Kidney and Pancreas Transplantation

A Practical Guide
1. Auflage 2010
ISBN: 978-1-60761-642-9
Verlag: Humana Press
Format: PDF
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, 442 Seiten

The transplant physicians and surgeons at Cleveland Clinic have collaborated to produce, Kidney and Pancreas Transplantation: A Practical Guide. This volume is devoted to kidney and pancreas transplantation and is well grounded in scientific principles, quantitative clinical reasoning, clinical pharmacology, tested clinical practices and overall clinical applicability. Also addressed are key aspects in the initiation, maintenance and sustained growth of viable clinical programs in kidney and pancreas transplantation. Kidney and Pancreas Transplantation: A Practical Guide will be of great value to transplant physicians as well as medical and surgical fellows who intend to pursue an interest in transplantation.

Autoren/Hrsg.

Inhaltsverzeichnis

1;Preface;6
2;Contents;8
3;Contributors;10
4;Chapter 1: The Immune Response to Transplanted Organs;13
4.1;Introduction;13
4.2;Ischemia-Reperfusion Injury;13
4.3;Induction of the Donor-Specific T-Cell Response;15
4.4;The Functional Development of T Cells during Activation;17
4.5;T-Cell-Mediated Cytolysis of Target Cells;19
4.6;Phenotypic Changes During TCR-Mediated Activation;20
4.7;T-Cell-Mediated Rejection;23
4.8;Memory Cells;24
4.9;B Cells and Antibody in Transplant Rejection;25
4.10;The Problem of Chronic Rejection;29
4.11;Summary;29
4.12;References;30
5;Chapter 2: The Histocompatibility Laboratory in Clinical Transplantation;35
5.1;Our History;35
5.2;Where We Are Now;41
5.3;Our Future;55
5.4;References;56
6;Chapter 3: Immunosuppressive Therapy in Kidney and Pancreas Transplantation;60
6.1;Introduction;60
6.2;Trends in Immunosuppression;60
6.3;Immunosuppressive Drugs Versus Regimens;61
6.4;Sites and Mechanisms of Actionof Immunosuppressive Agents;62
6.5;Induction Therapy;66
6.5.1;Depleting Antibodies;67
6.5.1.1;Polyclonal Antibodies;67
6.5.1.1.1;Mechanism of Action;67
6.5.1.1.2;Dosing and Administration;67
6.5.1.1.3;Side Effects;68
6.5.1.2;Monoclonal Antibodies;68
6.5.1.2.1;Mechanism of Action;68
6.5.1.2.2;Efficacy;68
6.5.1.2.3;Dosing and Administration;68
6.5.1.2.4;Side Effects;68
6.5.2;Nondepleting Antibodies;69
6.5.2.1;Anti-CD25 Monoclonal Antibodies/IL-2 Receptor Antibodies;69
6.5.2.1.1;Mechanism of Action;69
6.5.2.1.2;Dosing and Administration;69
6.5.2.1.3;Side Effects;69
6.5.2.2;Newer Agents for Induction Therapy;69
6.5.2.2.1;Mechanism of Action;69
6.5.2.2.2;Dosing and Administration;70
6.5.2.2.3;Side Effects;70
6.6;Maintenance Therapy;70
6.6.1;Calcineurin Inhibitors;70
6.6.1.1;Dosing and Monitoring;72
6.6.1.2;Side Effects;72
6.6.2;Antimetabolites;74
6.6.2.1;Dosing, Formulations, and Side Effects;75
6.6.3;Mammalian Target of Rapamycin (m-TOR) Inhibitors;76
6.6.4;Corticosteroids;77
6.6.4.1;Dosing and Side Effects;77
6.6.5;Intravenous Immune Globulin;78
6.6.5.1;Dosing and Side Effects;78
6.7;Emerging Immunosuppressive Agents;78
6.7.1;Small Molecules;78
