM OF PRODUCTION OF AMA - A PERSPECTIVE:

Physiology:

A normal homeostatic function involves input from the food, processing by the action of Agni at the levels of Amasaya, Mahabhoota and Dhatus, transformation of the raw materials in to the vital elements (Sara) consistent with tissue compatibility and waste products (Kitta or Malas) warranting expulsion. This process affects the nourishment of Dhatus, development and maintenance of Vyadhikshamatva (the capacity of the body to resist the disease onslaught) initiated by Kshut (appetite), Trit (thirst) and Malavisarjana (excretion).

 

          Hence, the total body homeostasis is the augmented effect of non-defective functioning of the multiple organizations called Srotases. Each Srotas has a feeding point, a target point, a controlling center (Srotomula) and a pathway (Srotas) and its function is appropriate transformation of the input raw material in to a finished product with elimination of the waste product, effected by the transformative principle Agni.

Pathology:

The Vikara or Dhatu Vaishamya is hence a defective transformation, giving rise to a morbid finished product. The cause for which may exist in the raw material provided, the Srotomula, the Srotas or in the target tissue, in the backdrop of impaired Vyadhikshamatva, effected by vitiated Agni and inflicted by Doshas.

          The resulting incompletely transformed product or Ama exhibits certain characteristic features, it is neither suitable for absorption nor is the body capable of excreting it. It is toxic and hence hinders the normal functions of the Srotases. The severity of morbidity is directly proportional to its accumulation.

 

LEVELS OF EXISTENCE OF AMA:

          As mentioned above, the Ama exists at three levels in the body.

A)   Ama at Jatharagni level: Amashaya is the substratum of Jatharagni, when the vitiated Agni acts upon the Ahara, it fails to completely transform Ahara into nourishing moieties. The resulting Ahara Rasa is a mixture of formed and unformed elements called Ama, which is thrown out of the Amashaya through the Urdhwamarga by the Chardi (vomiting) and through the Adhomarga (diarrhoea), or it may get displaced into the Grahani to remain stagnant. Due to prolonged stagnation, it may assume the properties of Visha. Further, Ama may associate with the Doshas, Dhatus and Malas after getting absorbed from Amashaya and manifest symptoms related with each of them.

          Dietetic indiscretions and emotional stresses may between them impair the functioning of the neurohumoral mechanisms responsible for ensuring proper secretion of the digestive juices, the disturbances of the pH in the gastro-intestinal environment and more often sluggish and sometime hyper-motility of the stomach and intestine, thus leading to Shuktata or Shuktapaka where food will be Avipakva, Asamyukta, Bahupicchila and Durgandha, due to fermentation and putrefaction of the carbohydrate, fat and protein components. Thus causes the toxic state - Visharupatvam.

 

This pathogenesis may cause the following metabolic disturbances

·       Toxic states:

1.    Intermediate toxic byproducts of metabolism

2.    Superadded microbial action

·       Malnutritional states

 

Intermediate toxic by products of metabolism: It is clear from the texts that Sama Ahara Rasa induces the production of various deranged metabolites like,

      i.         Sama Dosha: In Avasthapaka, there will be Udeerana of the Doshas i.e. Madhura Avasthapaka – Kapha (Amashaya),

Amla Avasthapaka – Pitta (Pittashaya)

Katu Avasthapaka – Vata (Pakvashaya)

But, due to Apakva Ahara produced by Mandagni, there will be Udeerana of Dushita Dosha called as Samadosha. Further in Nishthapaka, due to affliction of Rasa and Rakta Dhatu, there will be further increase of vitiated Kapha and Pitta in the form of Mala thus contributing to Sama Dosha.

 

ii.   Bhutagni and Dhatvagni Mandya: Jatharagnimandya will lead to Bhutagni and Dhatvagni Mandya also. Jatharagni is the Poshaka to the different Agni of the body, but Bhutagni and Dhatvagni can even get vitiated independently i.e. irrespective of Jatharagnimandya. Apakva Ahara from Avasthapaka when gets treated by Manda Bhutagni and Dhatvagni further causes Vikrita or Dushita Nishthapaka.

a)    Sama Dhatu: With affliction of both Avastha and Nishthapaka, the Dhatu Poshaka Rasa produced is Vikruta. Thus, with production of Sama Rasa Dhatu, succeeding Dhatu will also get vitiated producing Dhatu Pradoshaja Vikara. Sama Dhatu Utpatti is due to Bhutagni and Dhatvagni Mandya but it can even be independent of Jatharagni status.¹⁴

b)    Sama Mala: The word Mala includes 2 entities.

