Columbia university medical center renal transplant program

– Nephrologists– Surgeons– Pathologists– Tissue Typing– Consultants – Living Donor– Pre-Transplant– Post-Transplant– List maintenance • Administrator• Social Work• QA/PI• “Desensitization Team” – 4 Full-time transplant Nephrologists– 4 other Nephrologists participate in the care of transplant patients – 7 transplant surgeons, 5 also participate in Liver transplantation– 3 Living Donor surgeons– 1 Pediatric surgeon – Cardiology– Urology– Infectious Diseases– Pulmonary– Vascular Surgery– Psychiatry – 1 post-transplant coordinator – “Top 40” list • Living related• Living Unrelated, but Emotionally related• “Internet-related” donor • Standard living donor transplants• Paired kidney exchanges (“swaps”) Dedicated separate team, none involved with the care
of the potential recipient
• Living Donor Coordinator• Nephrologist• Dedicated Social Worker• Psychiatrist• Nutrition• Surgeon NYP/COLUMBIA
KIDNEY TRANSPLANT PROGRAM LIVING DONOR EVALUATION PROTOCOL

1. Questionnaire/Consent for Evaluation
2. Pretesting: ABO, HLA, BMP, urine analysis  Calculate BMI  Calculate eGFR (MDRD)  Calculate eCrCl (Cockroft and Gault) If either calculation is below 80ml/minute, patient to bring in 24 hour urine collection to first evaluation or complete Iothalamate GFR per the nephrologist’s recommendation 3. Donor Phone Intake The Donor must initiate the first contact with the transplant team. At that time, the results of the family study are discussed with the donor and a brief history is taken. 4. First Evaluation  Meet with a Donor Transplant Coordinator  A complete physical with a nephrologist  Blood and urine tests  Chest x-ray and EKG  Abdominal and pelvic CT scan angiogram 7. Discussion of patient at selection meeting by multidisciplinary transplant selection committee.  Pre-op testing to be completed 7-10 days prior to surgery; tests include a final cross match with the recipient,  Stress echocardiogram for all patients over the age of 50  Mammogram for women over the age of 40  Colonoscopy for everyone over the age of 50  PSA for all men over 50 years old and for all African Americans over age of 40 • Age < 18 years old• Measured gfr <80 ml/min• Abnormal glucose metabolism• Proteinuria, Hematuria• Hypertension• BMI > 40• Active psychiatric disorder/inability to give informed  Family history of ADPCKD, < 30 years old in the Options
• Living Donor Transplant• Deceased Donor Transplant• ABO Incompatible• + Cross match• Paired Kidney Exchange• Kidney after non-renal solid organ transplantation• Kidney re-transplantation following BK nephropathy Columbia University Medical Center – ThymoglobulinR 1-1.5 mg/kg daily x 4-5 days
– Solu-medrol 500 mg IV day 0; Solu-medrol 250
mg IV d 1; 125 mg IV day 2; Solu-medrol 75 mg IV day 3. – Tacrolimus (initial target level 10-12 ng/ml)– Mycophenolate sodium (MyforticR) – Depending on pathology (Steroid pulse, ThymoglobulinR, (OKT3), Plasmapheresis-IVIg) Columbia University Medical Center • Induction: (Elderly, Reduced LV function, HLA – SimulectR 20 mg day 0, day 4
– Solu-medrol 500 mg IV day 0; Solu-medrol 250
mg IV d 1; 125 mg IV day 2; Solu-medrol 75 mg IV day 3. – Tacrolimus (initial target level 10-12 ng/ml)– Mycophenolate sodium (MyforticR) – Depending on pathology (Steroid pulse, ThymoglobulinR, (OKT3), Plasmapheresis-IVIg) Renal Transplantation
Immunosuppression for Positive Crossmatch
Live Donor
• Identification of donor specific antibody, type, “strength”(titer) • Desensitization using plasmapheresis, IVIg, immunosuppression • Patients with a live donor with a flow cytometry positive crossmatch with Donor specific antibody, but a negative cytotoxic crossmatch, will receive 2 PP/IVIg treatments pre-transplant and 2 PP/IVIg treatments post-transplant – Tacrolimus 0.05 mg/kg/dose with Q 12hr dosing– Myfortic (MPA) 720 mg/dose with Q 12hr dosing for Caucasians, – MPA 1080 mg/dose with Q 12hr dosing for African Americans One volume exchange replaced with Albumin IVIg 100mg/Kg after each plasmapheresis treatment Starting Titer-
#PP/IVIg
Patients will receive a
Cytotoxic
Treatments Pre-
minimum of two
PP/IVIg treatments
Crossmatch
Transplant
following
transplantation
Following Cessation
of Plasmapheresis:
IVIg (10% sucrose
free) 1 gm/kg QD X 2
days (total dose 2
gm/kg) to be
administered every
other month for 3