6.7.2;Janus Kinase Inhibitors/CP-690,550;79
6.7.3;PKC Inhibition/AEB071 (Sotrastaurin);79
6.7.4;FTY 720;79
6.7.5;Biologic Agents;79
6.7.5.1;Belatacept/Costimulation Blockade;79
6.7.5.2;Targeting B Cells and Plasma Cells;80
6.7.5.2.1;Rituximab;80
6.7.5.2.2;Bortezomib (Velcade);80
6.8;Currently Used Combination Immunosuppressive Regimens and Outcomes;80
6.8.1;Choice of Induction Regimen;81
6.8.2;Choice of Calcineurin Inhibitors;81
6.8.3;Choice of Antiproliferative Agent;82
6.8.3.1;Mycophenolate Mofetil Versus Azathioprine;82
6.8.3.2;Mycophenolate Mofetil Compared to Sirolimus in Cyclosporine-Based Regimens;82
6.8.3.3;Mycophenolate Mofetil Versus Sirolimus with Tacrolimus;83
6.8.4;Calcineurin Inhibitor and Steroid Avoidance Regimens;83
6.8.4.1;Rationale and Impetus for Use;83
6.8.4.2;Calcineurin Inhibitor Avoidance: De Novo Studies;84
6.8.4.2.1;Mycophenolate Mofetil with Sirolimus;84
6.8.4.2.2;Calcineurin Inhibitor Withdrawal with Mycophenolate Mofetil;84
6.8.4.2.2.1;Patients with Stable Graft Function;84
6.8.4.2.2.2;Patients with Deteriorating Graft Function;86
6.8.4.2.3;Calcineurin Inhibitor Withdrawal or Substitution Using Sirolimus;86
6.8.4.2.4;Cyclosporine Withdrawal;86
6.8.4.2.5;Cyclosporine Substitution with Sirolimus;87
6.8.4.2.6;Corticosteroid Avoidance Regimens;87
6.9;Treatment of Acute Rejection;87
6.9.1;Global Considerations;87
6.9.2;Acute Cellular Rejection;88
6.9.2.1;Pulse Corticosteroids;88
6.9.3;Anti-T-Cell Antibody Therapy;88
6.9.4;Treatment-Resistant Rejections and Late Rejections;89
6.9.5;Treatment of Antibody-Mediated Rejection;89
6.10;Immunosuppression Management in Chronic Allograft Failure;90
6.11;Immunosuppression for Pancreas Transplantation;90
6.12;Using Immunosuppression in the Clinic;90
6.13;Conclusion;92
6.14;References;92
7;Chapter 4: Clinical Pharmacologic Principles and Immunosuppression;98
7.1;Introduction;98
7.1.1;Pharmacology;98
7.1.1.1;Corticosteroids;98
7.1.1.2;Calcineurin Inhibitors;99
7.1.1.3;Mycophenolic Acid;99
7.1.1.4;M-TOR Inhibitors;99
7.2;General Pharmacokinetic Principles;100
7.2.1;Bioavailability;100
7.2.1.1;Calcineurin Inhibitors (Cyclosporine and Tacrolimus; CNI )101
7.2.1.2;Mycophenolate Mofetil (MMF);102
7.2.1.3;Corticosteroids;102
7.2.2;Apparent Volume of Distribution (Vd);102
7.2.3;Binding;103
7.2.4;Clearance;103
7.2.5;Restrictive Clearance and Protein Binding;105
7.2.6;Pharmacogenetics;106
7.2.7;Interactions;107
7.2.8;Therapeutic Drug Monitoring;108
7.3;C2 Monitoring;108
7.3.1;Everolimus;113
7.4;Conclusion;113
7.5;References;113
8;Chapter 5: Pathology of Kidney and Pancreas Transplants;121
8.1;Introduction;121
8.1.1;General;121
8.1.2;Immunology;121
8.2;Allograft Biopsy Processing;122
8.3;Early Allograft Biopsies from Zero-Time to the Early Posttransplant Period;123
8.3.1;Donor Biopsies;123
8.3.2;Immediate Posttransplantation Biopsies;124
8.3.3;Early Posttransplant Graft Dysfunction;126
8.4;Early Transplant Interval;128
8.4.1;General;128
8.4.2;Acute Tubular Injury;128
8.4.3;Acute Rejection;129
8.4.4;Acute Tubulointerstitial Rejection;129