·       Mala of Ahara Rasa i.e. Pureesha, Mutra and Sweda and also the other Dhatugata Malas.

·       Dushita Dosha and Dhatu are also called Mala

 

Superadded microbial action: Toxins in the intestines in the present days are greatly attributed to the action of different microbes, thus leading to different manifestations like:

·       Infective gastro-enteritis

·       Toxic gastro-enteritis

·       Botulism

 

Intestinal flora in the human body exists in the state of symbiosis; these can be very well compared with Sahaja Krimi. Chakrapanidatta¹⁵ explains them as the one which exists within the body without causing diseases. Intestinal flora breaks the complex molecule which are not broken by the body, metabolises them into simple molecules by 2 kinds of actions. They are Fermentation and Putrefaction.

 

Putrefaction is similar to fermentation but it specifically refers to conversion of protein substances to smaller molecules with the liberation of various gases viz. Indol, Skatole, Phenol, Hydrogen sulphate and Ammonia that are characteristically pungent in odour. Fermentation is related to the Carbohydrate and fat metabolism by the microbes. Microbe’s metabolism releases few of the waste products vital for the body like Vit. B groups.

 

Among these microbes, there are some in borderline populations which under circumstances become parasitic. There are other groups of virulent organisms which invade body through food and drinks, producing abnormalities in the body. e.g.: Salmonella, Staphylococcus, B. botulinus, B. typhosus and coma bacillus of Koch. Hence, the normal food metabolism also includes the metabolism by Intestinal flora (Sahaja Krimi).

 

The following are circumstances which make the body susceptible to the infection.

·       Irradiation, metabolic abnormalities, emotional stress, overstrain, intense treatment with anti-microbial agents

·       Tissue produces an anti-microbial substance called Properdin. It has been shown that a low concentration of this substance in an area coincides with the highest susceptibility to the invasion of the tissue even by otherwise friendly intestinal flora causing bacteremia.

·       Experiments carried out at the Rockfeller institute and other research centers in U.S.A. have shown that susceptibility to microbial disease can be caused by manipulation of metabolism. e.g.: with such simple measures as temporary deprivation of food or feeding an unbalanced diet rich in Citrate. The resistance was again seen to have been restored back to normal within 2-3 days by the correction of nutritional errors.

·       But in case of epidemics and pandemics the microbes strike human irrespective of body strength, constitution and other predisposing factors. Interestingly, this phenomenon is observed when a microbe is newly introduced in a susceptible population which serves as a virgin soil.

          Ama is the immediate cause of most human affliction, exposure to disease causing microbes results in the disease only in those people where internal conditions are ripe for colonization. Louis Pasteur and Claude Bernard argued for years over the primacy of infective agents versus internal conditions, and it was only on his deathbed that Pasteur finally admitted that Bernard was right and that the milieu interior is more important than exposure to a pathogen. This is especially true of diseases in which no pathogen can be detected.⁶

 

Hence, different microbial infection occur in the body when it is made susceptible by predisposing factors like metabolic abnormalities, emotional stress, overstrain and other Agnimandyakara and Amotpattikara Nidana.

 

What causes chronic kidney disease (CKD)

 

Anyone can get CKD. Some people are more at risk than others. Some things that increase your risk for CKD include:

·         Diabetes

·         High blood pressure (hypertension)

·         Heart disease

·         Having a family member with kidney disease

·         Being African-American, Hispanic, Native American or Asian

·         Being over 60 years old

What are the symptoms of kidney failure?

You may notice one or more of the following symptoms if your kidneys are beginning to fail:

·         Itching

·         Muscle cramps

·         Nausea and vomiting

·         Not feeling hungry

·         Swelling in your feet and ankles

·         Too much urine (pee) or not enough urine

·         Trouble catching your breath

·         Trouble sleeping

If your kidneys stop working suddenly (acute kidney failure), you may notice one or more of the following symptoms:

·         Abdominal (belly) pain

·         Back pain

·         Diarrhea

·         Fever

·         Nosebleeds

·         Rash

·         Vomiting

Having one or more of any of the symptoms above may be a sign of serious kidney problems. If you notice any of these symptoms, you should contact your doctor right away.