Renal Transplantation
Immunosuppression for Positive Crossmatch
Live Donor (2)
• Intra-operative:
– Solumedrol 500 mg IVPB– Zenapax (Daclizumab) 2mg/Kg IV– Rituximab 375 mg/m2 • POD #0:
– Start Tacrolimus 0.05 mg/kg/dose with Q 12hr dosing when – Myfortic (MPA) 720 mg/dose with Q 12hr dosing for Caucasians, – MPA 1080 mg/dose with Q 12hr dosing for African Americans • POD #1:
– Solumedrol 250 mg IVPB– Tacrolimus target level 15-20– MPA as above---adjust as tolerated Renal Transplantation
Immunosuppression for Positive Crossmatch
Live Donor (3)
– Solumedrol 125 mg IVPB– Tacrolimus target level 15-20– MMF as above---adjust as tolerated – Solumedrol 75 mg IVPB– Tacrolimus target level 15-20– MPA as above---adjust as tolerated – Prednisone 20 mg X 2 weeks– Tacrolimus target level 15-20 for 3 months, then 10-15 for Renal Transplantation
Immunosuppression for Positive Crossmatch
Live Donor (4)
• POD #14:
– Zenapax (Daclizumab) 1 mg/Kg – Prednisone 15 mg QD X 2 weeks IV • POD #30 (1 month post-op):
– Prednisone 10 mg QD X 2 weeks– Zenapax (Daclizumab) 1 mg/Kg IV • POD #45 (6 weeks post-op):
– Prednisone 5 mg QD X 2 weeks– Zenapax (Daclizumab) 1 mg/Kg IV • POD #60 (2 months post-op):
– Prednisone 2.5 mg QD X 2 weeks then– Prednisone 2.5 mg QOD X 2 weeks then D/C at 3 months– Zenapax (Daclizumab) 1 mg/Kg IV Renal Transplantation
Follow-up Protocol for Positive Crossmatch
Live Donor Transplantation
• Protocol biopsies, Donor-specific crosssmatch• Weeks 1,2,4• Months 6, 12, 24 – Diagnosis (DSA, graft dysfunction, Histology – C4d+)– Treatment • Plasmapheresis, IVIg• Pulse steroids• (Thymoglobulin)• (Rituximab, High-dose IVIg)• Donor-specific antibody monitoring Renal Transplantation
Immunosuppression for ABO-Incompatible
Live Donor
Starting
#PP/IVIg
Isoagglutinin
Treatments
Transplant
is based on starting isoagglutinin titer and Renal Transplantation
Immunosuppression for ABO-Incompatible
Live Donor
– Tacrolimus 0.05 mg/kg/dose with Q 12hr dosing – MyforticR (MPA) 720 mg/dose with Q 12hr dosing for – MyforticR 1080 mg/dose with Q 12hr dosing for African Americans (?”intensified dosing regimen”) – Solumedrol 500 mg IVPB– Thymoglobulin 1.5 mg/kg (round off to nearest 25mg) (goal for total Thymoglobulin dose 6 mg/Kg) Renal Transplantation
Immunosuppression for ABO-Incompatible
Live Donor
– Start Tacrolimus 0.05 mg/kg/dose with Q 12hr dosing when – Myfortic (MPA) 720 mg/dose with Q 12hr dosing for Caucasians, – MPA 1080 gm/dose with Q 12hr dosing for African Americans – Solumedrol 250 mg IVPB– Thymoglobulin 1.5 mg/kg (round off to nearest 25mg) – (Thymoglobulin should be administered following plasmapheresis) – Tacrolimus target level 15-20– MPA as above---adjust as tolerated Renal Transplantation
Immunosuppression for ABO-Incompatible
Live Donor
• POD #2:
• Solumedrol 125 mg IVPB
• Thymoglobulin 1.5 mg/kg (round off to nearest 25mg) – goal for total
Thymoglobulin dose 6 mg/Kg---Thymoglobulin should be administered following plasmapheresis • Tacrolimus target level 15-20• MMF as above---adjust as tolerated • POD #3:
• Solumedrol 75 mg IVPB
• Thymoglobulin 1.5 mg/kg (round off to nearest 25mg) -Thymoglobulin
should be administered following plasmapheresis • Tacrolimus target level 15-20• MPA as above---adjust as tolerated• CBC with Differential on POD#3 for patients on Thymoglobulin with target percentage of Lymphocytes <5% and the absolute lymphocyte count <100 Renal Transplantation
Follow-up Monitoring for ABO-
Incompatible Live Donor
• POD #4:
– Tacrolimus target level 15-20 for 1 month, then 10-15 for 2nd • Desensitization for Deceased donor transplantation (per – Patient selection – waiting time based– IVIG (high dose)– Rituximab • Kidney Transplantation after other non-renal sold organ transplant (already on long-term immunosuppression) – Simulect induction– Sirolimus converted to Mycophenolic acid– Resume Sirolimus at 6 weeks • Repeat transplant with prior history of BK polyomavirus – Simulect induction– Tacrolimus, Leflunomide – Volumes
– Patient, graft survival, living donor and deceased
donor, adult and pediatric, benchmarked against US national results – Analysis of all graft failures, regardless of time after
– Analysis of all patient deaths, regardless of time
– Review of possible disease transmission from
donor kidney

Source: http://www.columbiasurgery.org/events/pdf/novartis_cohan_infrastructure_20090611.pdf