8.4.5;Rejection in the Vasculature;129
8.4.6;Infection;133
8.4.7;Recurrent Disease;134
8.5;Intermediate and Late Transplant Period;135
8.6;Posttransplant Proteinuria;137
8.7;Banff Schema and Rejection Classification;139
8.8;Pancreas Transplant Pathology;141
8.8.1;General;141
8.8.2;Acute Rejection;142
8.8.3;Chronic Rejection;145
8.8.4;Pancreatitis;145
8.8.5;Lesions in the Islets of Langerhans;146
8.9;References;146
9;Chapter 6: Design, Conduct, and Report of Clinical Trials of Immunosuppressive Regimens in Solid Organ Transplantation;149
9.1;Introduction;149
9.2;Designing a Clinical Study;149
9.2.1;What Is the Question?;149
9.2.2;How to Choose the Study Design?;149
9.2.2.1;Randomized Control (Placebo or Active) Studies;150
9.2.2.2;Observational Studies;152
9.2.2.3;Systematic Reviews and Metaanalysis;153
9.2.2.4;Registry Analyses;153
9.2.3;How to Determine the Experimental Group?;154
9.2.4;How to Select the Control Group?;154
9.2.5;What Are the Endpoints?;155
9.2.6;How Do We Define the Study Population?;156
9.2.7;How Many Study Subjects Do We Need?;157
9.3;Conducting a Clinical Study;157
9.3.1;How Do We Write the Protocol?;157
9.3.2;How Do We Manage the Data?;158
9.3.3;How Do We Analyze the Data?;159
9.3.4;What Are the Regulatory Considerations?;159
9.4;Reporting Clinical Trials;160
9.4.1;How Do We Report Clinical Trials Results?;160
9.5;Clinical Research Collaboration;161
9.5.1;Postapproval Company-Sponsored Clinical Studies;161
9.5.2;Post approval Clinical Studies Safety Monitoring;161
9.6;Summary;162
9.7;References;162
10;Chapter 7: Outcomes of Kidney and Pancreas Transplantation;164
10.1;Introduction;164
10.2;Understanding Survival Models;165
10.3;Transplantation Confers a Durable Survival Advantage Over Dialysis;167
10.3.1;Donor Source and Quality;167
10.4;Patient and Graft Survival in Kidney Transplantation;167
10.5;Patient and Graft Survival in Pancreas Transplantation;168
10.6;Long-Term Outcomes in Renal Transplantation;170
10.7;Factors Affecting Renal Allograft Survival;172
10.7.1;Donor–Recipient Factors;172
10.7.1.1;Delayed Graft Function;172
10.7.2;HLA Matching;172
10.7.3;Waiting Time and Preemptive Transplantation;173
10.7.4;Center Effect;174
10.7.5;Year of Transplant (Era Effects);174
10.7.6;Donor Factors;175
10.7.7;Donor Source: Deceased Versus Living Donor;175
10.7.8;Donor Age;175
10.7.9;Cold Ischemia Time;176
10.7.10;Donor Race;176
10.7.11;Donor Gender;176
10.7.12;Donor Nephron Mass;176
10.7.13;Expanded Criteria Donors;176
10.7.14;Recipient Factors;177
10.7.14.1;Recipient Age;177
10.7.15;Recipient Race;178
10.7.16;Recipient Gender;178
10.7.17;Recipient Sensitization: Before or after Transplantation;179
10.7.18;Acute Rejection;179
10.7.18.1;Recipient Hepatitis C Virus Antibody and Hepatitis B Virus Surface Antigen Positivity;179
10.7.19;Recipient Immunosuppression;179
10.7.19.1;Tacrolimus in Combination with MMF;180
10.7.19.2;MMF Compared to Sirolimus in Cyclosporine-Based Regimens;180
10.7.19.3;MMF Versus Sirolimus with Tacrolimus;181