Complications of CKD

Your kidneys help your whole body work properly. When you have CKD, you can also have problems with how the rest of your body is working. Some of the common complications of CKD include anemia, bone disease, heart disease, high potassium, high calcium and fluid buildup. Learn more about the complications of CKD.

Stages of CKD

Chronic kidney disease (CKD) refers to all 5 stages of kidney damage, from very mild damage in Stage 1 to complete kidney failure in Stage 5. The stages of kidney disease are based on how well the kidneys can do their job – to filter waste and extra fluid out of the blood. 

How can I prevent CKD?

Diabetes and high blood pressure are the most common causes of CKD. If you have diabetes or high blood pressure, working with your doctor to keep your blood sugar and blood pressure under control is the best way to prevent kidney disease.

Living a healthy lifestyle can help prevent diabetes, high blood pressure and kidney disease, or help keep them under control. Follow these tips to lower your risk for kidney disease and the problems that cause it:

·         Follow a low-salt, low-fat diet

·         Exercise at least 30 minutes on most days of the week

·         Have regular check-ups with your doctor

·         Do not smoke or use tobacco

·         Limit alcohol

How do I know if I have CKD?

CKD usually does not have any symptoms until your kidneys are badly damaged. The only way to know how well your kidneys are working is to get tested. Being tested for kidney disease is simple. Ask your doctor about these tests for kidney health:

·         eGFR (estimated glomerular filtration rate)

The eGFR is a sign of how well your kidneys are cleaning your blood.

Your body makes waste all the time. This waste goes into your blood. Healthy kidneys take the waste out of your blood. One type of waste is called creatinine. If you have too much creatinine in your blood, it might be a sign that your kidneys are having trouble filtering your blood.

You will have a blood test to find out how much creatinine is in your blood. Your doctor will use this information to figure out your eGFR. If your eGFR is less than 60 for three months or more, you might have kidney disease.

·         Urine test

This test is done to see if there is blood or protein in your urine (pee).

Your kidneys make your urine. If you have blood or protein in your urine, it may be a sign that your kidneys are not working well.

Your doctor may ask you for a sample of your urine in the clinic or ask you to collect your urine at home and bring it to your appointment.

·         Blood pressure

This test is done to see how hard your heart is working to pump your blood.

High blood pressure can cause kidney disease, but kidney disease can also cause high blood pressure. Sometimes high blood pressure is a sign that your kidneys are not working well.

For most people a normal blood pressure is less than 120/80 (120 over 80). Ask your doctor what your blood pressure should be.

How is CKD treated?

Damage to your kidneys is usually permanent. Although the damage cannot be fixed, you can take steps to keep your kidneys as healthy as possible for as long as possible. You may even be able to stop the damage from getting worse.

·         Control your blood sugar if you have diabetes.

·         Keep a healthy blood pressure.

·         Follow a low-salt, low-fat diet.

·         Exercise at least 30 minutes on most days of the week.

·         Keep a healthy weight.

·         Do not smoke or use tobacco.

·         Limit alcohol.

·         Talk to your doctor about medicines that can help protect your kidneys.

If you catch kidney disease early, you may be able to prevent kidney failure. If your kidneys fail, you will need dialysis or a kidney transplant to survive.

Kidney-friendly diet for CKD

You need to have a kidney-friendly meal plan when you have chronic kidney disease (CKD). Watching what you eat and drink will help you stay healthier. A kidney-friendly diet may also help protect your kidney from further damage by limiting certain foods to prevent the minerals in those foods from building up in your body. Learn more about the kidney-friendly diet for CKD.

Find kidney-friendly recipes on Kidney Kitchen

In Kidney Kitchen, you can:

·         Learn what healthy eating means for people in every stage of kidney disease, including those on dialysis or living with a kidney transplant.

·         Take a deep dive into what each nutrient means for people with kidney disease and how much of these nutrients common foods contain.

·         Find healthy, delicious recipes.