10.7.19.4;MMF with Sirolimus;181
10.7.19.5;Corticosteroid Avoidance Regimens;181
10.7.20;Recipient Compliance;182
10.7.21;Obesity;182
10.7.22;Hypertension in the Recipient;183
10.7.23;Recipient Dyslipidemia;183
10.7.24;Recurrence of Primary Disease in the Allograft;183
10.7.25;Proteinuria;184
10.8;Applying Outcomes Data in Practice;184
10.9;References;186
11;Chapter 8: Medical and Surgical Evaluation of the Adult Kidney Transplant Candidate;191
11.1;Introduction;191
11.1.1;Who Is a Kidney Transplant Candidate?;191
11.1.2;Preemptive Transplantation is Preferable When Feasible;192
11.1.3;Who Is Not Eligible for a Transplant?;192
11.1.4;Referral for Transplantation;193
11.2;Process of Evaluation;193
11.2.1;Education and Consent;193
11.2.1.1;Education;194
11.2.1.2;Consent;194
11.2.2;Medical Evaluation;195
11.2.2.1;Cardiovascular Disease;195
11.2.2.2;Pulmonary Disease;196
11.2.2.3;Cerebrovascular and Peripheral Vascular Disease;197
11.2.2.4;Evaluation of the Abdomen and Gastrointestinal Tract;197
11.2.2.5;Infections;197
11.2.2.6;Malignancy;198
11.2.3;The Elderly Transplant Recipient;199
11.2.4;Financial Considerations;200
11.2.5;Patients with Prior Transplants;200
11.2.6;Coagulopathy;201
11.2.7;The Highly Sensitized Patient;201
11.2.8;Waitlist Management;201
11.3;Native Kidney Disease and Recurrence;202
11.3.1;Focal and Segmental Glomerulosclerosis;202
11.3.2;IgA Glomerulonephritis;203
11.3.3;Obesity;203
11.3.4;Indications for Nephrectomy;203
11.4;Multiorgan Transplants;204
11.5;Management of Lower Urinary Tract Disease;204
11.6;Summary and Recommendations;204
11.7;Conclusions;205
11.8;References;205
12;Chapter 9: Selection and Preparation of the Pancreas Transplant Recipient;208
12.1;Introduction;208
12.2;Patient Selection for Pancreas Transplantation;208
12.3;Categories of Pancreas Transplantation;209
12.4;Medical Evaluation and Preparation;211
12.5;Summary and Conclusions;213
12.6;References;214
13;Chapter 10: Kidney Transplant Recipient Surgery;217
13.1;Implant Location;217
13.2;Preparation of Donor Kidney;217
13.2.1;Venous Preparation;218
13.2.2;Arterial Preparation;218
13.2.3;Ureteral Preparation;219
13.2.4;Final Preparation;220
13.3;Recipient Surgery;221
13.4;Pediatric En Bloc Transplant;222
14;Chapter 11: Issues and Surgical Techniques to Expand the Pool of Kidneys Available for Transplantation;224
14.1;Introduction;224
14.2;The Expanded Criteria Donor;224
14.3;The Recipient of an Expanded Criteria Donor Kidney: Selection Criteria;225
14.4;Clinical Evaluation of the Potential Deceased Donor;226
14.4.1;The Role of the Allograft Kidney Biopsy in Renal Transplantation;227
14.5;Organ Preservation and Pulsatile Perfusion;227
14.6;The Donor Kidney with Reduced Renal Function;229
14.7;The Donor Kidney with Prolonged Preservation times;229
14.8;The Non-Heart Beating Donor (Donation After Cardiac Death);229
14.9;The Elderly Deceased Donor Allograft and Dual Renal Transplantation;230
14.10;The Pediatric Deceased Donor Kidney;232
14.11;Single-Unit Pediatric Deceased Donor Transplantation;232
14.12;Pediatric En Bloc Deceased Renal Transplantation;232
14.12.1;The Anencephalic Infant Donor Kidney;233
14.12.2;The Deceased Donor with Hypertension;235
14.13;The Living Donor with Hypertension;235
14.13.1;Contaminated Donor Kidneys and the Donor with Systemic Infection;235
14.13.2;The Donor with Hepatitis;237
14.13.3;The Donor with History of Malignancy;238
14.13.4;The Donor with Diabetes;238
14.13.5;Glomerulonephritis, Lupus, Membranous Nephropathy, and Preexisting Lesions in the Donor Kidney;238
14.13.6;ABO Incompatible and the Positive Cross-Match Renal Transplant;239
14.13.7;The Anatomically Abnormal Allograft;240
14.13.8;The Horseshoe Deceased Kidney Donor;240
14.13.9;The Polycystic Deceased Donor Kidney;240
14.14;The Donor with Multiple Arteries and Vascular Abnormalities;241
14.15;Bench Table Vascular Reconstruction of the Deceased Kidney;243
14.15.1;The Donor Allograft with Ureteral Abnormalities;243
14.15.2;Expanded Criteria Living (Old Living) Renal Donor Transplantation;243
14.15.2.1;Elderly Living Donor;243
14.15.3;Living Unrelated Renal Transplantation, Altruistic Living Renal Transplantation, and Paired Living Donor Exchange Transplantation;245
14.16;Living Kidney Donor with Stones;245
14.16.1;The Radiographically Abnormal Live Donor Kidney;245
14.16.2;The Obese Living Donor;245
14.16.3;Immunosuppression Issues and the Expanded Criteria Donor;245
14.17;Summary;246
14.18;References;246
15;Chapter 12: Pancreas Transplantation: Surgical Techniques;254
15.1;Background;254
15.2;Surgical Technique;254
15.2.1;Incision and Exposure;255
15.2.2;Bench Preparation;255
15.2.2.1;Inspection of the Pancreas Allograft;255
15.2.2.2;Splenectomy;255
15.2.2.3;Portal Vein Mobilization;256
15.2.2.4;Reinforcement of the Mesenteric Root;256
15.2.2.5;Preparation of the Duodenal Segment;256
15.2.2.6;Arterial Reconstruction;256
15.2.3;Revascularization of the Pancreas Allograft;258
15.2.3.1;Venous Drainage;258
15.2.4;Portal Venous Drainage;258
15.2.5;Systemic Venous Drainage;259
15.2.6;Arterial Revascularization;259
15.3;Duct Management;259
15.4;Summary;261
15.5;References;262
16;Chapter 13: Laparoscopic Living Kidney Donation;264
16.1;Introduction;264
16.2;Preoperative Evaluation;265
16.3;Operative Technique;266
16.4;Summary;275
16.5;References;275
17;Chapter 14: Perioperative and Anesthetic Management in Kidney and Pancreas Transplantation Management;277
17.1;Introduction;277
17.2;Kidney Transplantation;277
17.2.1;Preoperative Assessment;277
17.2.2;Anesthetic Management;278
17.2.3;Deceased Donor Kidney Management;278
17.2.4;Living Donor Management;278
17.2.5;Recipient Anesthetic Management;279
17.2.6;Renal Preservation in Transplantation;279
17.2.7;Perioperative Fluid Management;279
17.2.8;Pharmacologic Therapies;280
17.2.9;Other Considerations;280
17.2.10;Management in the Recovery Room;280
17.2.11;Conclusion;281
17.3;Pancreas Transplantation;281
17.3.1;Perioperative Considerations;281
17.3.2;Anesthetic Management;282
17.4;References;283
18;Chapter 15: Surgical Complications after Kidney Transplantation;285
18.1;Surgical Complications;285
18.2;The Transplant Wound;285
18.2.1;The Incision;285
18.2.2;Hernias;286
18.2.3;The Infected Transplant Wound;288
18.2.4;Lymphocele;288
18.3;Vascular Problems;291
18.3.1;Hemorrhage;291
18.3.2;Renal Artery Thrombosis;291
18.3.3;Renal Vein Thrombosis;292
18.3.4;Renal Artery Stenosis;292
18.3.5;Renal Artery Pseudoaneurysm;293
18.3.6;Allograft Rupture;294
18.4;Urologic Problems;294
18.4.1;Ureteral Fistulae;294
18.4.2;Calyceal Fistulae;297
18.4.3;Bladder Fistulae;298
18.4.4;Ureteral Obstruction;298
18.4.5;Hydrocele;300
18.5;References;300
19;Chapter 16: Urologic Complications After Kidney Transplantation;303
19.1;Urologic Complications after Kidney Transplantation;303
19.2;Ureteral Complications;303
19.2.1;Ureteral Leak;304
19.2.2;Ureteral Stenosis;307
19.2.3;Prophylactic Ureteral Stents;309
19.3;Urinary Calculi in Transplant Recipients;309
19.4;Urinary Retention;310
19.5;Erectile Dysfunction;311
19.6;References;312
20;Chapter 17: Medical Management of Kidney Transplant Recipients;314
20.1;Introduction;314
20.2;Cardiovascular Disease;314
20.3;Hypertension;315
20.3.1;Epidemiology and Clinical Importance;315
20.3.2;Risk Factors and Pathogenesis;315
20.3.3;Diagnosis and Management;316
20.3.4;Treatment;316
20.3.4.1;Management of TRAS;318
20.4;Diabetes;318
20.4.1;Epidemiology and Clinical Importance;318
20.4.2;Risk Factors and Pathogenesis;319
20.4.3;Diagnosis and Management;319
20.5;Hyperlipidemia;322
20.5.1;Epidemiology and Clinical Importance;322
20.5.2;Risk Factors and Pathogenesis;322
20.5.3;Diagnosis and Monitoring;322
20.6;Cancer;324
20.6.1;Nonmelanomatous Skin and Lip Cancers;324
20.6.2;Malignant Melanoma;325
20.6.3;Cancers Associated with Viral Infections;325
20.6.4;Colorectal Cancer;325
20.6.5;Breast Cancer;325
20.6.6;Prostate Cancer;326
20.7;Bone Disease;326
20.7.1;Epidemiology and Pathogenesis;326
20.8;Treatment in Early Posttransplant Period;327
20.9;Treatment in the Late Posttransplant Period;327
20.10;Anemia;327
20.10.1;Epidemiology and Background;327
20.10.2;Risk Factors and Pathogenesis;328
20.10.3;Diagnosis and Management;328
20.10.4;Posttransplant Erythrocytosis (PTE);329
20.11;Pregnancy;329
20.11.1;Introduction;329
20.11.2;Infertility and Sexual Dysfunction;329
20.11.3;Optimal Timing and Contraception;330
20.11.4;Antenatal Period;330
20.11.5;Risks of Pregnancy to the Mother;330
20.11.6;Risks to Fetus;332
20.12;Miscellaneous;334
20.12.1;Hypophosphatemia;334
20.12.2;Hypomagnesemia;334
20.12.3;Hyperkalemia;334
20.13;References;334
21;Chapter 18: Infectious Complications: Prevention and Management;336
21.1;Introduction;336
21.2;Pretransplant Screening of Donor and Recipient, and Donor-Derived Infections;336
21.3;Posttransplant Infections: Overview;337
21.4;Posttransplant Infections: Surgical Site and Intraabdominal Infections;338
21.5;Postoperative Infections: Bloodstream Infections;340
21.6;Postoperative Infections: Urinary Tract Infections;340
21.7;Viral Infections: CMV, EBV, and Other Herpesviruses;341
21.7.1;Practical Management of CMV Infection and Viremia;343
21.7.2;Epstein-Barr Virus;344
21.8;BK Virus and Polyomavirus Allograft Nephropathy;344
21.8.1;Practical Management of BK Virus Infection;345
21.9;Hepatitis Viruses in Renal and Pancreatic Transplantation;346
21.9.1;Practical Approach to Hepatitis C in the Transplant Candidate and Recipient;347
21.10;Other Viral Infections;348
21.11;Pneumocystis and Fungal Infections;349
21.12;Practical Approach to Fungal Infections;351
21.13;Other Bacterial Infections: Clostridium difficile, Mycobacterium, Legionella, Nocardia, Listeria, Rhodococcus spp.;351
21.13.1;A Practical Approach to the Febrile Transplant Recipient;352
21.14;Preventing Infections in the Transplant Population: Exposures, Immunizations;354
21.15;Conclusion;354
21.16;References;354
22;Chapter 19: Living Kidney Donation: Pre- and Postdonation Evaluation and Management;360
22.1;Introduction;360
22.2;Donor Evaluation;361
22.2.1;Donor Age;361
22.2.2;Cardiovascular and Pulmonary Evaluation;364
22.2.3;Hypertension;365
22.2.4;Metabolic Derangements;366
22.2.4.1;Dyslipidemia;366
22.2.4.2;Impaired Fasting Glucose;366
22.2.4.3;Increased Body Mass Index and Obesity;367
22.2.5;Nephrolithiasis;367
22.2.6;Hematuria;368
22.2.7;Renal Mass and Function;368
22.3;Potential Risks Associated with Donor Nephrectomy;369
22.3.1;Immediate Complications;369
22.3.2;Late-Term Complications;370
22.3.2.1;Maternal and Fetal Complications following Donation;370
22.3.2.2;Late-Term Outcomes and Implications for Subsequent Kidney Disease and Overall Survival;370
22.4;Conclusion;371
22.5;References;372
23;Chapter 20: Psychology, Quality of Life, and Rehabilitation After Kidney and Pancreas Transplantation;375
23.1;Introduction;375
23.2;Psychological Aspects of ESRD;375
23.3;Psychological Adjustment to Dialysis;375
23.4;Quality of Life in ESRD and Transplantation;376
23.5;Psychiatric Referral in Patients with ESRD;376
23.6;Nonadherence with the Medical Regimen;377
23.7;Selection for Transplantation;377
23.8;Rehabilitation Posttransplantation;378
23.9;Psychiatric Symptoms and Disorders in Kidney–Pancreas Recipients, and Adaptation to Transplantation;378
23.9.1;Pretransplant Psychological Issues;378
23.9.2;Posttransplant Psychological Issues;379
23.9.3;Posttransplant Adherence to the Medication Regimen;380
23.9.4;Psychiatric Disorders in Kidney and Pancreas Transplant Recipients;380
23.9.5;Alcohol and Substance Abuse in Kidney and Pancreas Transplant Patients;381
23.9.6;Sleep Disorders;381
23.9.7;Pain;381
23.9.8;Antidepressant and Antipsychotic Drugs in ESRD;382
23.10;Summary and Conclusions;384
23.11;References;384
24;Chapter 21: Kidney Allocation System for Deceased Donor Kidneys in the United States;387
24.1;Introduction;387
24.2;What Is the National Infrastructure for Organ Allocation?;387
24.3;Ethical Issues in Organ Allocation;387
24.4;The Current Organ Allocation System;388
24.4.1;Wait Time;388
24.4.2;HLA Matching;389
24.4.2.1;Zero Mismatch (0MM) Sharing;389
24.4.3;Degree of Sensitization;389
24.4.4;Younger Age;389
24.4.5;Prior Organ Donation;390
24.5;Strengths and Weaknesses of the Current Kidney Allocation System;390
24.6;Additional Considerations for a New Allocation System;390
24.6.1;Life Years from Transplant;391
24.6.2;Donor Profile Index;391
24.6.3;Dialysis Time;391
24.6.4;Sensitization;392
24.7;Summary;392
24.8;References;392
25;Chapter 22: Ethics of Transplantation;393
25.1;Introduction;393
25.2;Brain Death;393
25.2.1;Consent for Brain Dead Donors;394
25.3;Donation After Cardiac Death;394
25.3.1;Criteria;395
25.3.2;Donors;395
25.3.3;Withdrawal of Life-Sustaining Measures;396
25.3.4;Medicolegal Challenges;396
25.4;Living Donor Issues;396
25.5;Transplant Commercialism and Tourism;398
25.6;Summary and Conclusions;399
25.7;References;399
26;Chapter 23: World-Wide Long-Term (20–40 Years) Renal Transplant Outcomes and Classification of Long-Term Patient and Allograft Survivals;401
26.1;Introduction;401
26.2;Overall Outcomes of Long-Term(20 Years or More) Renal Transplants;402
26.3;Subsets of Long-Term (20 Years or More) Renal Transplant Recipients;406
26.3.1;Pediatric Recipients;406
26.3.2;Protocol 20-Year Transplant Biopsy;407
26.3.3;23-Year Successes despite Long Cold Ischemia times;407
26.3.4;Effect of Viral Hepatitis on 20-Year Outcomes;407
26.3.5;Malignancy at 20–25 Years;407
26.3.6;Recurrent Glomerulonephritis at 20 Years;408
26.3.7;20-Year Outcomes with ABO Incompatibility;408
26.3.8;Effect of HLA Matching on 20-Year Outcomes;408
26.3.9;Chimerism Beyond 20 Years;408
26.3.10;Urinary Cytolytic Moleculesin Recipients with Allografts Functioning More than 20 Years;408
26.3.11;Acute Cellular Rejection and Antibody-Mediated Rejection after 20 Years;409
26.3.12;Individual Long-Term Renal Transplant Successes (25 Years to More than 40 Years);409
26.4;Summary;409
26.5;References;409
27;Chapter 24: Quantitative Aspects of Clinical Reasoning: Measuring Endpoints and Performance;412
27.1;Introduction;412
27.2;Data Sources: Strengths and Weaknesses;412
27.2.1;Clinical Trials;413
27.2.2;Single-Center Observational Studies;414
27.2.3;Multicenter Observational Studies;414
27.2.4;National Registries;414
27.3;Endpoints in Kidney Transplantation;416
27.3.1;Acute Rejection;416
27.3.2;Delayed Graft Function;416
27.3.3;Infections;416
27.3.4;Graft Loss;417
27.3.5;Patient Death;417
27.3.6;Renal Function;418
27.3.7;Costs and Resource Utilization;418
27.3.8;Provider Quality of Care;418
27.3.9;Patient Satisfaction and Quality of Life;419
27.3.10;Novel Endpoints;419
27.4;Statistical Models Utilized to Assess Endpoints;420
27.5;Transplant Center Quality Assurance;420
27.6;Summary;421
27.7;References;421
28;Chapter 25: The Business of Transplantation;423
28.1;Introduction;423
28.2;The Organ Transplant Network;424
28.3;Setting Up a Transplant Program;425
28.4;Administering a Program;425
28.4.1;Personnel;425
28.4.2;Finance;426
28.4.3;Compliance;429
28.4.4;Organ Procurement;430
28.4.5;Marketing;430
28.4.6;Internal and External Liaison;430
28.5;Tracking Outcomes;430
28.6;Conclusion;431
28.7;References;431
29;Index;432